NCLEX: Reproductive system disorders

Reproductive system disorders: Nursing diagnoses

Focus topic: Reproductive system disorders

Two nursing diagnoses are commonly used when referring to patients with reproductive disorders. These diagnoses are discussed here, along with appropriate nursing interventions and rationales.

 

Reproductive system disorders: Sexual dysfunction

Focus topic: Reproductive system disorders

Related to altered body structure or psychological stress, Sexual dysfunction can be applied to such conditions as endometriosis, PID, arousal and orgasmic dysfunction, dyspareunia, vaginismus, impotence, or premature ejaculation.

Expected outcomes
• Patient states understanding of sexual dysfunction related to his current situation.
• Patient discusses concerns with spouse or significant other.
• Patient has resources for post-discharge support, including a sex counselor and other appropriate professional, if necessary.

Nursing interventions and rationales
• Provide a nonthreatening, nonjudgmental atmosphere. This enhances communication and understanding between patient and caregiver.
• Allow the patient to express his feelings openly. This encourages him to ask questions specifically related to his current situation.
• Suggest that the patient discuss concerns with his partner. Sharing concerns helps strengthen relationships.

• Provide support for the patient’s partner. Supportive interventions (such as active listening) communicate concern, interest, and acceptance.
• Educate the patient and his spouse or partner about limitations that the patient’s physical condition imposes on sexual activity. Understanding these limitations helps the patient avoid complications or injury.
• Suggest referral to a sex counselor or other appropriate professional for future guidance and support.

Reproductive system disorders: Ineffective sexuality pattern

Focus topic: Reproductive system disorders

Related to illness or medical treatment, Ineffective sexuality pattern may be associated with genitourinary or gynecologic disorders or with STDs, such as AIDS, herpes, gonorrhea, and syphilis.

Expected outcomes
• Patient understands diagnosis and treatment.
• Patient communicates with partner concerns regarding change in sexual patterns.

Nursing interventions and rationales
• Plan for uninterrupted time to talk with the patient. This demonstrates your comfort with sexuality issues and reassures the patient that his concerns are acceptable for discussion.
• Provide a nonthreatening, nonjudgmental atmosphere to encourage the patient to express feelings about perceived changes in sexual identity and behaviors. This demonstrates unconditional positive regard for the patient and his concerns.
• Provide the patient and partner with information about the illness and its treatment. Answer questions and clarify any misconceptions. This helps them focus on specific concerns, encourages questions, and avoids misunderstandings.
• Encourage social interaction and communication between the patient and partner. This fosters sharing of concerns and strengthens relationships.
• Offer referral to counselors or support persons, such as a mental health professional, a sex counselor, or an illness-related support group (such as I Can Cope, Reach for Recovery, and the Ostomy Association).

Reproductive system disorders: Common reproductive disorders

Focus topic: Reproductive system disorders

This section discusses common female and male reproductive disorders, including STDs. For each disorder, you’ll find information on causes, assessment findings, diagnostic tests, treatments, nursing interventions, patient teaching, and evaluation criteria.

Reproductive system disorders: Endometriosis

Focus topic: Reproductive system disorders

In endometriosis, benign endometrial tissue appears outside the lining of the uterine cavity. This ectopic tissue can appear anywhere in the body, but it usually remains in the pelvic area, around the ovaries, fallopian tubes, uterosacral ligaments, and uterovesical peritoneum.

The age of endometriosis

Active endometriosis usually occurs between ages 25 and 35, especially in women who postpone childbearing. Severe symptoms of endometriosis may occur abruptly or develop slowly over many years.
Generally, endometriosis becomes progressively more severe during the menstrual years, and then subsides after menopause. Infertility is the primary complication, although spontaneous abortion may also occur.

Going through stages

A scoring and staging system created by the American Fertility Society quantifies endometrial implants according to size, character, and location.
• Stage I is minimal disease.
• Stage II signifies mild disease.
• Stage III indicates moderate disease.
• Stage IV indicates severe disease.

What causes it
The direct cause is unknown, but having a family member with the disease or having recent surgery that required opening the uterus (such as a cesarean birth) may predispose a woman to endometriosis. Other causes include immune system defects, inflammatory influence, spread through the lymphatic system, or environmental contaminants.

Pathophysiology
Ectopic endometrial tissue responds to estrogen and progesterone with proliferation and secretion. During menstruation, ectopic tissue bleeds and causes inflammation of the surrounding tissues. Inflammation leads to fibrosis, and fibrosis leads to adhesions that produce pain and infertility.

What to look for
Acquired dysmenorrhea is the classic symptom of endometriosis. Pain may be constant. It usually begins 5 to 7 days before menses and lasts for 2 to 3 days.

What a pain

The pain may be in the lower abdomen, vagina, posterior pelvis, and back. It commonly radiates down the legs. Multiple tender nodules occur on uterosacral ligaments or in the rectovaginal system. They enlarge and become more tender during menses. Ovarian enlargement may also be evident on palpation.

Location, location, location

Other signs and symptoms depend on the location of the ectopic tissue:
• appendix and small bowel: nausea and vomiting, which worsen before menses, and abdominal cramps
• bladder: suprapubic pain, dysuria, and hematuria
• cervix, perineum, and vagina: bleeding from endometrial deposits in these areas during menses
• colon and rectovaginal septum: painful bowel movements, rectal bleeding with menses, and pain in the coccyx or sacrum
• cul-de-sac or ovaries: deep-thrust dyspareunia
• ovaries and oviducts: infertility and profuse menses.

What tests tell you
• Laparoscopy may confirm the diagnosis and determine the stage of the disease.
• Barium enema rules out malignant or inflammatory bowel disease.

How it’s treated
Treatment varies according to the stage of the disease, the patient’s age, and her desire to have children. It includes:
• For young women who want to become pregnant: Conservative therapy includes androgens such as danazol, which produce a temporary remission in stages I and II. Progestins and hormonal contraceptives also relieve symptoms.

• With extensive disease (stages III and IV) or for women who don’t want to become pregnant: When ovarian masses are present, they should be removed to rule out cancer. Although this may be accomplished with conservative surgery, the treatment of choice is a total abdominal hysterectomy performed with bilateral salpingo-oophorectomy.

What to do
• Encourage the patient to contact a support group such as the Endometriosis Association for further information and counseling. Remind her to have an annual pelvic examination and Pap test.
• Note whether the patient is free from pain or can at least manage symptoms.
• Check for postoperative complications.
• Explain the possible consequences of delaying surgery if applicable.
• Make sure she understands the importance of frequent gynecologic examinations.

Reproductive system disorders

Reproductive system disorders: Erectile dysfunction

Focus topic: Reproductive system disorders

Erectile dysfunction, also known as impotence, prevents a man from achieving or maintaining penile erection sufficient to complete intercourse. Two types of impotence exist:

Primary impotence means that the patient has never achieved a sufficient erection.

Secondary impotence (more common and less serious) means that the patient has achieved and maintained erections in the past, even though he can’t do so now.
Erectile dysfunction affects men of all ages but is more common and frequent in older men. The prognosis depends on the severity and duration of impotence and on the underlying cause. Transient periods of erectile dysfunction aren’t considered dysfunctional and probably occur in 50% of adult males.

What causes it
Eighty percent of cases are believed to have an organic cause, such as arterial insufficiency or, more commonly, venous outflow dysfunction. Other organic causes include alcohol and drug abuse and medications such as amitriptyline, cimetidine (Tagamet), clonidine (Catapres), desipramine (Norpramin), digoxin (Lanoxin), hydralazine, methyldopa, nortriptyline (Aventyl), propranolol (Inderal), thiazide diuretics, and tranylcypromine (Parnate). Twenty percent of cases are believed to be psychogenic in nature, resulting from sexual performance anxiety, low selfesteem, or past failures in sustaining an erection.

Pathophysiology
Inappropriate adrenergic stimulation can cause a lack of autonomic signal or impairment of perfusion. This may interfere with arteriolar dilation and cause premature collapse of the sacs of the corpus cavernosum.
Psychogenic causes may exacerbate emotional problems in a circular pattern, with anxiety causing fear of erectile dysfunction, which in turn causes further emotional problems.

Anticlimax

In arterial insufficiency, there may be inadequate blood flow to the penis. In venous insufficiency, incompetent valves in the veins may cause the blood to exit the penis too quickly and diminish or prevent erection. In addition, pelvic steal syndrome causes increased blood flow to the pelvic muscles, resulting in loss of erection before ejaculation.

What to look for
Begin by assessing the patient’s entire health history, including his past and current medications, psychosocial history, and use of  alcohol and street drugs. Because the patient’s erectile dysfunction won’t be obvious to you, you’ll need to ask him questions to learn more about it. If he has secondary erectile dysfunction, base your questions on these categories:

partial: patient can’t achieve a full erection

intermittent: patient can sometimes maintain erection with the same partner

selective: patient can maintain erection only with certain partners.

Sorry, but I have to ask

Also ask the patient if he lost erectile function suddenly or gradually. Ask if he ever has an erection upon awakening in the morning. If the cause of his erectile dysfunction is psychogenic, ask if he can still achieve erection through masturbation. Ask how he feels before trying to have intercourse — is he anxious, with sweating and palpitations? Is he totally disinterested in sexual activity? Also ask the patient if he’s depressed. Depression can cause psychogenic impotence and result from both psychogenic and organic impotence.

What tests tell you
Diagnosis can generally be made from the patient’s history and physical examination. The following tests can aid in diagnosis:
• Blood tests may help identify underlying causes, such as vascular disease, diabetes, or low testosterone levels.
• Ultrasound imaging and Doppler studies can help identify penile blood flow patterns and problems.

How it’s treated
Treatment includes these measures:
• Sex therapy, largely directed at reducing performance anxiety, may cure psychogenic impotence. Such therapy should include both partners.
• If erectile dysfunction is caused by drug or alcohol abuse, treatment of those specific problems may be the solution.
• Treatment of organic impotence focuses on reversing the cause if possible. If not, psychological counseling may help the couple deal realistically with their situation and explore alternatives for sexual expression.
• Certain patients suffering from organic impotence may benefit from surgically inserted penile implants; those with low testosterone levels, from testosterone replacement therapy.
• Oral erectile dysfunction drugs, such as vardenafil (Levitra), sildenafil (Viagra), and tadalafil (Cialis), help increase blood flow to the penis when it is stimulated, resulting in a harder erection. Other drugs that cause erection, such as alprostadil (Edex), can be injected into the penis or given by penile suppository.
• Vacuum constriction devices can temporarily produce an erection by creating a vacuum that pulls blood into the penis.

What to do
• Help the patient feel comfortable about discussing his sexuality. Assess his sexual health during your initial nursing history. When appropriate, refer him for further evaluation or treatment.
• Help prevent erectile dysfunction by providing information about resuming sexual activity as part of your discharge instructions for any patient with a condition that requires modification of daily activities. Such patients include those with cardiac disease, diabetes, hypertension, or chronic obstructive pulmonary disease, and all postoperative patients.

• Evaluate the patient. He should report achieving and maintaining an erection and express satisfaction with his sexual relationships.

Reproductive system disorders

Reproductive system disorders: PID

Focus topic: Reproductive system disorders

PID refers to any acute, subacute, recurrent, or chronic infection of the oviducts and ovaries, with adjacent tissue involvement. It includes inflammation of the cervix (cervicitis), uterus (endometritis), fallopian tubes (salpingitis), and ovaries (oophoritis), which can extend to the connective tissue lying between the broad ligaments (parametritis).

No time to waste!

Early diagnosis and treatment prevent damage to the reproductive system. Complications of PID include infertility and potentially fatal septicemia, pulmonary emboli, and shock. Untreated PID may be fatal.

What causes it
PID can result from infection with aerobic or anaerobic organisms. About 60% of cases result from overgrowth of one or more of the common bacterial species found in cervical mucus, including staphylococci, streptococci, diphtheroids, chlamydiae, and coliforms such as Pseudomonas and Escherichia coli.
PID also results from infection with Neisseria gonorrhoeae. Finally, multiplication of typically nonpathogenic bacteria in an altered endometrial environment can cause PID. This occurs most commonly during parturition.

PID promoters

These factors increase the patient’s chances of developing PID:
• history of STD or bacterial vaginosis
• more than one sexual partner
• conditions, such as uterine infection, or procedures, such as conization or cauterization of the cervix, that alter or destroy cervical mucus, allowing bacteria to ascend into the uterine cavity
• any procedure that risks transfer of contaminated cervical mucus into the endometrial cavity by instrumentation, such as use of a biopsy curet or an irrigation catheter, tubal insufflation, abortion, or pelvic surgery
• infection during or after pregnancy
• an infectious focus within the body, such as drainage from a chronically infected fallopian tube, a pelvic abscess, a ruptured appendix, or diverticulitis of the sigmoid colon.

Reproductive system disorders

Pathophysiology
Various conditions, procedures, or instruments can alter or destroy the cervical mucus, which usually serves as a protective barrier. As a result, bacteria enter the uterine cavity, causing inflammation of various structures.

What to look for
Signs and symptoms vary with the affected area and include:
• profuse, purulent vaginal discharge
• low-grade fever and malaise (especially if N. gonorrhoeae is the cause)
• lower abdominal pain
• extreme pain on movement of the cervix or palpation of the adnexa.

What tests tell you
• Gram stain of secretions from the endocervix or cul-de-sac to help identify the infecting organism.
• Culture and sensitivity testing to aid selection of the appropriate antibiotic. Urethral and rectal secretions may also be cultured.
• Ultrasonography to identify an adnexal or uterine mass.
• Culdocentesis to obtain peritoneal fluid or pus for culture and sensitivity testing.

How it’s treated
Effective management eradicates the infection, relieves symptoms, and leaves the reproductive system intact. It includes:
• Aggressive therapy with multiple antibiotics beginning immediately after culture specimens are obtained. Therapy can be re evaluated as soon as laboratory results are available (usually after 24 to 48 hours). Infection may become chronic if treated inadequately.
• For PID resulting from gonorrhea: I.V. doxycycline (Vibramycin) and I.V. cefoxitin, followed by doxycycline by mouth (P.O.). Outpatient therapy may consist of I.M. cefoxitin, amoxicillin P.O., or ampicillin P.O. (each with probenecid), followed by doxycycline P.O. A patient with gonorrhea may also require therapy for syphilis.
• Supplemental treatment, including bed rest, analgesics, and I.V. therapy.
• Adequate drainage if a pelvic abscess develops.
• For a ruptured pelvic abscess (a life-threatening complication): Possible total abdominal hysterectomy with bilateral salpingooophorectomy.
• Nonsteroidal anti-inflammatory drugs for pain relief (preferred treatment); opioids if necessary.

What to do
• After establishing that the patient has no drug allergies, administer antibiotics and analgesics as ordered.
• Check for elevated temperature.
• Watch for abdominal rigidity and distention, possible signs of developing peritonitis.
• Provide frequent perineal care if vaginal drainage occurs.
• Evaluate the patient. She shouldn’t have pain, discharge, fever, or recurring infection. However, many patients experience occasional pain, and up to 25% may become infertile after one episode of PID.

Reproductive system disorders

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