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NURSING PROCESS: THE PATIENT WITH A VULVOVAGINAL INFECTION
The woman with vulvovaginal symptoms should be examined as soon as possible after the onset of symptoms. She is instructed not to douche because doing so removes the vaginal discharge needed to make the diagnosis. The area is observed for erythema, edema, excoriation, and discharge. Each of the infection-producing or-ganisms produces its own characteristic discharge and effect (see Table 47-1). The patient is asked to describe any discharge and other symptoms, such as odor, itching, or burning. Dysuria often occurs as a result of local irritation of the urinary meatus. A uri-nary tract infection may need to be ruled out by obtaining a urine specimen for culture and sensitivity testing.
The patient is asked about the occurrence of factors that may contribute to vulvovaginal infection:
· Physical and chemical factors, such as constant moisture from tight or synthetic clothing, perfumes and powders, soaps, bubble bath, poor hygiene, and use of feminine hy-giene products
· Psychogenic factors (eg, stress, fear of STDs, abuse)
· Medical conditions or endocrine factors, such as a predis-position to vulvar involvement in a patient who has diabetes or is elderly
· Use of medications such as antibiotics, which may alter the vaginal flora and allow an overgrowth of monilial organisms
· New sex partner, multiple sex partners, previous vaginal infection
The patient is also asked about other factors that could con-tribute to infection, including hygiene practices (tampons, douching), use or nonuse of condoms, and use of chemicals such as nonoxynol-9 with barrier methods of birth control.
The nurse may prepare a vaginal smear (wet mount) to assist in diagnosing the infection. A common method for preparing the smear is to collect vaginal secretions with an applicator and place the secretions on two separate glass slides. A drop of saline solu-tion is added to one slide and a drop of 10% potassium hydrox-ide is added to another slide for examination under a microscope. If bacterial vaginosis is present, the slide with normal saline solu-tion added shows epithelial cells dotted with bacteria (clue cells). If Trichomonas species is present, small motile cells are seen. In the presence of yeast, the potassium hydroxide slide reveals typi-cal characteristics. Discharge associated with bacterial vaginosis produces a strong odor when mixed with potassium hydroxide. This is called a positive “whiff test.” Testing the pH of the dis-charge with Nitrazine paper assists in proper diagnosis.
Based on the nursing assessment and other data, the patient’s major nursing diagnoses may include the following:
· Discomfort related to burning, odor, or itching from the in-fectious process
· Anxiety related to stressful symptoms
· Risk for infection or spread of infection
· Deficient knowledge about proper hygiene and preventive measures
The major goals for the patient may include relief of discomfort, reduction of anxiety related to stress symptoms, prevention of re-infection or infection of sexual partner, and acquisition of knowl-edge about methods for preventing vulvovaginal infections and managing self-care.
Treatment with the appropriate medication usually relieves dis-comfort. Sitz baths are occasionally recommended. Use of corn-starch powder may relieve discomfort and skin irritation.
Although vulvovaginal infections are upsetting and require treat-ment, they are not life-threatening. The patient who experiences such an infection, however, may be anxious and fearful about the significance of the symptoms and possible causes. Explaining the cause of symptoms may reduce anxiety related to fear of a more serious illness. Discussing ways to help prevent vulvovaginal in-fections may help the patient adopt specific strategies to decrease infection and the related symptoms.
There is a risk of another episode of the same infection or spread of the infection to sexual partners. The patient needs to be in-formed about these risks and the importance of adequate treat-ment of herself and her partner, if indicated. Other strategies to prevent persistence or spread of infection include abstaining from sexual intercourse when infected, treatment of sexual partners, and minimizing irritation of the affected area. When medications such as antibiotic agents are prescribed for any infection, the nurse instructs the patient about the usual precautions related to using these agents. If vaginal itching occurs, the patient can be re-assured that this is usually not an allergic reaction but may be a yeast or monilial infection resulting from altered vaginal bacteria. Treatment for monilial infection is prescribed.
Another goal of treatment is to reduce tissue irritation caused by scratching or wearing tight clothing. The area needs to be kept clean by daily bathing and adequate hygiene after voiding and defecation. The use of a cool-air hairdryer and application of top-ical corticosteroids may be useful to keep the area dry and mini-mize irritation.
When teaching the patient about medications such as sup-positories and devices such as applicators to dispense cream or ointment, the nurse may demonstrate the procedure by using a plastic model of the pelvis and vagina. The nurse should also stress the importance of hand washing before and after each ad-ministration of medication. To prevent the medication from es-caping from the vagina, the patient should recline for 30 minutes after it is inserted, if possible. The patient is informed that seep-age of medication may occur, and the use of a perineal pad may be helpful.
Vulvovaginal conditions are treated on an outpatient basis, unless the patient has other medical problems. Patient teaching, tact, and reassurance are important aspects of nursing care. Women may ex-press embarrassment, guilt, or anger and may be concerned that the infection may be serious (causing infertility) or that it may have been acquired from a sex partner. In some instances, treat-ment plans include the partner.
In addition to reviewing ways of relieving discomfort and pre-venting reinfection, the nurse assesses each patient’s learning needs relative to the immediate problem. The patient needs to know the characteristics of normal as opposed to abnormal dis-charge. Questions often arise about douching. Normally, douch-ing and use of feminine hygiene sprays are unnecessary because daily baths or showers and proper hygiene after voiding and defe-cating keep the perineal area clean. Douching tends to eliminate normal flora, reducing the body’s ability to ward off infection. In addition, repeated douching may result in vaginal epithelial breakdown and chemical irritation and has been associated with other pelvic disorders.
Therapeutic douching, however, may be recommended and prescribed to reduce unpleasant, abnormal odors; to remove ex-cessive discharge; to change the pH (eg, vinegar douches); and to serve as an antiseptic irrigating solution. The procedure is re-viewed with the patient, as is the care and cleaning of equipment so that it is properly disinfected.
In the case of recurrent yeast infections, the perineum should be kept as dry as possible. Loose-fitting cotton instead of tight-fitting synthetic, nonabsorbent, heat-retaining underwear is rec-ommended. The patient is instructed to perform a monthly inspection of the vulvar region for changes.
Expected patient outcomes may include:
1) Experiences reduced discomfort
a) Cleans the perineum as instructed
b) Reports that itching is relieved
c) Maintains urine output within normal limits and with-out dysuria
2) Experiences relief of anxiety
3) Remains free from infection
a) Has no signs of inflammation, pruritus, odor, or dysuria
b) Notes that vaginal discharge appears normal (thin, clear, not frothy)
4) Participates in self-care
a) Takes medication as prescribed
b) Wears absorbent underwear
c) Avoids unprotected sexual intercourse
d) Douches only as prescribed
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