Chapter - 007 Powerpoint For Nov 13

Chapter 7
Sexually Transmitted & Other Infections

Fall 2015
November 13, 2015
Copyright 2016 by Elsevier Inc. All rights reserved.
Learning Objectives
Describe prevention of sexually transmitted infections

in women, including risk reduction measures.
Differentiate signs, symptoms, diagnosis, and
management of nonpregnant and pregnant women
with selected sexually transmitted bacterial infections
(chlamydia, gonorrhea, syphilis).
Examine the care of nonpregnant and pregnant
women with selected sexually transmitted viral
infections (human immunodeficiency virus [HIV];
hepatitis A, B, and C; human papillomavirus; genital
herpes).
Learning Objectives (Cont.)
Compare and contrast signs, symptoms, and

management of selected vaginal infections in
nonpregnant and pregnant women.
Discuss the effect of group B streptococci (GBS) on
pregnancy and management of pregnant women with
GBS.
Identify the effects of TORCH infections on
pregnancy and the fetus.
Describe the health consequences (e.g., ectopic
pregnancy, infertility) for women who are infected
with reproductive tract infections.
Review principles of infection control for HIV and
blood-borne pathogens.
Prevention
Primary prevention
Primary prevention the most effective way of

reducing STIs in women
Secondary prevention
Prompt diagnosis and treatment can prevent

personal complications and transmission to others
Prevention (Cont.)
Risk reduction measures
Knowledge of partner
Reduction of the number of partners
Low-risk sex
Avoiding exchange of body fluids
Vaccination
Prevention (Cont.)
Risk reduction measures
Physical barriers
Condoms
Chemical barriers
Nonoxynol-9
Communication
Expressing feelings and fears
Attention to partners response
Nurses must suggest strategies to enhance a womans
condom negotiation and communication skills.
Vaccination
Bacterial Sexually Transmitted

Infections
Chlamydia trachomatis
Most common and fastest spreading STI

Infections often silent and highly destructive
Difficult to diagnose
Sexually active women ages 15 to 24 years have the
highest rates of infection, with women ages 18 to 20
years having the highest rates (CDC, 2012e).
Screening and diagnosis

Asymptomatic and pregnant women
Comparisons of diagnostic procedures

Infections (Cont.)
Chlamydia
Management
Doxycycline
Azithromycin
All exposed sexual partners should be treated.
Perinatal transmission
Antibiotic ointment
Normal Cervix
Source: Claire E. Stevens, Seattle STD/HIV Prevention Training Center
Chlamydia Cervicitis
Copyright 2016
by Elsevier
Inc. All rights reserved.
Source: St. Louis STD/HIV Prevention
Training
Center
10
Mucopurulent Cervicitis
Copyright
2016 by Elsevier
Source: Seattle STD/HIV Prevention
Training
Center
Drip
s
11

Infections (Cont.)
Gonorrhea
Aerobic gram-negative diplococcus

Oldest communicable disease in the United States
Second to chlamydia in reported cases
Highest rates among teenagers, young adults, and
African-Americans
Women often asymptomatic
12

Infections (Cont.)
Gonorrhea

CDC recommends screening all women at risk.
Testing performed during first trimester and at 36 weeks
of pregnancy
Is a reportable disease
Management
Antibiotic therapy: cefixime or ceftriaxone
Concomitant treatment for chlamydia
Perinatal complications of gonococcal infection
13
Gonorrhea Gram Stain

Source: Cincinnati STD/HIV Prevention
Training Center
Drip
s
14

Infections (Cont.)
Syphilis
Treponema pallidum, a motile spirochete

Earliest described STI
Transmission by entry into subcutaneous tissue through
microscopic abrasions that can occur during sexual
intercourse
Also transmitted through kissing, biting, or oral-genital
sex
Transplacental transmission may occur at any

time during pregnancy.
15
Bacterial Sexually Transmitted Infections

(Cont.)
Syphilis
Can lead to serious systemic disease and even

death when untreated
Infection manifests in distinct stages
Primary: 5 to 90 days after exposure
Secondary: 6 weeks to 6 months
Tertiary: develops in one third of women infected
16

Infections (Cont.)
Syphilis
Screening and
diagnosis
Pregnant women
Serologic tests
False-positive results
Management
Penicillin
Sexual abstinence
during treatment
17
Primary Syphilis

Source: Centers for Disease Control
and Prevention
18
Primary Syphilis Chancre

Source: Florida STD/HIV Prevention
Training Center
19
Secondary Syphilis Rash

Training Center
20

Infections (Cont.)
Pelvic inflammatory disease (PID)
An infectious process that most commonly

involves the fallopian tubes, uterus, and
occasionally the ovaries and peritoneal surfaces
Multiple organisms have been found to cause PID.
21

Infections (Cont.)
Pelvic inflammatory disease (PID)
Risk factors for acquiring PID

Young age
Nulliparity
Multiple partners
High rate of new partners
History of STIs and PID
Those with PID are at increased risk for
Ectopic pregnancy
Infertility
Chronic pelvic pain
22

Infections (Cont.)
Pelvic inflammatory disease (PID) (Cont.)
Symptoms
Depend on type of infection
Acute
Subacute
Chronic

History
CDC routine criteria
Management
Prevention
Hospitalization
Education
23
Pelvic Inflammatory Disease
Copyright 2016
by Elsevier
Training
Center
24
Viral Sexually Transmitted Infections
Human papillomavirus
(HPV)
Condylomata acuminata
Affects 20 million
Americans
Most prevalent viral STI
seen in ambulatory
health care settings
Previously named genital
or venereal warts
More frequent in
pregnant women
25

(Cont.)
Human papillomavirus (HPV) (Cont.)

History of known exposure
Physical inspection
Pap test
Viral screening and typing for HPV are available but not
standard practice.
Management of HPV
Removal
Medications
Counseling
26
Perianal Wart

Training Center
27
HPV Cervical Warts
Source: Cincinnati STD/HIV Prevention Training Center
28
HPV Warts on the Thigh

Training
Copyright 2016
by Elsevier Center
29

(Cont.)
Herpes simplex virus (HSV)
Herpes simplex virus 1 (HSV-1)

Transmitted nonsexually
Herpes simplex virus 2 (HSV-2)
Transmitted sexually
Initial infection characterized by multiple painful lesions,
fever, chills, malaise, and severe dysuria
30

(Cont.)
Herpes simplex virus (HSV) (Cont.)
Chronic and recurring disease for which there is

no known cure
Systemic antiviral medications partially control the
symptoms
Maternal infection with HSV-2 can have adverse effects
on mother and fetus
Neonatal herpes
Most severe complication of HSV

Most mothers lack history of HSV
31
Sor
es
Genital Herpes Simplex
32
Source: Florida STD/HIV Prevention Training Center
32
Genital Herpes Simplex in Females

Source: Centers for Disease Control
and Prevention
33
Herpes and pregnancy
Adverse effects on mother and infant

1st trimester infection miscarriage rate
Neonatal herpes potentially fatal - 60% /
disabling in 50% who survive
Transmission highest with primary contraction
near term
Lower with recurrent herpes
34

(Cont.)
Viral hepatitis
Hepatitis A virus (HAV)

Acquired primarily through a fecal-oral route
Vaccination the most effective means of preventing HAV
transmission
Characterized by flulike symptoms with malaise, fatigue,
anorexia, nausea, pruritus, fever, and right upper
quadrant pain
35

(Cont.)
Viral hepatitis (Cont.)
Hepatitis B virus (HBV)

Most threatening to the fetus and neonate
Disease of the liver and often a silent infection
Transmitted parenterally, perinatally, and, rarely, orally as
well as through intimate contact
Vaccination series available
No specific treatment; recovery is usually spontaneous
within 3-16 weeks
36

(Cont.)
Viral hepatitis (Cont.)
Hepatitis C virus (HCV)

Most common blood-borne infection in the United States
Important health problem as increasing numbers acquire
disease
Risk factor for pregnant women is history of injecting IV
drugs
Interferon-alfa or ribavirin is main therapy for HCV
infection
Effectiveness of treatment varies
37

(Cont.)
Human immunodeficiency virus (HIV)
47,500 new HIV infections occur in United States

each year
Heterosexual transmission now the most common
means of transmission in women
20% of these new infections occur in women
Transmission of HIV occurs primarily through
exchange of body fluids
38

(Cont.)
Human immunodeficiency virus (HIV) (Cont.)
Severe depression of the cellular immune system

associated with HIV infection characterizes AIDS
Symptoms: fever, headache, night sweats,
malaise, generalized lymphadenopathy, myalgias,
nausea, diarrhea, weight loss, sore throat, and
rash
39

(Cont.)

Antibody testing
Detection
Counseling for HIV testing
Counseling before and after HIV testing is standard
nursing practice today

HIV testing offered early in pregnancy
Perinatal transmission decreases
Consider confidentiality and documentation
Pretest and posttest counseling
Notification of results
40

(Cont.)
Management
Resources
Death and dying

Suicide prevention
Financial assistance
Legal advocacy
Prevention of transmission
No cure available yet
41

(Cont.)
HIV and pregnancy

HIV counseling and testing should be offered to all
women at their initial entry into prenatal care as part of
routine prenatal testing unless the woman opts out of the
screening (CDC, 2010c).
Perinatal transmission has decreased because of
antiretroviral prophylaxis.
Decreases transmission to 1% to 2%
Intrapartum zidovudine
Cesarean birth is recommended.
42
Case Study
Your patient is a 20-year-old, single, G0P0 who
presents to the clinic as a walk-in. She appears upset.
After you bring her to an examination room and take her
vital signs, you ask her what the reason is for her visit
today.
She replies, A couple of days ago, I noticed some
painful, pimple-like bumps on the outside of my vagina.
I dont know what to do.
While you take her health history, what are some
especially important questions to include?
43
Case Study (Cont.)

After the physical exam, you explain to the
patient that a diagnosis of herpes simplex virus
is suspected and will be confirmed with the lab
culture.
The patient asks, Can the doctor prescribe me
some antibiotics to get rid of the infection?
As the nurse, what is your best response?
What other patient teaching is important to
include before the patient departs?
44
Case Study (Cont.)

The patient states that she is heterosexual and
is currently sexually active with one partner, her
boyfriend. She has a history of 2 past sexual
partners. She denies any previous history of
STIs.
As a nurse, you may perform part of the
examination or you may be present to assist the
provider with the exam.
What is important to include in the focused
physical examination?
45
Vaginal Infections
Vulvovaginitis
Inflammation of the vulva and vagina

Many different causes
Bacterial vaginosis (BV)
Syndrome in which normal H2O2-producing

lactobacilli are replaced with high concentrations
of anaerobic bacteria
Associated with preterm labor and birth
Treatment with metronidazole orally
46
Vaginal Infections (Cont.)
Candidiasis
Candida albicans or nonC. albicans infection

Vulvovaginal candidiasis, or yeast infection, is
second most common type of vaginal infection
Numerous factors have been identified as
predisposing a woman to yeast infections.
In women with HIV, symptoms are more severe
and persistent.
47
Candidiasis (Cont.)
Predisposing factors
Antibiotic therapy
Diabetes
Pregnancy
Obesity
Diets high in refined sugars
Use of corticosteroids and hormones
Immunosuppressed states
48
Candidiasis (Cont.)
Common symptoms
Vulvar pruritus
Vaginal pruritus
Physical examination
Vaginal pH
Management
Over-the-counter agents
Intravaginal treatment or oral agent

Full course of treatment must be completed
Other comfort measures
49
Trichomoniasis
Caused by Trichomonas vaginalis

Often considered an STI
Common cause of vaginal infection
Inflammation of the vagina and/or vulva
Speculum examination
Pap test
Management
Metronidazole
The risk for sexual transmission must be communicated
to infected women.
50
Group B streptococci (GBS)
A part of the normal vaginal flora, present in 20%

to 30% of healthy women
Associated with poor pregnancy outcomes
Important factor in neonatal morbidity and
mortality
Screening at 36-37 weeks of gestation
Intrapartum intravenous prophylaxis
51
Maternal and Fetal Effects of

Sexually Transmitted Infections
STIs in pregnancy are responsible for

significant morbidity and mortality
Pregnancy effects
Premature rupture of membranes
Premature labor
Postpartum sepsis
Dystocia
Miscarriage
52
Maternal and Fetal Effects of Sexually

Transmitted Infections (Cont.)
STIs in pregnancy are responsible for

significant morbidity and mortality.
Fetal effects
Preterm birth
Pneumonia
Systemic infection
Congenital infection
Stillbirth
53

Transmitted Infections (Cont.)
TORCH infections
Form group of infections capable of crossing the

placenta and adversely affecting the fetus
Toxoplasmosis
Other infections (e.g., hepatitis, HIV)
Rubella virus
Cytomegalovirus
Herpes simplex virus (HSV)
54

Transmitted Infections: Care Management
Assessment and nursing diagnoses
History
Ask about lifestyle behaviors that place clients at risk for
STIs
Physical examination
Ensure comfort during examination
Laboratory tests
55
Maternal and Fetal Effects of Sexually Transmitted

Infections: Care Management (Cont.)
Expected outcomes of care
Plan of care and interventions
Focus on physical and psychologic needs with

emphasis on avoidance of reinfection and harmful
sequelae
Infection control
Management during pregnancy
Evaluation
56
Infection Control
Interrupting the transmission of infection is

crucial to STI control
Many STIs are reportable; all states require
that these STIs be reported to public health
officials
Gonorrhea
Syphilis
Chancroid
Lymphogranuloma venereum
Granuloma inguinale
57
Key Points
Reproductive tract infections include STIs and

common genital tract infections.
Risk-reduction sexual practices are key STIprevention strategies.
HIV is transmitted through body fluids,
primarily blood, semen, and vaginal
secretions.
58
Key Points (Cont.)
Prevention of mother-to-newborn HIV

transmission is most effective when the
woman receives antiretroviral drugs during
pregnancy and labor and birth, and the infant
receives the drugs after birth.
HPV is the most common viral STI.
Syphilis has reemerged as a common STI,
affecting African-American women more than
any other ethnic or racial group.
59
Key Points (Cont.)
Chlamydia is the most common STI in

women in the United States and the most
common cause of PID.
Viral hepatitis has several forms of
transmission; HBV infections carry the
greatest risk.
Young, sexually active women who do not
practice risk-reducing sexual behaviors and
have multiple partners are at greatest risk for
STIs and HIV.
60
Key Points (Cont.)
STIs are responsible for substantial mortality

and morbidity, great personal suffering, and
heavy economic burden in the United States.
STIs and vaginitis are biologic events for
which all individuals have a right to expect
objective, compassionate, and effective
health care.
61
Key Points (Cont.)
Pregnancy confers no immunity against

infection, and both mother and fetus must be
considered when the pregnant woman
contracts an infection.
Because history and examination cannot
reliably identify everyone with HIV or other
blood-borne pathogens, blood and body-fluid
precautions should be used consistently for
everyone all the time.
62
Question
1. A nurse is providing discharge instructions to
a client who has just been diagnosed with
human papillomavirus (HPV) on her cervix.
What is the most important discharge
instruction for this client?
a. Take a multivitamin every day.
b. Check for external lesions around the vagina
every month.
c. Have Pap tests done as recommended by her
provider.
d. Avoid using an intrauterine device (IUD).
63

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Chapter 7

Sexually Transmitted & Other Infections

Copyright 2016 by Elsevier Inc. All rights reserved.

Describe prevention of sexually transmitted infections

Learning Objectives (Cont.)

Compare and contrast signs, symptoms, and

Primary prevention the most effective way of

Prompt diagnosis and treatment can prevent

Copyright 2016 by Elsevier Inc. All rights reserved.

Risk reduction measures

Copyright 2016 by Elsevier Inc. All rights reserved.

Risk reduction measures

Copyright 2016 by Elsevier Inc. All rights reserved.

Bacterial Sexually Transmitted

Most common and fastest spreading STI

Screening and diagnosis

Copyright 2016 by Elsevier Inc. All rights reserved.

Bacterial Sexually Transmitted

Copyright 2016 by Elsevier Inc. All rights reserved.

Copyright 2016 by Elsevier Inc. All rights reserved.

Source: Claire E. Stevens, Seattle STD/HIV Prevention Training Center

Bacterial Sexually Transmitted

Aerobic gram-negative diplococcus

Copyright 2016 by Elsevier Inc. All rights reserved.

Bacterial Sexually Transmitted

Screening and diagnosis

Copyright 2016 by Elsevier Inc. All rights reserved.

Gonorrhea Gram Stain

Copyright 2016 by Elsevier Inc. All rights reserved.

Bacterial Sexually Transmitted

Treponema pallidum, a motile spirochete

Transplacental transmission may occur at any

Copyright 2016 by Elsevier Inc. All rights reserved.

Bacterial Sexually Transmitted Infections

Can lead to serious systemic disease and even

Copyright 2016 by Elsevier Inc. All rights reserved.

Bacterial Sexually Transmitted

Copyright 2016 by Elsevier Inc. All rights reserved.

Copyright 2016 by Elsevier Inc. All rights reserved.

Primary Syphilis Chancre

Copyright 2016 by Elsevier Inc. All rights reserved.

Secondary Syphilis Rash

Copyright 2016 by Elsevier Inc. All rights reserved.

Bacterial Sexually Transmitted

Pelvic inflammatory disease (PID)

An infectious process that most commonly

Copyright 2016 by Elsevier Inc. All rights reserved.

Bacterial Sexually Transmitted

Pelvic inflammatory disease (PID)

Risk factors for acquiring PID

Copyright 2016 by Elsevier Inc. All rights reserved.

Bacterial Sexually Transmitted

Pelvic inflammatory disease (PID) (Cont.)

Screening and diagnosis

Copyright 2016 by Elsevier Inc. All rights reserved.

Pelvic Inflammatory Disease

Viral Sexually Transmitted Infections

Copyright 2016 by Elsevier Inc. All rights reserved.

Viral Sexually Transmitted Infections

Human papillomavirus (HPV) (Cont.)

Screening and diagnosis

Copyright 2016 by Elsevier Inc. All rights reserved.

Copyright 2016 by Elsevier Inc. All rights reserved.