Health
Nurses who work with women in reproductive care set- tings must understand what is meant by healthy sexual function before they can begin to recognize and under- stand how a behavior becomes dysfunctional. A newer vision of sexuality in women (Basson, 2002; Katz, 2007) takes into account relationships for women by including emotional intimacy, sexual stimuli, and relationship satis- faction as a model of sexual response. Thus, women’s sex- ual response is far more complex and complicated than the achievement of an orgasm with intercourse. Sexuality for women encompasses much more than the physical dimension of the sex act.
Sexual dysfunction for women is defi ned as any sexual situation that causes distress for the woman herself. If the woman is comfortable with a situation, there is no dys- function. If she is distressed by any physical, emotional, or relationship aspect of her sexuality, she may be experienc- ing a dysfunction (Hicks, 2004). Dysfunction can be manifested in the form of pain, arousal disorder, orgasmic disorder, or desire disorder (American Psychiatric Associ- ation [APA], 2000).
ASSESSMENT
A fi rst step in the sexual and reproductive health assess- ment involves the establishment of a trusting relation- ship where the patient feels safe asking questions and sharing concerns. Discussion of sexual issues can be embarrassing for women. Nurses need to be aware of their own sexual biases and beliefs and educate them- selves about the many aspects of sexuality. When assess- ing women for sexual concerns, it is important not to make assumptions about partner preferences or sexual
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140 unit two The Process of Human Reproduction
activity. Misguided assumptions can bring an abrupt ending to any therapeutic communications. For exam- ple, speaking with a woman about contraceptive choices may halt further dialogue with the patient who is lesbian and has sexual concerns unrelated to a heterosexual rela- tionship (Martinez, 2007).
When working with very young patients, the nurse must avoid communicating personal views that adoles- cent sexual behavior is wrong or shameful. Regardless of involvement in sexual activity, teenagers need a reliable source of education and information. They must fi rst feel accepted before they can ask questions and share concerns about sexuality and sexual behavior.
Assessing women for current or past problems that may interfere with or contraindicate pregnancy or the use of cer- tain types of contraception (products that prevent preg- nancy) is an important nursing role in reproductive health care. For example, women with chronic health problems such as diabetes, stroke, multiple sclerosis, cancer, or pain may be taking medications that are contraindicated with certain contraceptives or are associated with fetal anomalies (Table 6-1). Individualized counseling, guidance, and reli- able information helps empower them to make informed, realistic choices about reproductive planning. Other chronic conditions, including endometriosis and polycystic ovarian disease, may interfere with fertility and create a sense of powerlessness in those who desire pregnancy. Nurses are in a unique position to listen generously to these women, make appropriate referrals, and assist them in resolving their grief and feelings of loss (Katz, 2007; Martinez, 2007).
Women also need to be counseled about the ideal age for childbearing and the implications of delaying preg- nancy too long. Those who have not conceived by the mid- to late 30s may remain childless and burdened with guilt. Outside pressures exerted by cultural infl uences and family expectations often compound the feelings of remorse. Providing all women with current, factual infor- mation about the natural aging process and its infl uence on fertility empowers women of all ages to make informed decisions that best suit their needs.
Obtaining the Sexual History
The sexual history elicits information concerning prior treatment for sexually transmitted infections (STIs), pain with intercourse (dyspareunia), postcoital spotting or bleeding, and frequency of intercourse. Women who have intercourse more frequently and on a regular basis are more likely to become pregnant. The probability for pregnancy with each unprotected intercourse is about 20% (Nelson & Marshall, 2004). An important compo- nent of holistic reproductive care centers on helping women to understand their body’s natural functioning in relation to the menstrual cycle, so that they can problem- solve about the timing of intercourse to achieve preg- nancy, if desired.
The nurse also inquires about the number of past sex- ual partners. This information is useful in developing an estimate of the patient’s risk for STIs and guides the nurse in providing appropriate education about safe sex practices. It is estimated that 4 out of 10 Americans between 18 and 59 years of age have had fi ve or more partners (Haffner & Stayton, 2004). Since the risk of contracting a sexually transmitted infection increases with
each sexual partner, this information is very important for women whose reproductive life plan includes future pregnancy. Sexual health promotion includes providing correct information about the implications of multiple sexual partners; this information empowers women to make knowledgeable, informed choices. Depending on the situation and purpose of the visit, other appropriate components of the patient assessment may include a physical examination and diagnostic testing.
Now Can You— Discuss the nurse’s role in reproductive health care?
1. Explain why nurses who work in a reproductive health care setting must be comfortable with their own sexuality?
2. Develop six questions that will assist with taking a patient’s sexual history?
3. Analyze the nurse’s role in the reproductive health assessment?
NURSING DIAGNOSES FOR PATIENTS SEEKING CONTRACEPTIVE CARE
Depending on the purpose of the visit and analysis of the assessment fi ndings, a number of nursing diagnoses may be appropriate. For women seeking contraception, diag- noses may include decisional confl ict regarding choice of birth control because of a health concern, contraceptive alternatives, or the partner’s willingness to agree on the contraceptive method. Other possible nursing diagnoses are listed in Box 6-1.
PLANNING AND IMPLEMENTATION OF CARE Regardless of the patient’s age and contraceptive method selected, the nurse must fi rst seek the woman’s confi rma- tion that she truly wants contraception. Birth control is always an individual choice. Feelings of helplessness and manipulation may result when the woman believes that someone else has decided what is “best” for her or coerces her into contraceptive use.
One of the primary goals during the contraceptive care visit is to determine and provide the contraceptive method of “best fi t” for the woman or couple. Obtaining the medi- cal, social, and cultural history helps to safeguard the
Box 6-1 Possible Nursing Diagnoses for Reproductive Care
Ineffective Sexuality patterns related to fear of pregnancy
Knowledge Defi cit related to new use of the contraceptive method of choice
Effective Therapeutic Management related to birth control method of choice
Risk for Spiritual Distress related to discrepancy between religious or cultural beliefs and choice of contraception
Risk for Infection related to use of contraceptive method or unprotected sexual intercourse
Broken skin or mucous membrane after surgery or intrauterine device (IUD) insertion
Fear related to contraceptive method side effects
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chapter 6 Human Sexuality and Fertility 141
Table 6-1 Drugs that Adversely Affect the Female Reproductive System
Drug Class Drug Possible Adverse Reactions
Androgens Danazol Vaginitis, with itching, dryness, burning,
or bleeding; amenorrhea
Amenorrhea and other menstrual irregularities;
virilization, including clitoral enlargement Fluoxymesterone, methyltestosterone,
testosterone
Antidepressants Tricyclic antidepressants
Selective serotonin reuptake inhibitors
Changed libido, menstrual irregularity Decreased libido, anorgasmia Antihypertensives Clonidine, reserpine
Methyldopa
Decreased libido
Decreased libido, amenorrhea Antipsychotics Chlorpromazine, perphenazine,
prochlorperazine, thioridazine, trifl uoperazine, haloperidol
Inhibition of ovulation (chlorpromazine only), menstrual irregularities, amenorrhea, change in libido
Beta blockers Atenolol, labetalol hydrochloride, nadolol, propanolol hydrochloride, metoprolol
Decreased libido
Cardiac glycosides Digoxin Changes in cellular layer of vaginal walls in postmenopausal women
Corticosteroids Dexamethasone, hydrocortisone, prednisone Amenorrhea and menstrual irregularities
Cytotoxics Busulfan Amenorrhea with menopausal symptoms in
premenopausal women, ovarian suppression, ovarian fi brosis and atrophy
Chlorambucil Amenorrhea
Cyclophosphamide Gonadal suppression (possibly irreversible), amenorrhea, ovarian fi brosis
Methotrexate Menstrual dysfunction, infertility
Tamoxifen Vaginal discharge or bleeding, menstrual
irregularities, pruritus vulvae (intense itching of the female external genitalia)
Thiotepa Amenorrhea
Estrogens Conjugated estrogens, esterifi ed estrogens, estradiol, estrone, ethinyl estradiol
Altered menstrual fl ow, dysmenorrhea, amenorrhea, cervical erosion or abnormal secretions, enlargement of uterine fi bromas, vaginal candidiasis
Dienestrol Vaginal discharge, uterine bleeding with
excessive use Progestins Medroxyprogesterone acetate,
norethindrone, norgestrel, progesterone
Breakthrough bleeding, dysmenorrhea, amenorrhea, cervical erosion, and abnormal secretions
Thyroid hormones Levothyroxine, sodium, thyroid USP, and others
Menstrual irregularities with excessive doses
Miscellaneous Lithium carbonate Decreased libido
L-tryptophan Decreased libido
Spironolactone Menstrual irregularities, amenorrhea, possible polycystic ovarian syndrome
Source: Dillon, P.M. (2007). Nursing health assessment. Clinical pocket guide (pp. 234–235). Philadelphia: F.A. Davis.
Reprinted with permission.
patient’s health and guide discussion of the contraceptive choices available to her. Patients often come for care with a specifi c birth control method in mind. However, it is essential that the nurse explore the woman’s knowledge and understanding of contraceptive choices, her motiva-
tions for using a method, and her level of commitment to use the method consistently. On occasion, the desired contraceptive method is contraindicated or associated with side effects that outweigh the personal benefi ts.
Open, honest discussion where appropriate information
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142 unit two The Process of Human Reproduction
can be provided in a nonthreatening environment empow- ers the patient to make an informed choice of a birth con- trol method that is best suited to her lifestyle (Fig. 6-1).
Across Care Settings:
Enhancing contraceptive decision makingThe choice of a contraceptive method usually rests with the individual, although certain types of birth control may not be the best fi t for special populations. Methods that require planning ahead, visiting a restroom for insertion, or are considered “messy” may not be the best choice for adolescents. Combination hormonal methods may be contraindicated in women with a history of breast cancer or diabetes, and these patients need assistance in fi nding another method that safely suits their lifestyle and health needs. An essential nursing role centers on obtaining a comprehensive history and educating patients about options, special considerations, and side effects. Often the nurse enlists the assistance of other health professionals such as health educators, social workers, translators, and home health workers in teaching about contraception and in managing appropriate follow-up care.
EVALUATION
When obtaining contraception is the purpose of the reproductive health visit, an immediate evaluation may take place at the conclusion of the patient encounter. This evaluation centers on mutually agreed upon outcomes that refl ect the patient’s understanding of, and comfort level with, the chosen method. Examples of possible out- comes are listed below.
The patient:
• Voices understanding about the selected contraceptive method.
• Voices an understanding of all information necessary to provide informed consent.
• Voices a comfort level with use of the contraceptive method selected.
Intermediate and long-term evaluation of outcomes is especially important in the area of contraceptive care because patients who discontinue use of a birth control
method are at risk for pregnancy. Ideally, patients should be reassessed within a few weeks after initiating a new method. At this time, appropriate outcomes may include the following.
The patient:
• Has used the contraceptive method correctly and consistently.
• Has experienced no adverse side effects from use of the contraceptive method.
• Voices continued satisfaction with the selected contra- ceptive method.
• Consistently uses the contraceptive method without pregnancy for the following year.