NURSING PROCESS: THE PATIENT WITH A SEXUALLY TRANSMITTED DISEASE
The patient should be asked to describe the onset and progres-sion of symptoms and to characterize any lesions by location and by describing drainage, if present. Protecting confidential-ity is important when discussing sexual issues. When a detailed sexual history is necessary, it is important to respect the patient’s right to privacy. Brief explanations of why the information is asked are often helpful. Clarification of terms may be necessary if the patient or nurse uses words unfamiliar to the other. Ask-ing specific information about sexual contacts usually should be done only when the nurse is part of a team that will contact the partners for follow-up. In the history-taking process, discussion about the patient’s understanding of responsibility to inform sexual partners may be helpful in determining patient teaching goals.
During physical examination, the examiner looks for rashes, lesions, drainage, discharge, or swelling. Inguinal nodes are pal-pated to elicit tenderness and to assess swelling. Women are ex-amined for abdominal or uterine tenderness. The mouth and throat are examined for signs of inflammation or exudate. The nurse wears gloves while examining the mucous membranes, and gloves are changed and replaced after vaginal or rectal examination.
Based on assessment data, the patient’s major nursing diagnoses may include the following:
· Deficient knowledge about the disease and risk for spread of infection and reinfection
· Anxiety related to anticipated stigmatization and to prog-nosis and complications
· Noncompliance with treatment
Based on assessment data, potential complications that may de-velop include the following:
· Increased risk for ectopic pregnancy
· Transmission of infection to fetus resulting in congenital abnormalities and other outcomes
· Gonococcal meningitis
· Gonococcal arthritis
· Syphilitic aortitis
· HIV-related complications
Major goals are increased patient understanding of the natural history and treatment of the infection, reduction in fear, increased compliance with therapeutic and preventive goals, and absence of complications.
Education about and prevention of the spread of STDs to others is often accomplished simultaneously. Discussion about risk fac-tors should emphasize that the same behaviors that led to infection with one STD may introduce risk for any other STD, including HIV. Methods used to contact sexual partners should be dis-cussed. The patient should understand that, until the partner has been treated, continued sexual exposure to the same person may lead to reinfection. Patients may need help in planning discussion with partners. If the patient is especially apprehensive about this aspect, referral to a social worker or other specialist may be ap-propriate. Such support is especially important when the patient has newly diagnosed HIV infection.
The relative value of condoms in reducing the risk for infection with STDs should be addressed. When appropriate, the patient should be encouraged to discuss any reasons for resistance to con-dom use, so that decision making about this preventive method can be facilitated.
The infected patient should be told what the causative organ-ism is and should receive an explanation of the usual course of the infection (including interval of potential communicability to others) and possible complications. The nurse should stress the importance of following therapy as prescribed and the need to report any therapeutic side effects or symptom progression.
When appropriate, the patient is encouraged to discuss anxieties and fear associated with the diagnosis, therapy, or prognosis. By individualizing teaching efforts, factual information applied to specific needs may offer reassurance. For example, patients with HIV should be encouraged to participate in well-coordinated programs in which support, education, counseling, and thera-peutic goals are combined. Such programs are designed to offer coordinated care throughout the course of disease progression.
In group settings (eg, offered in an outpatient obstetric setting) or in a one-on-one setting, open discussion about STD informa-tion facilitates patient teaching. Discomfort can be reduced by factual explanation of causes, consequences, treatments, preven-tion, and responsibilities. Because most communities have ex-panded STD prevention resources, referrals to appropriate agencies can complement individual educational efforts and ensure that later questions or uncertainties can be addressed by experts. Patients can obtain more information by using the CDC website (http:// w ww.cdc.gov/) or by using the voice mail number (1-888-CDC FACT).
STDs may lead to PID and, with it, increased risk for ectopic pregnancy and infertility.
All STDs can be transmitted to infants in utero or at the time of birth. Complications of congenital infection can range from lo-calized infection (eg, throat infection with N. gonorrhoeae) to con-genital abnormalities (eg, stunting of growth or deafness from congenital syphilis), to life-threatening disease (eg, congenital herpes simplex virus).
STDs can cause disseminated infection. The central nervous sys-tem may be infected, as seen in cases of neurosyphilis or gono-coccal meningitis. Gonorrhea that infects the skeletal system may result in gonococcal arthritis. Syphilis can infect the cardiovascular system by forming vegetative lesions on the mitral or aortic valves.
HIV, which is primarily spread as an STD, leads to the profound immunosuppression of AIDS. Complications of HIV infection include many opportunistic infections, including Pneumocystiscarinii, Cryptococcus neoformans, cytomegalovirus, and Myco-bacterium avium.
Expected patient outcomes may include the following:
1) Acquires knowledge and understanding of STDs
2) Demonstrates a less anxious demeanor
a) Discusses anxieties and goals for treatment
b) Inspects self for lesions, rashes, and discharge
c) Accepts support education, and counseling when in-dicated
d) Assists with sharing information about infection to sexual partners
e) Discusses risk-reduction behaviors and safer sex prac-tices
3) Complies with treatment
a) Achieves effective treatment
b) Reports for follow-up examination if necessary
4) Absence of complications
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