NR 602 Final Exam Study Guide / NR602 Final Exam Study Guide(V1)(Latest, 2024): Chamberlai | Study Guides, Projects, Research Nursing | Docsity (2024)

Download NR 602 Final Exam Study Guide / NR602 Final Exam Study Guide(V1)(Latest, 2024): Chamberlai and more Study Guides, Projects, Research Nursing in PDF only on Docsity! 1 NR 602 Final Exam Study Guide Week 8: ACOG guidelines regarding well women exams ACOG Pap smear guidelines Start @ 21, every 3 Age 30+ PAP & HPV repeat every 5 if negative (co-test) or 3 yr no co-test @65 may stop if (-) hx for 10 yrs or hysterectomy w/o hx of cancer Amenorrhea (Primary and Secondary) Primary and Secondary Amenorrhea  Primary amenorrhea : No menarche by the age of 15 years (with or without development of secondary sexual characteristics). Half of cases are caused by chromosomal disorders (50%) such as Turner syndrome.  Puberty is delayed if there is no breast development by age 13 years, absence of pubic hair at age 14 years, and no menarche by age 15 years.  Secondary amenorrhea : No menses for three cycles, or 6 months if previously had menses. Most common cause is ). Secondary Amenorrhea Associated With Exercise and Underweight  Excessive exercise and/or sports participation have a higher incidence of amenorrhea (and infertility) due to relative caloric deficiency  "Female athlete triad"; anorexia nervosa/restrictive eating, amenorrhea, and osteoporosis Labs  Pregnancy test (serum human chorionic gonadotropin [hCG])  Serum prolactin level (rule out prolactinoma-induced amenorrhea)  SerumTSH; also follicle-stimulating hormone (FSH) and luteinizing hormone (LH; rule out premature ovarian failure)  If amenorrhea for more than 6 months, measure bone density Treatment Plan  Educate about increasing caloric intake and decreasing exercise  Prescribe calcium with vitamin D 1,200 to 1,500 mg daily and vitamin E 400 IU daily Complications  Osteopenia/osteoporosis (stress fractures)  Myocardial atrophy, arrhythmia (sudden death), bradycardia, hypotension  Hypoglycemia, dehydration, electrolytes  Lanugo (fine downy hair), telogen effluvium (hair loss), xerosis (dry skin), infertility  Low body mass index (BMI), cachexia, anemia, respiratory failure American Cancer Society recommendations Breast cancer recommendations: Baseline mammogram: Start at age 50 years and repeat every 2 years until the age of 74 years Age 75 years or older: Insufficient evidence for routine mammogram Does not apply to women with known genetic mutations (BRCA1orBRCA2), familial breast cancer, history chest radiation at a young age or previously diagnosed with high-risk breast lesion who may benefit from starting screening in their 40s NOTE: Age 40 to 49 years (individualize based on risk factors, if done). The American Cancer Society recommends starting routine screening at age 40 years. *U.S. Preventive Services Task Force (USPSTF) Recommendation Statement (January 2016). Cervical Cancer Screening Age Group. Recommendations for Pap/Liquid Cytology Age 20 years or younger Do not screen (even if sexually active with multiple partners). Cervical cancer is rare before age 21 years. Age 21 to 65 years Baseline at age 21 years. Screen every 3 years. Age 30 to 65 years Another option starting at age 30 years is to screen with combination of cytology plus human papillomavirus (HPV) testing every 5 years. Had hysterectomy with removal of cervix If hysterectomy with cervical removal was not due to cervical intraepithelial neoplasia (CIN grade 2) or cervical cancer, then can stop screening. 2 Women older than 65 years who had adequate prior screening Do not screen if history of adequate prior screening and is otherwise not at high risk for cervical cancer. Source: USPSTF (2012). Notes* These recommendations do not apply to women who are immunocompromised (i.e., Hiv infection), had in utero exposure to diethylstilbestrol (DES), or have a diagnosis of high-grade precancerous cervical lesion or cervical cancer. *USPSTF Screening Recommendations for Cervical Cancer (July 2015). Ovarian cancer- ACS RECOMMENDATIONS - The typical patient is a middle-aged or older woman with vague symptoms of abdominal bloating and discomfort, low-back pain, pelvic pain, and changes in bowel habits. Look for family history of having two or more first- or second-degree relatives with a history of ovarian cancer or a combination of ovarian cancer, especially women of Ashkenazi Jewish ethnicity with a first-degree relative (or second-degree relatives on the same side of the family) with breast or ovarian cancer (American Cancer Society, U.S. Preventive Services Task Force [USPSTF], 2012). Very-high-risk women with suspectedBRCA 1/BRCA 2mutations should be referred for genetic counseling pre- and posttest. The screening starts at age 30 years (or 5 to 10 years before the earliest age of first diagnosis of ovarian cancer in a family member). Androgen insensitivity/resistance syndrome description/features Inability of body to respond properly to male sex hormone, produced during pregnancy Sx- genetic make up is male but physical traits of woman vagin* but no cervix, inguinal hernia w/ testes, normal female breasts, testes in abd or other place of body ASCUS/HSIL results from Paper Test Report (atypical squamous cell undetermined significance) from CDC--- For non-pregnant women between 25 and 65 years of age with ASCUS cytology who have not had HPV co-testing already, HPV testing is the preferred next step (high-risk HPV testing only). With a negative HPV test (either on co- test or after cytology), repeat co-testing every three years is recommended. Normal Pap and Negative HPV Rescreen in 5 years. Normal Pap and Positive HPV Repeat co-test in one year or do HPV DNA typing now (see ASCCP guidelines above). ASCUS Pap, No HPV Test Repeat cytology in one year or do HPV test now (see ASCCP guidelines above). ASCUS Pap and Negative HPV LSIL Pap and Negative HPV Repeat Pap and co-test at interval as per ASCCP guidelines. ASCUS Pap and Positive HPV LSIL Pap and Positive or Unknown HPV ASC-H Pap HSIL Pap Colposcopy and/or referral to gynecologist. 5 Cervix- firm structure 3-4 cm diameter, projects into vagin*. Multiparous may have lac, irregular shape or nodularity may be r/t nabothian cyst, Firm may be tumor or cancer. Normally mobile can be moved 2-4cm w/o pain-restricted movement could mean inflammation Friable cervix= easily irritated, prone to bleeding esp after intercourse--- suspicious for cervical ca firm and easily friable Uterus- 1/2 size of pt’s fist. Pear shaped thick walled organ between base of bladder and rectum. 2 portions. The body and smaller cervix below. Cimetidine H2 receptor agonist -acid reducer for heartburn and GERD safe in pregnancy, sit up 30 min after Condyloma acuminate (genital warts)- pg 628—lesion that describes= verruciform warts, single soft flesh, papillary kertanized growth. Meds- podofilox Caused by HPV, high risk ages 16-18 Prevention- vaccine Sx -white, papillary growth w/ fingerlike projections containing capillaries, hyperkeratotic lesion Dx- clinical, biopsy Tx- bichloracetic acid, podophyllin in tincture, cryo, electrosurgery, surgical excision,pt can do podofilox soltion gel Condyloma lata Associated w/ secondary syphilis Generalized maculopapular rash on trunk and proximal extremities and spreads to entire body including palms, soles and scalp. Sx- wart-like lesions found in genital area Contraceptives Oral Contraceptives Combined Oral Contraceptives (COCs; 9% Typical Use Failure Rate) Dosed Monophasic Pills LoestrinFE1/20: 21 consecutive days of estrogen/progesterone (same dose daily). For the last 7 days of the cycle, the placebo pills contain iron supplementation (7 days of iron pills). Biphasic Pills Ortho-Novum 10/11: Contains two different progesterone doses (two phases). The progesterone dose increases about halfway through the cycle. Other brands are Mircette, Jenest, etc. Triphasic Pills Ortho Tri-Cyclen: Contains 21 days of active pills and 7 days of placebo pills. The dose of hormones varies weekly for 3 weeks ("triphasic"). Progestin used is norgestimate. Indicated for acne. Other brands are Cyclessa, Tri-Norinyl, Tri-Levlen, Triphasil, etc. Extended-Cycle Pills Seasonale: Contains 84 consecutive days (3 months) of estrogen/progesterone with a 7-day pill-free interval. This method typically results in four periods per year although breakthrough bleeding is not uncommon. Ethinyl Estradiol and Drospirenone Yaz (24 active pills and four placebo pills)/Yasmin: Uses drospirenone (a spironolactone analog) as the progestin component. Consider for women with acne,PCOS, hirsutism, or premenstrual dysphoric disorder (PMDD). Higher risk of deep vein thrombosis (DVT) and hyperkalemia. 6  Labs: Check the potassium level if patient is on an angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or potassium-sparing diuretic. PROGESTIN-ONLY PILLS  Safe for breastfeeding women, and most effective if woman is exclusively breastfeeding. Also known as the "minipill."  It is very important to take the pill at the same time each day. If dose is late (≥3 hours) or a day is missed, the woman should use condoms (backup contraception) or abstain from sexual intercourse for 2 days (Kaunitz, 2017). There is no placebo week with progestin-only pills (Association of Reproductive Health Professionals, 2014).  Micronor: Take one pill daily at about the same time each day (each pack contains 28 pills). Start taking pill on day 1 of menstrual cycle. CONTRAINDICATIONS TO ORAL CONTRACEPTIVE USE Absolute Contraindications  Any condition (past or present) that increases the risk of blood clotting  History of thrombophlebitis or thromboembolic disorders (i.e.,DVT)  Genetic coagulation defects such as factor V Leiden disease  Major surgery with prolonged immobilization  Smoker older than the age of 35, more than 15 cigarettes per day  Also considered a relative contraindication because women younger than 35 years who smoke can take the pill (if no other contraindications exist)  Any condition that increases the risk of strokes  Migraine with aura or focal neurological symptoms or migraine without aura age 35 years or older  History of cerebrovascular accidents (CVAs) and transient ischemic attacks (TIAs)  Hypertension (if systolicBP>160 mmHg or diastolicBP>100 mmHg)  Inflammation and/or acute infections of the liver with elevatedLFTs  In acute infection or inflammation of the liver (i.e., mononucleosis) with elevatedLFTs, estrogen is contraindicated  WhenLFTsare back to normal, can go back on birth control pills  Hepatocellular adenomas or malignant (hepatoma)  Cholestatic jaundice of pregnancy  Known or suspected cardiovascular disease  Moderately to severely impaired cardiac function, complicated valvular heart disease  Coronary artery disease (CAD)  Diabetes with vascular component  Systemic lupus erythematosus  Hypertension ifSBPis ≥160 orDBP(diastolic blood pressure) 100 mmHg  Some reproductive system conditions or cancers  Known or suspected pregnancy  Undiagnosed genital bleeding or breast mass  Breast, endometrial, or ovarian cancer (or any estrogen-dependent cancer) less than 21 days postpartum Absolute Contraindications Mnemonic: "MyCUPLETS" MyMigraines with focal neurological aura C CADorCVA U Undiagnosed genital bleeding P Pregnant or suspect pregnancy L Liver tumor or active liver disease E Estrogen-dependent tumor T Thrombus or emboli S Smoker age 35 or older Relative Contraindications  Migraine headaches  Migraine older than age 35 years  Migraines with focal neurological findings are an absolute contraindication due to increased risk of stroke 7  Smoker younger than age 35 years  Fracture or cast on lower extremities  Adequately controlled hypertension ADVANTAGES OF THE PILL ( AFTER 5 OR MORE YEARS OF USE)  Ovarian cancer and endometrial cancers (decreased by 40%-50%)  Decreased incidence of:  Dysmenorrhea and cramps (decrease in prostaglandins)  Decreases symptoms of endometriosis (less pelvic pain)  Acne and hirsutism (lower levels of androgenic hormones)  Ovarian cysts (due to suppression of ovulation)  Heavy and/or irregular periods (due to suppression of ovaries) CONSIDERATIONS WHEN CHOOSING AN ORAL CONTRACEPTIVE PILL  Typical use failure rate is 9%.  Traditional oral contraceptive pills have 21 days of "active" pills and 7 days of placebo pills. The last 7 days are the "hormone-free" days. The menstrual period usually starts within 2 to 3 days after the last active pill was taken (from very low levels of estrogen/progesterone).  Some brands of birth control pills (e.g., LoestrinFE) contain iron in the pills taken during the last 7 days of the pill cycle (instead of a placebo pill). The last 7 days (hormone-free) of the pill cycle are there to reinforce the habit of daily pill-taking.  For thefirstpill cycle, advise patient to use "backup" (an alternative form of birth control).  All theCOCs, the patch, and the NuvaRing contain both estrogen (e.g., ethinyl estradiol) and progesterone (e.g., levonorgestrel, norethindrone, desogestrel, others).  The contraceptive patch (e.g., Ortho Evra) results in higher levels of estrogen exposure compared toCOCs(higher risk of blood clots,DVT).  The estrogen inCOCscan elevate blood pressure. Patients'BPshould be checked within 4 to 8 weeks.  Breastfeeding women can use the progestin-only pill ("minipill"; e.g., Micronor,Nor-QD) Other Contraceptive Methods Intrauterine Device (0.2%-0.8% Typical Use Failure Rate) The intrauterine device (IUD) is the second most commonly used method of contraception in the world (female sterilization is the first). Paragard is copper-bearing (effective up to 10 years) and Mirena contains the hormone levonorgestrel, which decreases vagin*l bleeding. MirenaIUDis effective for up to 5 years and is slightly more effective than copper-bearingIUDs(Cu-IUDs). Typical failure rate ofCu-IUDis 0.5% to 0.8%. Contraindications ActivePIDor history ofPIDwithin the past year Suspected or confirmed pregnancy or hasSTD Uterine or cervical abnormality (e.g., bicornate uterus) Undiagnosed vagin*l bleeding or uterine/cervical cancer History of ectopic pregnancy Increased Risk Endometrial and pelvic infections (first few months after insertion only) Perforation of the uterus Heavy or prolonged menstrual periods Education Educate patient to check for missing or shortened string periodically, especially after each menstrual period. If the patient or clinician does not feel the string, order a pelvic ultrasound. DEPO-PROVERA Each dose by injection lasts 3 months. Also known as depot medroxyprogesterone acetate (DMPA). Highly effective. Check for pregnancy before starting dose. Start within first 5 days of cycle (day 1-5) because females are less likely to ovulate at these times. Women on Depo-Provera for at least 1 year (or longer) have amenorrhea because of severe uterine atrophy from lack of estrogen.  Do not recommend to women who want to become pregnant in 12 months. Causes delayed return of fertility. It takes up to 1 year for most women to start ovulating.  Black Box Warning:Avoid long-term use (more than 2 years). Increases risk of osteopenia/osteoporosis that may not be fully reversible. Using Depo-Provera for more than 2 years is discouraged. History of Anorexia Nervosa 10 stop itch scratch cycle and minimize inflamm. General hygiene avoid tight undies, cleanse daily w/ soap and dry. Oral antihistamine @ HS, clobetasole (Dermovate) potent topical steroid twice daily x2 wks then once daily x2 wks, taper down ****Can progress to vulvar carcinoma Lichen simplex chronicus -chronic eczematous disease characterized by intense and unrelenting itching and scratching Sx- benign epithelial thickening and hyperkeratosis from chronic irritation EX- perfume pads, chronic vulvovagin*l infect. Itching leads to rubbing and scratching Tx- vulvar hygiene, sitz bath, lubricants, oral antihistamine for itching, medium potency steroids. Should resolve in 4-6 wks to heal Mammogram- Breast US & mammo reason -screening method for breast ca. Cancer may be id 2 yr b4 size detected via palpation. US- not recommended for screening in general population. IS AN ADJUNCT TO ABNORMAL MAMMO. May be added to high-risk woman. Can help decrease false-neg rate of mammo and eval mammographically occult palpable breast mass  Mammography is the breast imaging modality of choice and the only screening method that has been consistently found to decrease mortality of breast cancer.Some breast cancers can be identified by mammography as early as 2 years before reaching a size detectable by palpation. magnetic resonance imaging (MRI) are not recommended for screening the general population, and their primary role is as adjuncts to an abnormal mammogram. The use of a targeted ultrasound can help decrease the false-negative rate of mammograms and evaluate the mammographically occult palpable breast mass. Metronidazole- inhibits DNA synthesis and rapidly bactericidal Drug of choice for: Gardenerella vagin*lis, trich, BV Adverse effects- do not take w/ ETOH (antabuse like effects) HA, N/V; metallic unpleasant taste, prolonged use can cause peripheral neuropathy Molluscum contagiosum -viral skin infection, benign epithelial poxvirus-induced tumor Sx- round firm painless bumps that size from pinhead to eraser, have small indentation (umbilication), itchy, may be seen on genitals, lower abd and iner thighs if was spread sexually Transmit- direct person-to-person contact, sexual contact w/ affected Prevent- wash hands, avoid touching bumps, avoid sexual contact, cover bumps Tx- self limited, can be treated with desiccation, freezing, chemical caut Nabothian glands- -mucus filled cyst on surface of cervix. Develop when tunnel of columnar endocervical epithelium is covered by squamous metaplasia. Small white raised bump Tx- no tx necessary PCOS Hormonal abnormality marked by anovulation, infertility, excessive androgen production, and insulin resistance. These females are at higher risk for type 2 diabetes, dyslipidemia, metabolic syndrome, endometrial hyperplasia, obesity, and obstructive sleep apnea. Classic Case Obese teen or young adult complains of excessive facial and body hair (hirsutism 70%), bad acne, and amenorrhea or infrequent periods (oligomenorrhea). Dark thick hair (terminal hair) is seen on the face, cheek, and beard areas. Treatment Plan 11  Transvagin*l ultrasound: Enlarged ovaries seen with multiple small follicles (sizes vary).  Serum testosterone, dehydroepiandrosterone (DHEA), and androstenedione are elevated.FSHlevels are normal or low.  Fasting blood glucose and 2-hour oral glucose tolerance test (OGTT) are abnormal. Medications  Use low-dose oral contraceptives to suppress ovaries.  Spironolactone is used to decrease and control hirsutism.  If patient does not want oral contraceptives, give medroxyprogesterone tablets (Provera) 5 to 10 mg daily for 10 to 14 days (repeat every 1-2 months to induce menses).  Metformin (Glucophage) is used to induce ovulation (if desires pregnancy). Warn reproductive-age diabetic females (who do not want to become pregnant) to use birth control.  Weight loss reduces androgen and insulin levels. Complications PCOS patients are at increased risk for:  Coronary heart disease (CHD)  Type 2 diabetes mellitus and metabolic syndrome  Cancer of the breast and endometrium  Central obesity  Infertility PID -inflamm of upper femal genital tract w/ combo of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. o Prevention- screening and tx sexually active women and sex partners for gonorrhea and chlamydia o Sx- insidious or acute lower abd/pelvic pain usually bilateral. Pelvic pressure/back pain ass w/ purulent vag d/c. N, HA, fever is NOT necessary. Abd tenderness, may be distended bowel sounds hypo or absent. Bimanual= extreme tenderness or cervix o ****CDC says empiric tx should be initiated in sex active young women and those @ risk for STD and if 1 or more of following criteria- cervix motion tenderness, uterine tenderness, and adnexal tenderness. o DX-+endocervical swabs…but all may be normal. o Tx- empirically with presumptive dx. Rocephin 250 IM +doxycycline 100 mg BID x14 + metronidazole 500 mg BID x14  Often diagnosed clinically based on the presence of cervical motion tenderness or uterine or adnexal tenderness  Sexually transmitted organisms, particularly N gonorrhoeae and C trachomatis, are implicated in many cases. However, microorganisms that comprise the vagin*l flora (eg, anaerobes, G vagin*lis, Haemophilus influenzae, enteric gram-negative rods, and Streptococcus agalactiae) are also associated with PID, which is often polymicrobial Pyelonephritis -bacteria in urine culture/ bacterial infection of kidney Sx- fever, shaking, chills, CVA tenderness N/V, HA, increased urinary frequency, and dysuria. –pyuria on UA w/ WBC casts….absence of pyuria should raise suspicion for other dx. Dx - UA w/ culture Tx- (outpt) Bactrim 14-21 days, antipyretics for fever Rectocele- Rectocele(posterior)- -When thin tissue of vagin* separates the vagin*l and rectum allowing vagin*l wall to bulge Sx- soft bulge of tissue in vagin*l, difficult BM, sensation of rectal pressure, incomplete emptying after BM, sexual concerns Causes- 12 constipation/strain, chronic cough, heavy lifting, overweight, childbirth, age Prevention- kegels, prevent constipation, avoid heavy lifting, cough, avoid wt gain Skene’s glands - (same as female prostate) -Part of female reproductive tract Large paraurethral gland that opens beside the external urethral orifice in the vestibule. STDs Risk factors  Younger ages (females aged 15-24 years); sex initiated at a younger age  Multiple sexual partners, new sexual partner in past 60 days  Inconsistent condom use, unmarried status  History of previousSTDinfection, illicit drug use  Genital ulceration (increases risk ofHivtransmission)  Use of alcohol or illicit drugs  Adolescents  Herpes Simplex pg 701 -chronic viral infection caused by HSV1 or HSV2, relapsing Prevention: consistent condom use b/c viral shedding can occur in asymptomatic periods and can lead to transmission. W/ symptoms- Valacyclovir 500 mg daily Sx-multiple painful vesicular or ulcerative lesion on genitals, can be absent. Virus lays dormant and can be reactivated Dx-cell culture and PCR Tx- systemic antiviral. Acyclovir 7-10 days for 1st episode, suppressive 200 mg daily BID  Chancroid pg 704 -Transmitted via sexual contact or on hands that have touched lesion. Caused by Haemophillus ducreyi -Reportable disease -Sx- erythematous papule that evolves into pustule and degenerates into saucer shaped ragged ulcer that is circ*mscribed by inflammatory wheal. Tender, heavy foul discharge that is contagious Dx-culture that grows H ducreyi Tx- Abx azithromycin 1 g PO one time, ceftriaxone 250 mg IM 1 x, cipro 500 mg PO BID x3 days erythromycin 500 mg PO TID x7 days. Personal hygiene, clean w/ soap and water, sitz bath  Syphilis pg 707 -chronic, systemic disease caused by a sphirochete transmitted via contact with infectious moist lesion. Sexually acquired or vertically transmitted from infected mom. Reportable disease -Transmitted in primary and secondary stages Primary-mucus mem 10-90 days later. Secondary- 2 wks-6mo after primary lesion then generalized cutaneous eruption of secondary may appear. Latent- may last a lifetime  Prevention- condom, wash w/ soap and water after sex, screen ppl @ high risk (men that have sex with men, drug trafficers, correctional facilities) Sx- [Primary]- Chancre- indurated firm painless papule or ulcer w/ raised borders, women can have cervical or vagin*l lesion….on any mucus mem. [Secondary}-viral syndrome w/ diffuse lymphadenopathy AEB dermatitis, papulosquamous lesion on palms and soles. Lesions on trunk will be macular or maculopapular popular or pustular other systemic include patchy alopecia, hepatitis, nephritis. [Latent]- resolution of lesion of primary and secondary or finding of serologic test w/o therapy Dx- T pallidum sphirochetes on dark field exam of cutaneous lesion, serologic testsing antibody titers Tx- PCN G parenterally  Chlamydia trachomatis pg 714 - negative whiff w/ mucupurulent d/c and + clue cells. Gold standard test is NAT, not culture Most common reported disease w/ highest prev in ppl < 25. Reportable Prevention: annual screening <25 and older women w/ risk factors. Refer + for sex partners STI, can be silent and undiagnosed infection, can ascend into endometrium and fallopian tubes causing salpingitis and pelvic peritonitis, and infect fetus via birth canal