NCLEX: Reproductive system disorders

Diagnostic tests

Diagnostic testing can help you assess reproductive organs and associated structures for abnormalities, detect cancers, or determine the cause of infertility or sexual dysfunction. Diagnostic procedures include endoscopic tests, radiographic and ultrasound studies, and tissue analyses.

Endoscopic tests

Endoscopic tests are invasive procedures that allow examination of internal reproductive structures to assess lesions, cancers, or infections or to perform various therapeutic procedures. Such tests include colposcopy and laparoscopy.

Colposcopy
During colposcopy, the examiner studies the vulva, cervix, and vagina with a colposcope, an instrument that contains a magnifying lens and a light. The areas to be studied are first bathed in white vinegar (5% acetic acid), which causes abnormal areas to turn white.

Coping with a colposcope

Although originally used to screen for cancer, colposcopy is now used to:
• evaluate abnormal cytologic specimens or grossly suspicious lesions
• examine the cervix and vagina to confirm cancer after a positive Pap test result
• monitor patients whose mothers took diethylstilbestrol during pregnancy.
During the examination, a biopsy may be performed and photographs taken of suspicious lesions using the colposcope and its attachments.

Nursing considerations
• Tell the patient that she doesn’t need to restrict food or fluids before the test.
• Explain that the procedure takes 10 to 15 minutes. A biopsy may be performed during the examination and may cause cramping and pain for a short time as well as minimal, easily controlled bleeding.
• Warn the patient to abstain from intercourse after the biopsy and not to insert anything into her vagina (except a tampon) until the practitioner confirms healing of the biopsy site.

• Instruct the patient to call the practitioner if she begins to bleed more heavily than during a period. She should also call the practitioner if she has signs and symptoms of infection — such as discharge, pain, and fever. Reassure her that abstaining from douching, sexual intercourse, and tub baths will help prevent these complications.

Laparoscopy
Laparoscopy allows a doctor to inspect the organs in the peritoneal cavity by inserting a small fiberoptic telescope (laparoscope) through the anterior abdominal wall.

A scope for all reasons

This test is used to:
• detect abnormalities, such as cysts, adhesions, fibroids, and infection
• determine the cause of pelvic pain
• diagnose endometriosis, ectopic pregnancy, or pelvic inflammatory disease (PID)
• evaluate pelvic masses or the fallopian tubes of infertile patients.
• stage cancer.
Therapeutic uses of this procedure include lysis of adhesions, tubal sterilization, removal of foreign bodies, and fulguration of endometriotic implants.

Nursing considerations
• Instruct the patient to fast after midnight before the test or at least 8 hours before surgery.
• Assure the patient that she’ll receive either a local or general anesthetic, and tell her that the procedure will require either an outpatient visit or overnight hospitalization.
• Check the patient’s history to make sure she isn’t hypersensitive to the anesthetic. Make sure that all laboratory work is completed and results reported before the test.
• During the procedure, check for proper drainage of the urinary catheter, and monitor vital signs and urine output. Report sudden changes immediately — they may indicate complications. After administration of a general anesthetic, check for allergic reactions. Monitor electrolyte and hemoglobin levels and hematocrit as ordered.
• After recovery, help the patient walk as ordered. Instruct her to restrict activity for 2 to 7 days as ordered. Reassure her that some discomfort at the puncture site and in the abdomen, along with shoulder pain (from carbon dioxide pumped into the abdomen during the procedure), is normal and should disappear in 24 to 36 hours. Provide pain medication as ordered.

Radiographic and ultrasound studies

Radiographic and ultrasound studies are tests that use X-rays and high-frequency sound waves to inspect internal reproductive structures.

Hysterosalpingography
Hysterosalpingography allows the doctor to visually inspect the uterine cavity, fallopian tubes, and peritubal area. A contrast medium is injected through a cannula that’s inserted through the cervix. Fluoroscopic X-rays are taken as the contrast medium flows through the uterus and the fallopian tubes.

Long name, lotsa uses

This test is usually performed as part of an infertility study to confirm tubal abnormalities, such as adhesions and occlusion, and uterine abnormalities, such as foreign bodies, congenital malformations, and traumatic injuries.
A practitioner may also order this test to evaluate repeated fetal loss or to follow up after surgery, especially uterine unification procedures and tubal reanastomosis.

Nursing considerations
• Warn the patient that she may have moderate cramping, nausea, and dizziness during or after the procedure but that she may receive a mild sedative such as diazepam (Valium) beforehand to relax her. Reassure her that these reactions are transient.
• When monitoring the patient, watch for an allergic reaction to the contrast medium (such as hives, itching, or hypotension) and for signs and symptoms of infection (such as fever, pain, increased pulse rate, malaise, and muscle aches).

Pelvic ultrasonography
During pelvic ultrasonography, a crystal generates high-frequency sound waves that are reflected to a transducer. The transducer then converts sound energy into electrical energy and forms images of the interior pelvic area on an oscilloscope screen. This test is most commonly used to:
• evaluate symptoms that suggest pelvic disease to confirm a tentative diagnosis
• determine fetal viability, position, gestational age, and growth rate during pregnancy.

Nursing considerations
• Reassure the pregnant patient that ultrasonography won’t harm the fetus, and provide emotional support during the test.

• Instruct the patient that the test requires a full bladder, so she may have to drink several glasses of water beforehand. A full bladder helps to conduct the sound waves and improves the images of the pelvic organs.
• Explain that a water enema may be necessary to produce a better outline of the large intestine.
• Allow the patient to empty her bladder immediately after the test.

Tissue analysis

Analysis of cervical material may be useful for detecting cancers and infections.

Pap test
A Pap test screens for premalignant and malignant cervical changes in women who have no symptoms or findings suggesting cancer. It’s widely used for:
• early detection of cervical cancer
• detection of inflammatory tissue changes that may occur with infections or other cervical diseases
• assessment of the patient’s response to chemotherapy and radiation therapy.

Scrape, spread, slide

To perform a Pap test, the practitioner scrapes secretions from the patient’s cervix and spreads them on a slide. After the slide is immersed in a fixative, it’s sent to the laboratory for cytologic analysis. Alternatively, the Thin Prep Pap test may be used, in which the collection device is rinsed in a vial of preservative solution and sent to the laboratory.

Paps all around

Recently, the American Congress of Obstetricians and Gynecologists (ACOG) developed new guidelines for Pap tests. These guidelines apply even to women who have been vaccinated against human papillomavirus. ACOG recommends the following schedule:
• Women ages 21 to 30 should have a Pap test every 2 years.
• Women ages 30 to 65 or 70 who have had three consecutive negative test results may undergo screening once every 3 years.
• At age 65 or 70, women who have had no abnormal test results for 10 years may stop testing. Women with certain risk factors—such as immunosuppression, previous abnormal Pap smears, or a cervical cancer diagnosis–may need more frequent screening. Regardless of age, women who have had a total hysterectomy for noncancerous reasons shouldn’t undergo routine cervical cytology testing.

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Nursing considerations
• Explain to the patient that the Pap test allows cervical cells to be studied. Stress the test’s importance in detecting cancer at a stage when it commonly produces no symptoms and is still curable.
• Explain that the test shouldn’t be scheduled during menses. The best time is 1 week before or after menses, when there are more cervical cells and less mucus.
• Instruct the patient not to have intercourse for 24 hours before the test and not to douche or insert vaginal medications for 72 hours before the test. These activities can wash away cellular deposits and change the vaginal pH.
• Obtain an accurate patient history, and note any pertinent data on the laboratory request.
• If the patient is anxious, be supportive and tell her that test results should be available within a few days.
• Just before the test, ask the patient to empty her bladder.
• Preserve the slides immediately. A delay in fixing a specimen allows the cells to dry, destroys the effectiveness of the nuclear stain, and makes cytologic interpretation difficult.
• Make sure that you aspirate and scrape the specimen from the cervix. Aspiration of the posterior fornix of the vagina can supplement a cervical specimen but shouldn’t replace it.

• If vaginal or vulval lesions are present, take scrapings directly from the lesion.
• If the patient’s uterus is involuted or atrophied from age, use a small pipette, if necessary, to aspirate cells from the squamocolumnar junction and the cervical canal.

Treatments

To provide effective care for the patient with a reproductive disorder, you’ll need a working knowledge of current drug therapy, surgery, and related treatments.

All stressed out

Keep in mind that many of these disorders place your patient under enormous social and psychological stress, so your ability to maintain a caring, nonjudgmental attitude will prove especially valuable.

Drug therapy

Drugs are the treatment of choice for many reproductive disorders. For example, estrogens are prescribed for several disorders associated with estrogen deficiency and for inoperable prostatic cancer, breast cancer, and hypogonadism. Gonadotropins are used to treat certain forms of infertility as well as undescended testes in males. Medication in combination with disease management may help men with erectile dysfunction.

Surgery

Women with gynecologic disorders may need surgery. Gynecologic surgeries include dilatation and curettage (D&C), dilatation and evacuation (D&E), and hysterectomy. Such surgery may cause an altered body image. Therefore, you must consistently provide these patients with strong emotional support. Men with erectile dysfunction may benefit from penile prosthesis implantation.

D&C and D&E
During a D&C or D&E — the most common gynecologic procedures — the doctor expands or dilates the cervix to access the endocervix and uterus. In D&C, he uses a curette to scrape endometrial tissue. In D&E, he applies suction to extract the uterine contents. D&C is used to treat an incomplete abortion, to control abnormal uterine bleeding, and to obtain an endometrial or endocervical tissue specimen for cytologic study. D&E is also a treatment for an incomplete abortion. In addition, it’s used for a therapeutic abortion, usually up to 12 weeks’ gestation but occasionally as late as 16 weeks’.

Patient preparation
Before the procedure, take these steps:
• Make sure the patient has followed preoperative directions for fasting and has used an enema to empty her colon before admission.
• Remind her that she’ll be groggy after the procedure and won’t be able to drive. Make sure that she has arranged for help with transportation home.
• Ask the patient to void before you administer preoperative medications, such as meperidine (Demerol) or diazepam (Valium).
• Start I.V. fluids (either dextrose 5% in water or normal saline solution) as ordered to facilitate administration of the anesthetic. The patient may receive monitored sedation, a general anesthetic, a regional paracervical block, or a local anesthetic.

Monitoring and aftercare
After the procedure, take these steps:
• Administer an analgesic as ordered. Expect the patient to have moderate cramping and pelvic and lower back pain. Continuous, sharp abdominal pain that doesn’t respond to the analgesic may indicate perforation of the uterus. Report it at once.
• Monitor the patient for hemorrhage and signs of infection such as purulent, foul-smelling vaginal drainage. Also monitor the color and volume of urine (hematuria indicates infection). Report any of these signs immediately.
• Administer fluids as tolerated, and allow food if the patient requests it. Keep the bed’s side rails raised, and help the patient walk to the bathroom if she’s unsteady on her feet.

Home care instructions
Before the patient is discharged, take these steps:
• Warn the patient to report signs of infection. Tell her not to use tampons or take tub baths until healing is complete because these activities increase the risk of infection.
• Tell her to expect moderate cramps and lower back pain, and to take analgesics as needed. Warn her that she should report unrelenting sharp pain immediately.
• Explain that spotting and discharge may last a week or longer (up to 4 weeks after an abortion procedure). She should report any bright red blood.

• Advise her to follow her practitioner’s instructions for scheduling an appointment for a routine checkup.
• Tell the patient to resume activity as tolerated but to follow her practitioner’s instructions concerning vigorous exercise and sexual intercourse. These are usually discouraged until 2 weeks after the follow-up visit.
• Advise the patient to seek birth control counseling if needed, and refer her to an appropriate center.

Hysterectomy
A hysterectomy involves removing the uterus. Although it can be performed using a vaginal or an abdominal approach, the abdominal approach allows better visualization of the pelvic organs and a larger operating field.

A different approach

The vaginal approach may be used to repair relaxed pelvic structures, such as cystocele or rectocele, at the same time as hysterectomy.

Patient preparation
The patient will enter the hospital on the day of surgery or 1 day before. Prepare her for surgery by taking these steps:
• Take time to talk to her about what she expects from the surgery and about her menstrual and reproductive status after surgery.
• Review what the surgical approach involves and the extent of the excision.
• If the patient is having an abdominal hysterectomy, tell her that she’ll need to:
– douche and have an enema the evening before surgery
– take a shower with an antibacterial soap shortly before surgery
– have an indwelling urinary catheter inserted to keep the bladder empty during surgery and to help prevent urinary retention after surgery
– have a nasogastric (NG) tube or rectal tube inserted if she develops abdominal distention
– expect temporary abdominal cramping and pelvic and lower back pain after the procedure.
• If the patient is scheduled for a vaginal hysterectomy, tell her to expect abdominal cramping afterward. She’ll also have a perineal pad in place because moderate amounts of drainage occur postoperatively.
• Inform the patient that after surgery she needs to lie in a supine position or in a low- to mid-Fowler’s position.
• Demonstrate the exercises that she’ll need to perform to prevent venous stasis.

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Monitoring and aftercare
After the procedure, take these steps:
• If the patient has had a vaginal hysterectomy, change her perineal pad frequently. Provide analgesics to relieve cramps.
• If she has had an abdominal hysterectomy, tell her to remain in a supine position or a low- to mid-Fowler’s position. Encourage her to perform the prescribed exercises and to walk early and frequently to prevent venous stasis. Monitor her urine output because retention commonly occurs.
• If abdominal distention develops, relieve it by inserting an NG tube or rectal tube as ordered. Note bowel sounds during routine assessment.

Home care instructions
Before the patient is discharged, take these steps:
• If the patient has had a vaginal hysterectomy, instruct her to report severe cramping, heavy bleeding, or hot flashes (common with oophorectomy) to her practitioner immediately.
• If she has had an abdominal hysterectomy, tell her to avoid heavy lifting, rapid walking, or dancing, which can cause pelvic congestion. Encourage her to walk a little more each day and to avoid sitting for a prolonged period.
• Advise any posthysterectomy patient to eat a high-protein, high-residue diet to avoid constipation, which may increase abdominal pressure. The practitioner may also order increased fluid intake.
• Mention that the practitioner will inform her when she can resume sexual activity (usually 6 weeks after surgery).
• Explain to the patient and her family that abrupt hormonal fluctuations may cause the patient to feel depressed or irritable for a while. She may also have feelings of loss or depression for up to 1 year after the surgery. Encourage family members to respond calmly and with understanding.
• If her ovaries were removed, the patient may receive hormone replacement therapy, which requires monitoring.

Penile prosthesis implantation
A penile prosthesis is surgically implanted in the corpora cavernosa of the penis. Prostheses come in two types: those consisting of a pair of semirigid rods and those made of inflatable cylinders. They’re used to treat both organic and psychogenic erectile dysfunction.

A semirigid penile prosthesis is especially helpful for the patient with limited hand or finger function because it doesn’t require manual dexterity. However, the prosthesis keeps the penis semierect, which may embarrass the patient. Also, some couples complain that the semirigid prosthesis produces an erection that isn’t sufficiently stiff to be sexually satisfying.
An inflatable prosthesis provides a more natural erection. The patient controls the erection by squeezing a small pump in the scrotum that releases radiopaque fluid from a reservoir into the implanted cylinders. This device, however, is contraindicated in patients with iodine sensitivity.

Patient preparation
Before implant surgery, take these steps:
• Reinforce the doctor’s explanation of the surgery and answer any questions.
• Reassure the patient that the prosthesis won’t affect ejaculation or orgasmic pleasure. If the patient experienced either before surgery, he can experience them afterward.
• Recognize that the patient and his partner are likely to be anxious before surgery, so provide emotional support.

Squeaky clean

• Instruct the patient to shower both the evening before and the morning of surgery, using an antimicrobial soap.
• Begin antibiotic therapy if ordered.

Monitoring and aftercare
After surgery, take these steps:
• Apply ice packs to the patient’s penis for 24 hours after surgery.
• Empty the surgical drain when it’s full, or as ordered, to reduce the risk of infection.
• If the patient has an inflatable prosthesis, tell him to pull the scrotal pump downward to ensure proper alignment.
• With the practitioner’s approval, encourage the patient to practice inflating and deflating the prosthesis when the pain subsides. Pumping promotes healing of the tissue sheath around the reservoir and pump.

Home care instructions
Before the patient is discharged, take these steps:
• Tell the patient to wash the incision daily with an antimicrobial soap.
• Caution him to watch for signs of infection and to report them to the practitioner immediately.
• Inform him that scrotal swelling and discoloration may last up to 3 weeks.

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