The nurse who is obtaining information from the patient for the health history and performing physical assessment is in an ideal po-sition to discuss the woman’s general health issues, health promo-tion, and health-related concerns. Topics that are relevant would include fitness, nutrition, cardiovascular risks, health screening, sex-uality, abuse, health risk behaviors, and immunizations. Recom-mendations for health screening are summarized in Chart 46-1.
HEALTH HISTORY AND CLINICAL MANIFESTATIONS
In addition to obtaining a general health history, the nurse asks about past illnesses and experiences that are specific to women’s health. Data should be collected about the following:
• Menstrual history (including menarche, length of cycles, length and amount of flow, presence of cramps or pain, bleeding between periods or after intercourse, bleeding after menopause)
• History of pregnancies (number of pregnancies, outcomes of pregnancies)
• History of exposure to medications (diethylstilbestrol [DES], immunosuppressive agents, others)
• Pain with menses (dysmenorrhea), pain with intercourse (dyspareunia), pelvic pain
• History of vaginal discharge and odor or itching
• History of problems with urinary function (ie, frequency or urgency); may be related to STDs or pregnancy
• History of problems with bowel or bladder control
• Sexual history
• History of sexual abuse or physical abuse
• History of surgery or other procedures on reproductive tract structures (including female genital mutilation or female circumcision)
• History of chronic illness or disability that may affect health status, reproductive health, need for health screening, oraccess to health care
• History of genetic disorder
In collecting data related to reproductive health, the nurse is in a unique position to teach patients about normal physiologic processes, such as menstruation and menopause, and to assess possible abnormalities. Many problems experienced by young or middle-aged women can be corrected easily. If allowed to go un-treated, however, they may result in anxiety and health problems. Issues related to sexuality and sexual function are typically brought more often to the attention of the gynecologic or women’s health care provider than other health care providers; any nurse, how-ever, should consider these issues to be part of routine health assessment.
A sexual assessment includes both subjective and objective data. Health and sexual histories, physical examination findings, and laboratory results are all part of the database. The purpose of a sexual history is to obtain information that provides a picture of the woman’s sexuality and sexual practices and promotes sexual health. The sexual history may enable the patient to discuss sex-ual matters openly and to discuss sexual concerns with an in-formed health professional. This information can be obtained with the health history after the gynecologic-obstetric or geni-tourinary history is completed. By incorporating the sexual his-tory into the general health history, the nurse can move from areas of lesser sensitivity to areas of greater sensitivity after estab-lishing initial rapport.
Taking the sexual history becomes a dynamic process reflecting an exchange of information between the patient and the nurse and provides the opportunity to clarify myths and explore areas of con-cern that the patient may not have felt comfortable discussing in the past. In obtaining a sexual history, the nurse must not assume the patient’s sexual preference until clarified. When asking about sex-ual health, the nurse also cannot assume that the patient is married or unmarried. Asking a woman to label herself as single, married, widowed, or divorced may be seen as an inappropriate inquiry by the patient. Asking about a partner or about current meaningful re-lationships may be a less offensive way to initiate a sexual history.
The PLISSIT (Permission, Limited Information, Specific Suggestions, Intensive Therapy) model of sexual assessment and intervention may be used to provide a framework for nursing in-terventions (Annon, 1976). The assessment begins by introduc-ing the topic and asking the woman for permission to discuss issues of sexual functioning with her.
The nurse can begin by explaining the purpose of obtaining a sexual history (eg, “I ask all my patients about their sexual health. May I ask you some questions about this?”). History taking con-tinues by inquiring about present sexual activity and sexual ori-entation (eg, “Are you currently having sex with a man, a woman, or both?”). Inquiries about possible sexual dysfunction may in-clude, “Are you having any problems related to your current sex-ual activity?” Such problems may be related to medication, life changes, disability, or the onset of physical or emotional illness. Patients can be asked about their thoughts on what is causing the current problem.
Limited information about sexual function may be provided to the patient. As the discussion progresses, the nurse may offer specific suggestions for interventions. For some women, a pro-fessional who specializes in sex therapy may provide more inten-sive therapy as needed. By initiating an assessment about sexual concerns, the nurse communicates to the patient that issues about changes in sexual functioning are valid health topics for discus-sion and provides a safe environment for discussing these sensi-tive topics.
Risk for STDs can be assessed by asking about number of part-ners in the past year or in the patient’s lifetime. An open-ended question related to the patient’s need for further information should be included (eg, “Do you have any questions or concerns about your sexual health?”). Nurses should be aware that some women and men are using the Internet to seek partners; obtain-ing sexual partners this way has been associated with an increased risk for STDs (McFarlane, Bull & Rietmeijer, 2000; U.S. Depart-ment of Health and Human Services, 2001).
Young women may be apprehensive about irregular periods, may be concerned about STDs, or may need contraception. They may want information on using tampons, emergency contracep-tion, or issues related to pregnancy. Perimenopausal women may have concerns about irregular menses; menopausal women may be concerned about vaginal dryness and burning with inter-course. Women of any age may have concerns about sexual satis-faction, orgasm or anorgasmia (lack of orgasm).
Female genital mutilation (FGM) refers to the partial or total re-moval of the external female genitalia or other injury to female or-gans. Individuals from some cultures believe that FGM promotes hygiene, protects virginity and family honor, prevents promiscu-ity, improves female attractiveness and male sexual pleasure, and enhances fertility. It is viewed in some cultures as a rite of passage to womanhood. Many organizations (eg, World Health Organi-zation, Amnesty International) are working to end this practice.
Four types of FGM are known: excision of the clitoral pre-puce; total excision of the clitoral prepuce and glans with partial or total excision of the labia minora; excision of part or all of the external genitalia and stitching or narrowing of the vaginal open-ing (referred to as infibulation); and unclassified, which includes pricking, piercing, or incision of the clitoris, the labia, or both, stretching of the clitoris or surrounding tissues, and introduction of corrosive substances into the vagina (American College of Ob-stetricians and Gynecologists [ACOG] Committee Opinion #151, 1995). FGM is usually performed between 4 and 10 years of age; hemorrhage and infection may be consequences.
A growing number of women entering the U.S. health care system underwent FGM before coming to this country (Ng, 2000). Others have undergone FGM since they arrived in the United States. Because FGM can affect sexual function, men-strual hygiene, and bladder function, the possibility of FGM is included in the sexual history, particularly for women from cul-tures and countries where the practice is common.Long-term complications of FGM include urinary problems, chronic vaginitis and pelvic infections, inability to undergo pelvic examination, painful intercourse, impaired sexual response, ane-mia, increased risk for HIV infection due to tearing of scar tissue, and psychological and psychosexual sequelae (American Medical Association, 1995). Nurses who care for patients who have under-gone FGM need to be sensitive, empathetic, knowledgeable, and nonjudgmental.
Domestic violence is a broad term that includes child abuse, elder abuse, and abuse of women and men. Abuse can be emotional, physical, sexual, or economic. Battering involves repeated physical or sexual assault in a context of coercive control and, more broadly, emotional degradation, threats, and intimidation. Nurses need to be aware of the prevalence of abuse and violence directed against women in our society. Abuse is related to the need to maintain con-trol of a partner and involves fear of one partner by another and control by threats, intimidation, and physical abuse. Violence is rarely a one-time occurrence in a relationship; it usually continues and escalates in severity. This is an important point to emphasize when a woman states that her partner has hurt her but has promised to change. Batterers can change their behavior, but not without ex-tensive counseling and motivation. If a woman states that she is being hurt, sensitive care is required (Chart 46-2). Because more than 6 million women experience domestic violence each year, battered women are encountered daily in nursing practice. By knowing about this major public health problem, being alert to abuse-related problems, and learning how to elicit information from women about abuse in their lives, nurses can offer inter-vention for a problem that might otherwise go undetected. Asking each woman about violence in her life in a safe environment (ie, a private room with the door closed) is part of a comprehensive as-sessment and universal screening. The Abuse Assessment Screen has been found effective in identifying the presence of abuse and should be included in the health history of all women (Chart 46-3).
No specific signs or symptoms are diagnostic of battering; however, nurses may see an injury that does not fit the account of how it happened (eg, a bruise on the side of the upper arm after “I walked into a door”). Manifestations of abuse may involve sui-cide attempts, drug and alcohol abuse, frequent emergency department visits, vague pelvic pain, and depression. However, there may be no obvious signs or symptoms.
Women in abusive situations often report that they do not feel well, due to the stress of fear and anticipation of abuse. Nurses need to be knowledge-able about abuse, ask every woman patient about abuse in her life, provide resources, and follow written protocols within their in-stitution to ensure comprehensive care.
Because more than one in five women has experienced incest or childhood sexual abuse, nurses frequently encounter women who have been sexually traumatized. It has been reported that female survivors of sexual abuse have more health problems and undergo more surgery than women who were not victimized. Victims of childhood sexual abuse are reported to experience more chronic de-pression, posttraumatic stress disorder, morbid obesity, marital in-stability, gastrointestinal problems, and headaches, as well as greater use of health care services, than persons who were not vic-tims. Chronic pelvic pain in women is often associated with phys-ical violence, emotional neglect, and sexual abuse in childhood (ACOG Educational Bulletin #259, 2001). Women who have ex-perienced rape or sexual abuse may have difficulty with pelvic ex-aminations, labor, pelvic or breast irradiation, or any treatment or examination that involves hands-on treatment or requires removal of clothing. Nurses should be prepared to offer support and refer-ral to psychologists, community resources, and self-help groups.
Sexual assault occurs every 6 minutes in the United States. Men, women, and children may be victims. Sexual assault nurse exam-iners, emergency department staff, and gynecologists perform the painstaking collection of forensic evidence that is needed for criminal prosecution. Oral, anal, and genital tissue is examined for evidence of trauma, semen, or infection. Saliva, hair, and fin-gernail evidence is also collected. Cultures are obtained for STDs, and prophylactic antibiotics are prescribed. HIV testing is offered and is repeated in 3 to 6 months. HIV prophylaxis is not univer-sally recommended but is considered when mucosal exposure to contamination has occurred. Prophylaxis against chlamydia and gonorrhea are provided (Kaplan, Feinstein, Fisher et al., 2001). Emergency contraception is provided if requested. Emotional counseling is provided, and follow-up treatment visits are arranged. Rape trauma syndrome is the emotional reaction to a sexual as-sault and may consist of shock, sleep disturbances, nightmares, flashbacks, anxiety, anger, mood swings, and depression. It is im-portant for survivors to discuss the experience and to obtain pro-fessional counseling.
Screening for abuse, rape, and violence should be part of routine assessment because women often do not report or seek treatmentfor assault. Often, the assailant is a partner, husband, or date. Nurses may encounter women with infections or pregnancies re-lated to sexual assault that were never treated.
Studies have shown that women with disabilities receive less primary health care and preventive health screening than other women, often because of access problems and health care providers’ focus on the causes of disability rather than on general health issues of concern to all women. To address these issues, the history should include questions about barriers to health care experienced by dis-abled women and the effect of their disability on their health sta-tus and health care. Other issues to be addressed are identified in Chart 46-4. If the patient has hearing loss, vision loss, or another disability, the nurse may need to obtain the assistance of a signer or interpreter. The nurse assessing a person with a disability may re-quire additional time and the assistance of others to be certain that accurate information is obtained from the patient. Extra time may be needed to conduct the assessment in a sensitive and unhurried manner (Kirschner, Gill, Reis & Welner, 1998; Smeltzer, 2000).
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