Assessment and Health Promotion

Anatomy Review

Animations

Audio Glossary

Audio Key Points

Case Study

NCLEX Review Questions

Nursing Skill

Spanish Guidelines

Menstruation

Physical Examination

Video—Nursing Skills

Assisting with a Pelvic Examination

Teaching Breast Self-Examination

External Structures

The external genital organs, or vulva, include all structures visible externally from the pubis to the perineum: the mons pubis, the labia majora, the labia minora, the clitoris, the vestibular glands, the vaginal vestibule, the vaginal orifice, and the urethral opening. The external genital organs are illustrated in Figure 4-1. The mons pubis is a fatty pad that lies over the anterior surface of the symphysis pubis. In the postpubertal female, the mons is covered with coarse, curly hair. The labia majora are two rounded folds of fatty tissue covered with skin that extend downward and backward from the mons pubis. The labia are highly vascular structures whose outer surfaces develop hair after puberty. They protect the inner vulvar structures. The labia minora are two flat reddish folds of tissue visible when the labia majora are separated. No hair follicles are in the labia minora, but many sebaceous follicles and a few sweat glands are present. The interior of the labia minora is composed of connective tissue and smooth muscle and supplied with extremely sensitive nerve endings. Anteriorly, the labia minora fuse to form the prepuce (hoodlike covering of the clitoris) and the frenulum (fold of tissue under the clitoris). The labia minora join to form a thin flat tissue called the fourchette underneath the vaginal opening at midline. The clitoris is located underneath the prepuce. It is a small structure composed of erectile tissue with numerous sensory nerve endings. During sexual arousal the clitoris increases in size.

The vaginal vestibule is an almond-shaped area enclosed by the labia minora that contains openings to the urethra, Skene glands, vagina, and Bartholin glands. The urethra is not a reproductive organ but is considered here because of its location. It usually is found about 2.5 cm below the clitoris. Skene glands are located on each side of the urethra and produce mucus, which aids in lubrication of the vagina. The vaginal opening is in the lower portion of the vestibule and varies in shape and size. The hymen, a connective tissue membrane, surrounds the vaginal opening. It can be perforated during strenuous exercise, insertion of tampons, masturbation, and vaginal intercourse. Bartholin glands (see Fig. 4-1) lie under the constrictor muscles of the vagina and are located posteriorly on the sides of the vaginal opening, although the ductal openings are usually not visible. During sexual arousal, the glands secrete a clear mucus to lubricate the vaginal introitus.

The area between the fourchette and the anus is the perineum, a skin-covered muscular area that covers the pelvic structures. The perineum forms the base of the perineal body, a wedge-shaped mass that serves as an anchor for the muscles, fascia, and ligaments of the pelvis. The pelvic organs are supported by muscles and ligaments that form a sling.

Internal Structures

The internal structures include the vagina, the uterus, the uterine tubes, and the ovaries. The vagina is a fibromuscular, collapsible tubular structure that extends from the vulva to the uterus and lies between the bladder and rectum. During the reproductive years the mucosal lining is arranged in transverse folds called rugae. These rugae allow the vagina to expand during childbirth. Estrogen deprivation that occurs after childbirth, during lactation, and at menopause causes dryness and thinning of the vaginal walls and smoothing of the rugae. The vagina, particularly the lower segment, has few sensory nerve endings. Vaginal secretions are slightly acidic (pH 4 to 5) so that vaginal susceptibility to infections is reduced. The vagina serves as a passageway for menstrual flow, as a female organ of copulation, and as a part of the birth canal for vaginal childbirth. The uterine cervix projects into a blind vault at the upper end of the vagina. There are anterior, posterior, and lateral pockets called fornices (singular, fornix) that surround the cervix. The internal pelvic organs can be palpated through the thin walls of these fornices.

The uterus is a muscular organ shaped like an upside-down pear that sits midline in the pelvic cavity between the bladder and rectum and above the vagina. Four pairs of ligaments support the uterus: the cardinal, the uterosacral, the round, and the broad. Single anterior and posterior ligaments also support the uterus. The cul-de-sac of Douglas is a deep pouch, or recess, posterior to the cervix formed by the posterior ligament.

The uterus is divided into two major parts, an upper triangular portion called the corpus and a lower cylindric portion called the cervix (Fig. 4-2). The fundus is the dome-shaped top of the uterus and is the site at which the uterine tubes enter the uterus. The isthmus (lower uterine segment) is a short, constricted portion that separates the corpus from the cervix.

The uterus serves for reception, implantation, retention, and nutrition of the fertilized ovum and later of the fetus during pregnancy, and for expulsion of the fetus during childbirth. It also is responsible for cyclic menstruation.

The uterine wall comprises three layers: the endometrium, the myometrium, and part of the peritoneum (membrane that covers the abdominal wall). The endometrium is a highly vascular lining made up of three layers, the outer two of which are shed during menstruation. The myometrium is made up of layers of smooth muscles that extend in three different directions (longitudinal, transverse, and oblique) (Fig. 4-3). Longitudinal fibers of the outer myometrial layer are found mostly in the fundus, and this arrangement assists in expelling the fetus during the birth process. The middle layer contains fibers from all three directions, which form a figure-eight pattern encircling large blood vessels. These fibers assist in ligating blood vessels after childbirth and control blood loss. Most of the circular fibers of the inner myometrial layer are around the site where the uterine tubes enter the uterus and around the internal cervical os (opening). These fibers help keep the cervix closed during pregnancy and prevent menstrual blood from flowing back into the uterine tubes during menstruation.

The cervix is made up of mostly fibrous connective tissues and elastic tissue, making it possible for the cervix to stretch during vaginal childbirth. The opening between the uterine cavity and the canal that connects the uterine cavity to the vagina (endocervical canal) is the internal os. The narrowed opening between the endocervix and the vagina is the external os, a small circular opening in women who have never been pregnant. The cervix feels firm (like the end of a nose) with a dimple in the center, which marks the external os.

The outer cervix is covered with a layer of squamous epithelium. The mucosa of the cervical canal is covered with columnar epithelium and contains numerous glands that secrete mucus in response to ovarian hormones. The squamocolumnar junction, where the two types of cells meet, is usually located just inside the cervical os. This junction also is called the transformation zone, the most common site for neoplastic changes (see Fig. 11-12); cells from this site are scraped for the Pap test (see later discussion).

The uterine tubes (fallopian tubes) attach to the uterine fundus. The tubes are supported by the broad ligaments and range from 8 to 14 cm in length. The tubes are divided into four sections: the interstitial portion is closest to the uterus; the isthmus and the ampulla are the middle portions; and the infundibulum is closest to the ovary. The uterine tubes form passages between the ovaries and the uterus for the passage of the ovum. The infundibulum has fimbriated ends, which pull the ovum into the tube. The ovum is pushed along the tubes to the uterus by rhythmic contractions of the muscles of the tubes and by the current that is produced by the movement of the cilia that line the tubes. The ovum is usually fertilized by the sperm in the ampulla portion of one of the tubes.

The ovaries are almond-shaped organs located on each side of the uterus below and behind the uterine tubes. During the reproductive years they are approximately 3 cm long, 2 cm wide, and 1 cm thick; they diminish in size after menopause. Before menarche each ovary has a smooth surface; after menarche they become nodular because of repeated ruptures of follicles at ovulation. The two functions of the ovaries are ovulation and hormone production. Ovulation is the release of a mature ovum from the ovary at intervals (usually monthly). Estrogen, progesterone, and androgen are the hormones produced by the ovaries.

The Bony Pelvis

The bony pelvis serves three primary purposes: protection of the pelvic structures, accommodation of the growing fetus during pregnancy, and anchorage of the pelvic support structures. Two innominate (hip) bones (consisting of ilium, ischium, and pubis), the sacrum, and the coccyx make up the four bones of the pelvis (Fig. 4-4). Cartilage and ligaments form the symphysis pubis, the sacrococcygeal joint, and two sacroiliac joints that separate the pelvic bones. The pelvis is divided into two parts: the false pelvis and the true pelvis (Fig. 4-5). The false pelvis is the upper portion above the pelvic brim or inlet. The true pelvis is the lower, curved bony canal, which includes the inlet, the cavity, and the outlet through which the fetus passes during vaginal birth. The upper portion of the outlet is at the level of the ischial spines, and the lower portion is at the level of the ischial tuberosities and the pubic arch (see Fig. 4-4). Variations that occur in the size and shape of the pelvis are usually due to age, race, and sex. Pelvic ossification is complete at about age 20 years.

Breasts

The breasts are paired mammary glands located between the second and sixth ribs (Fig. 4-6). About two thirds of the breast overlie the pectoralis major muscle, between the sternum and midaxillary line, with an extension to the axilla referred to as the tail of Spence. The lower third of the breast overlies the serratus anterior muscle. The breasts are attached to the muscles by connective tissue or fascia.

The breasts of healthy mature women are approximately equal in size and shape, but often are not absolutely symmetric. The size and shape vary depending on the woman’s age, heredity, and nutrition. However, the contour should be smooth, with no retractions, dimpling, or masses. Estrogen stimulates growth of the breast by inducing fat deposition in the breasts, development of stromal tissue (i.e., increase in its amount and elasticity), and growth of the extensive ductile system. Estrogen also increases the vascularity of breast tissue.

Once ovulation begins in puberty, progesterone levels increase. The increase in progesterone causes maturation of mammary gland tissue, specifically the lobules and acinar structures. During adolescence, fat deposition and growth of fibrous tissue contribute to the increase in the gland’s size. Full development of the breasts is not achieved until after the end of the first pregnancy or in the early period of lactation.

Findings from several studies using ultrasound imaging to investigate the anatomy of the breast found differences from previous descriptions (Geddes, 2007; Love & Barsky, 2004; Ramsay, Kent, Hartmann, & Hartmann, 2005). The following description incorporates these findings. Each mammary gland is made of a number of lobes that are divided into lobules. Lobules are clusters of acini. An acinus is a saclike terminal part of a compound gland emptying through a narrow lumen or duct. The acini are lined with epithelial cells that secrete colostrum and milk. Just below the epithelium is the myoepithelium (myo, or muscle), which contracts to expel milk from the acini.

The ducts from the clusters of acini that form the lobules merge to form larger ducts draining the lobes. Ducts from the lobes converge in a single nipple (mammary papilla) surrounded by an areola. The anatomy of the ducts is similar for each breast but varies among women. Protective fatty tissue surrounds the glandular structures and ducts. Cooper’s ligaments, or fibrous suspensory, separate and support the glandular structures and ducts. Cooper’s ligaments provide support to the mammary glands while permitting their mobility on the chest wall (see Fig. 4-6). The round nipple is usually slightly elevated above the breast. On each breast the nipple projects slightly upward and laterally. It contains 4 to 20 openings from the milk ducts. The nipple is surrounded by fibromuscular tissue and covered by wrinkled skin (the areola). Except during pregnancy and lactation, there is usually no discharge from the nipple.

The nipple and surrounding areola are usually more deeply pigmented than the skin of the breast. The rough appearance of the areola is caused by sebaceous glands directly beneath the skin called Montgomery tubercles. These glands secrete a fatty substance, thought to lubricate the nipple. Smooth muscle fibers in the areola contract to stiffen the nipple to make it easier for the breastfeeding infant to grasp.

Besides their function of lactation, breasts function as organs for sexual arousal in the mature adult.

The vascular supply to the mammary gland is abundant. In the nonpregnant state, the skin has no obvious vascular pattern. The normal skin is smooth without tightness or shininess. The skin covering the breasts contains an extensive superficial lymphatic network that serves the entire chest wall and is continuous with the superficial lymphatics of the neck and abdomen. In the deeper portions of the breasts, the lymphatics form a rich network as well. The primary deep lymphatic pathway drains laterally toward the axillae.

The breasts change in size and nodularity in response to cyclic ovarian changes throughout reproductive life. Increasing levels of both estrogen and progesterone in the 3 to 4 days before menstruation increase the vascularity of the breasts, induce growth of the ducts and acini, and promote water retention. The epithelial cells lining the ducts proliferate in number, the ducts dilate, and the lobules distend. The acini become enlarged and secretory, and lipid (fat) is deposited within their epithelial cell lining. As a result, breast swelling, tenderness, and discomfort are common symptoms just before the onset of menstruation. After menstruation, cellular proliferation begins to regress; the acini begin to decrease in size; and retained water is lost. After breasts have undergone changes numerous times in response to the ovarian cycle, the proliferation and involution (regression) are not uniform throughout the breast. In time, after repeated hormonal stimulation, small persistent areas of nodulations may develop. This normal physiologic change must be remembered when breast tissue is examined. Nodules may develop just before and during menstruation, when the breast is most active. The physiologic alterations in breast size and activity reach their minimal level about 5 to 7 days after menstruation stops.

The best time for a woman who wishes to perform a breast self-examination (BSE) (palpation of breasts to detect changes in breast tissue) is during this phase of the menstrual cycle or whenever the breasts are not tender or swollen (see Teaching for Self-Management box: Breast Self-Examination).

Table 4-1 compares the variations in physical assessment related to age differences in women.

Menarche and Puberty

Although young girls secrete small, rather constant amounts of estrogen, a marked increase occurs between ages 8 and 11 years. The term menarche denotes first menstruation. Puberty is a broader term that denotes the entire transitional stage between childhood and sexual maturity. Increasing amounts and variations in gonadotropin and estrogen secretion develop into a cyclic pattern at least a year before menarche. In North America this occurs in most girls at about age 13 years.

Initially, for most women, periods are irregular, unpredictable, painless, and anovulatory (no ovum released from the ovary). After 1 or more years, a hypothalamic-pituitary rhythm develops, and the ovary produces adequate cyclic estrogen to make a mature ovum. Ovulatory (ovum released from ovary) periods tend to be regular, monitored by progesterone.

Although pregnancy can occur in exceptional cases of true precocious puberty, most pregnancies in young girls occur after the normally timed menarche. All young adolescents of both sexes would benefit from knowing that pregnancy can occur at any time after the onset of menses.

Menstrual Cycle

Menstruation is the periodic uterine bleeding that begins approximately 14 days after ovulation. It is controlled by a feedback system of three cycles: hypothalamic-pituitary, ovarian, and endometrial. The average length of a menstrual cycle is 28 days, but variations are normal. The first day of bleeding is designated day 1 of the menstrual cycle, or menses (Fig. 4-7). The average duration of menstrual flow is 5 days (range, 3 to 6 days), and the average blood loss is 50 ml (range, 20 to 80 ml), but these vary greatly.

For about 50% of women, menstrual blood does not appear to clot. The menstrual blood clots within the uterus, but the clot usually liquefies before being discharged from the uterus. Uterine discharge includes mucus and epithelial cells in addition to blood.

The menstrual cycle is a complex interplay of events that occur simultaneously in the endometrium, the hypothalamus, the pituitary glands, and the ovaries. The menstrual cycle prepares the uterus for pregnancy. When pregnancy does not occur, menstruation follows. The woman’s age, physical and emotional status, and environment influence the regularity of her menstrual cycles.

Prostaglandins

Prostaglandins (PGs) are oxygenated fatty acids classified as hormones. The different kinds of PGs are distinguished by letters (PGE, PGF), numbers (PGE₂), and letters of the Greek alphabet (PGF_2α).

Prostaglandins are produced in most organs of the body, including the uterus. Menstrual blood is a potent prostaglandin source. PGs are metabolized quickly by most tissues. They are biologically active in minute amounts in the cardiovascular, gastrointestinal, respiratory, urogenital, and nervous systems. They also exert a marked effect on metabolism, particularly on glycolysis. Prostaglandins play an important role in many physiologic, pathologic, and pharmacologic reactions. PGF_2α, PGE₄, and PGE₂ are most commonly used in reproductive medicine.

Prostaglandins affect smooth muscle contractility and modulation of hormonal activity. Indirect evidence suggests that PGs have an effect on ovulation, fertility, changes in the cervix, and cervical mucus that affect receptivity to sperm, tubal and uterine motility, sloughing of endometrium (menstruation), onset of abortion (spontaneous and induced), and onset of labor (term and preterm).

After exerting their biologic actions, newly synthesized PGs are rapidly metabolized by tissues in such organs as the lungs, the kidneys, and the liver.

Prostaglandins may play a key role in ovulation. If PG levels do not increase along with the surge of LH, the ovum remains trapped within the graafian follicle. After ovulation, PGs may influence production of estrogen and progesterone by the corpus luteum.

The introduction of PGs into the vagina or into the uterine cavity (from ejaculated semen) increases the motility of uterine musculature, which can assist the transport of sperm through the uterus and into the oviduct.

Prostaglandins produced by the woman cause regression of the corpus luteum, regression of the endometrium, and sloughing of the endometrium, resulting in menstruation. PGs increase myometrial response to oxytocic stimulation, enhance uterine contractions, and cause cervical dilation. They may be a factor in the initiation of labor, the maintenance of labor, or both. They also may be involved in dysmenorrhea (see Chapter 6) and preeclampsia-eclampsia (see Chapter 27).

Climacteric and Menopause

The climacteric is a transitional phase during which ovarian function and hormone production decline. This phase spans the years from the onset of premenopausal ovarian decline to the postmenopausal time when symptoms stop. Menopause (from the Latin mensis, month, and Greek pausis, to cease) refers only to the last menstrual period. Unlike menarche, however, menopause can be dated with certainty only 1 year after menstruation ceases. The average age at natural menopause is 51.4 years, with an age range of 35 to 60 years. Perimenopause is a period preceding menopause that lasts about 4 years. During this time, ovarian function declines. Ova slowly diminish, and menstrual cycles may be anovulatory, resulting in irregular bleeding. The ovary stops producing estrogen, and eventually menses no longer occur.

Preconception Counseling and Care

Preconception health promotion provides women and their partners with information that is needed to make decisions about their reproductive future. Preconception counseling guides couples on how to prevent unintended pregnancies and to achieve pregnancy when desired, stresses risk management, and identifies healthy behaviors that promote the well-being of the woman and her potential fetus (Moos, 2006).

All providers who treat women for well-woman care or other routine care should incorporate preconception health screening as part of the routine care for women of reproductive age (Johnson, Posner, Biermann, Cordero, Atrash, Parker, et al., 2006). The initiation of activities that promote healthy mothers and babies must occur before the period of critical fetal organ development, which is between 17 and 56 days after fertilization. By the end of the eighth week after conception and certainly by the end of the first trimester, any major structural anomalies in the fetus are already present. Because many women do not realize that they are pregnant and do not seek prenatal care until well into the first trimester, the rapidly growing fetus may be exposed to many types of intrauterine environmental hazards during this most vulnerable developmental phase.

Preconception care is important for women who have had a problem with a previous pregnancy (e.g., miscarriage, preterm birth). Although causes are not always identifiable, in many cases, problems can be identified and treated and may not recur in subsequent pregnancies. Preconception care is also important to minimize fetal malformations. For example, the woman may be exposed to teratogenic agents such as drugs, viruses, and chemicals, or she may have a genetically inherited disease. Preconception counseling can educate the woman about the effects of these agents and diseases, which can help prevent harm to the fetus or allow the woman to make an informed decision about her willingness to accept potential hazards should a pregnancy occur (Atrash, Johnson, Adams, Cordero, & Howse, 2006).

A model for preconception care of women of reproductive age targets all women from menarche to menopause at every encounter, not just in maternity and women’s health. Providing optimal health care for women whether or not they desire to conceive can result in a high level of preconception wellness (Moos, 2006). Suggested components of preconception care, such as health promotion, risk assessment, and interventions, are outlined in Box 4-1.

Pregnancy

A woman’s entry into health care is often associated with pregnancy, either for diagnosis or for actual care. The possibility of pregnancy is realized most commonly when a woman is late with her menses. If she is pregnant, it is desirable for a woman to enter prenatal care within the first 12 weeks. This allows early pregnancy counseling, especially for the woman who has had no preconception care. Major goals of prenatal care are found in Box 4-2 and should be initiated at the first visit. Extensive discussion of pregnancy is found in Chapter 15.

Well-Woman Care

Current trends in the health care of women have expanded beyond a reproductive focus. A holistic approach to women’s health care includes a woman’s health needs throughout her lifetime. This view goes beyond simply her reproductive needs. This restructuring places women’s health within the primary health care delivery system. Women’s health assessment and screening focus on a multisystem evaluation emphasizing the maintenance and enhancement of wellness.

Many women first enter the health care delivery system for a Pap test or contraception. Visits to the nurse may be their only contact with the system unless they become ill. Some women postpone examination until a specific need arises, such as pregnancy, pain, abnormal bleeding, or vaginal discharge.

Health care needs vary with culture, religion, age, and personal differences. The changing responsibilities and roles of women, their socioeconomic status, and their personal lifestyles also contribute to differences in the health and behavior of women. Employment outside of the home, physical disability, inadequate or no health insurance, divorce, single parenthood, and sexual orientation also can affect women’s ability to seek and receive health care in clinical settings. As women age, many continue to address their primary health care needs within their established gynecologic care setting; therefore, well-women’s health care should include a complete history, physical examination, age-appropriate screening, and health promotion.

Fertility Control and Infertility

As women become more informed about themselves and their health care, they are more willing to seek counseling and contraception appropriate to their varied and specific needs. Some women first enter the health care system to obtain such advice. More than half of the pregnancies in the United States each year are unintended, many even with contraception use (Trussell, 2007). Education is the key to encouraging women to make family planning choices based on preference and actual benefit-to-risk ratios. Providers can influence the user’s motivation and ability to use the method correctly (see Chapter 8 for further discussion of contraception).

The concept of health promotion applies to contraception, as can be seen in Box 4-3. The nurse can influence women positively regarding the need for child spacing, methods of family planning that are consistent with religious and personal preferences, noncontraceptive benefits of certain methods, the appropriate use of methods selected, and the protection of future fertility when so desired.

Women also enter the health care system because of their desire to achieve a pregnancy. Approximately 15% of couples in the United States have some degree of infertility. Many couples have delayed starting their families until they are in their 30s or 40s, which allows more time to be exposed to situations negatively affecting fertility (including age-related infertility for the woman). In addition, sexually transmitted infections (STIs), which can predispose to decreased fertility, are becoming more common, and many women and men are in workplaces and home settings where they may be exposed to reproductive environmental hazards.

Steps toward prevention of infertility should be undertaken as part of ongoing routine health care, and such information is especially appropriate in preconception counseling. Primary care providers can undertake initial evaluation and counseling before couples are referred to specialists. For additional information about infertility, see Chapter 9.

Menstrual Problems

Irregularities or problems with the menstrual period are among the most common concerns of women and often cause them to seek help from the health care system. Common menstrual disorders include amenorrhea, dysmenorrhea, premenstrual syndrome, endometriosis, and menorrhagia or metrorrhagia. Simple explanation and counseling may handle the concern; however, history and examination must be completed, as well as laboratory or diagnostic tests, if indicated. Questions should never be considered inconsequential. Age-specific reading materials are recommended, especially for teenagers. Information should also consider cultural relevance and be available in languages appropriate for the population with whom the nurse is working. See Chapter 6 for an in-depth discussion of menstrual problems.

Perimenopause

The body responds to this natural transition in a number of ways, most of which are due to the decrease in estrogen. Most women seeking health care during the perimenopausal period do so because of irregular bleeding. Others are concerned about vasomotor symptoms (hot flashes and flushes). Although fertility is greatly reduced during this period, women are urged to maintain some method of contraception because pregnancies still can occur. All women need to have factual information, the dispelling of myths, a thorough examination, and periodic health screenings thereafter. See Chapter 6 for discussion of perimenopause and menopause.

Financial Issues

Parts of the health care delivery system remain in a state of flux. Great variation occurs depending on type and size of the system, source of payment for services, private versus public programs, availability of and accessibility to providers, individual preferences, and insurance coverage or ability to pay. The existing system continues to be oriented to treatment of acute or episodic conditions rather than the promotion of health and comprehensive care (see discussion in Chapter 1).

A health care reform bill was signed by President Obama on March 23, 2010. However, the impact of this legislation on the American people will not be known for years because not all benefits will be immediate (Gaulin, 2010).

Cultural Issues

As our nation becomes more racially, ethnically and culturally diverse, the health of minority groups becomes a major issue. A variety of reasons are given to explain some of the differences in accessing care when financial barriers are adjusted. Unfair treatment was described by women who experienced racial discrimination or disrespectful, disillusioning, or discouraging encounters with community service providers such as social services and health care providers. A lack of training in cross-cultural communication may present problems. Desired health outcomes are best achieved when the health care providers have a knowledge and understanding about the culture, language, values, priorities, and health beliefs of minority groups. Conversely, members of the group should understand the health goals to be achieved and the methods proposed to do so. Language differences can produce profound barriers between women and health care providers. Even with an interpreter, information may be skewed in either direction.

Providers must consider culturally based differences that could affect the treatment of diverse groups of women, and the women themselves should share their practices and beliefs that could influence their management, responses, or willingness to comply (see Cultural Considerations box: Female Genital Mutilation). For example, women in some cultures value privacy to such an extent that they are reluctant to disrobe and, as a result, avoid physical examination unless absolutely necessary. Other women rely on their husbands to make major decisions, including those affecting the woman’s health. Religious beliefs may dictate a specified plan of care, such as limiting assisted reproductive technology, contraception measures, blood transfusions, cardiopulmonary resuscitation, or assisted ventilation. Some cultural groups prefer folk medicine, homeopathy, or prayer to traditional Western medicine, and others attempt combinations of various practices

Gender Issues

Gender influences provider-client communication and may influence access to health care in general. The most obvious gender consideration is that between men and women. Researchers have reported significant male-female differences in receipt of major diagnostic and therapeutic interventions, especially with cardiac and kidney problems. Women tend to use primary care services more often than men and, some believe, more effectively. The sex of the provider plays a role; studies have shown that female clients have Pap tests and mammograms more consistently if they are seen by female providers.

Sexual orientation may produce another barrier. Lesbian women have primary erotic attractions and relations with other women. Some lesbians may not disclose their orientation to

health care providers because they feel they may be at risk for hostility, inadequate health care, or breach of confidentiality. In many health care settings, heterosexuality is assumed, and the setting may be one in which the woman does not feel welcome (magazines, brochures, and environment reflect heterosexual couples, or the health care provider shows discomfort interacting with the woman). Another problem is that lesbians themselves may hold beliefs that are incorrect, such as that they have immunity to human immunodeficiency virus (HIV), STIs, and certain cancers (e.g., cervical). The perceived lack of risk can result in lesbians avoiding medical care as well as in health care providers giving incorrect advice or not doing appropriate cancer screening for these women. Not all gynecologic cancers are related to sexual activity; lesbians who have never had children may be more at risk for breast, ovarian, and endometrial cancer. Their risk for heart disease, cancer of the lung, and colon cancer is the same as that of the heterosexual woman. To offset stereotypes, it is necessary for providers to develop an approach that does not assume that all women are heterosexual. Revising forms to be inclusive of sexual diversity and providing an environment that promotes acceptance and inclusiveness are two strategies suggested by researchers (Goldberg, 2005-2006; Roberts, 2006).

Age

Socioeconomic Status

Differences exist among people from different socioeconomic levels and ethnic groups with respect to risk for illness and distribution of disease and death. Some diseases are more common among people of selected ethnicity, for example, sickle cell anemia in African-Americans, Tay-Sachs disease in Ashkenazi Jews, adult lactase deficiency in Chinese, beta thalassemia in Mediterranean peoples, and cystic fibrosis in northern Europeans. Cultural and religious influences also increase health risks because the woman and her family may have life and societal values and a view of health and illness that dictate practices different from those expected in the Judeo-Christian Western model. These practices may include food taboos or frequencies, methods of hygiene, effects of climate, care-seeking behaviors, willingness to undergo screening and diagnostic procedures, and value conflicts.

Socioeconomic status affects birth outcomes. Social consequences for poor women as single parents are great because many mothers with few skills are caught in the bind of having income that is insufficient to afford child care. These families generate fewer and fewer resources and increase their risks for health problems. Multiple roles for women in general produce overload, conflict, and stress, resulting in higher risks for psychologic illness.

Substance Use and Abuse

Use of illicit drugs and inappropriate use of prescription drugs continue to increase and are found in all ages, races, ethnic groups, and socioeconomic strata. Addiction to substances is seen as a biopsychosocial disease, with several factors contributing to risk. These include biogenetic predisposition, lack of resilience to stressful life experiences, and poor social support. Women are less likely than men to abuse drugs, but the rate in women is increasing significantly. Substance-abusing pregnant women create severe problems for themselves and their offspring, including interference with optimal growth and development and addiction. In many instances, the use of substances is identified through screening programs in prenatal clinics and obstetric units (see Chapter 32).

Nutrition

Good nutrition is essential for optimal health. A well-balanced diet helps prevent illness and treat certain health problems. Conversely, poor eating habits, eating disorders, and obesity are linked to disease and debility.

Dietary Guidelines for Americans 2010 provides evidenced-based recommendations to promote health and reduce risks for chronic diseases through diet (U.S. Department of Health and Human Services [USDHHS] & U.S. Department of Agriculture [USDA], 2010) (www.cnpp.usda.gov/Dietaryguidelines/htm).

Physical Fitness and Exercise

Physical activity promotes health, psychological well-being, and ideal body weight for height. It enhances independence, and improves quality of living across the life span. Women should engage in 2½ hours per week of moderate intensity or 1¼ hours per week of vigorous intensity aerobic physical activity or a combination of both according to the current Physical Activity Guidelines for Americans (USDHHS, 2008).

Exercise can reduce risks for a variety of conditions that are influenced by obesity and a sedentary lifestyle such as cardiovascular disease, cerebrovascular disease, and diabetes. Exercise plays an important role in the management of chronic conditions such as hypertension, arthritis, respiratory disorders, and osteoporosis. Exercise contributes to stress reduction and improving the quality of sleep. Women report that engaging in regular exercise improves their body image and self-esteem and acts as a mood enhancer.

Aerobic exercise contributes to cardiovascular fitness while increasing oxygen levels to working muscles. Anaerobic exercise, such as weight training, improves individual muscle mass without stress on the cardiovascular system. Because women are concerned about both cardiovascular and bone health, weight-bearing aerobic exercises such as walking, running, racket sports, and dancing may be preferred. Sustained excessive exercise can lead to hormonal imbalances, such as amenorrhea, which can usually be reversed when the body returns to normal levels of activity.

Stress

The modern woman faces increasing levels of stress and as a result is prone to a variety of stress-induced complaints and illnesses. Stress often occurs because of multiple roles, such as when coping with job and financial responsibilities conflicts with parenting and duties at home. To add to this burden, women are socialized to be caretakers, which is an emotionally draining role in itself. They also may find themselves in positions of minimal power that do not allow them to have control over their everyday environments. Some stress is normal and contributes to positive outcomes. Many women thrive in busy surroundings. However, excessive or high levels of ongoing stress trigger physical reactions in the body, such as rapid heart rate, elevated blood pressure, slowed digestion, release of additional neurotransmitters and hormones, muscle tenseness, and a weakened immune system. Consequently, constant stress can contribute to clinical illnesses such as flare-ups of arthritis or asthma, frequent colds or infections, gastrointestinal upsets, cardiovascular problems, and infertility. Box 4-5 lists symptoms that may be related to chronic or extreme stress. Psychologic signs such as anxiety, irritability, eating disorders, depression, insomnia, and substance abuse are associated with stress.

Sexual Practices

Potential risks related to sexual activity are undesired pregnancy and STIs. The risks are particularly high for adolescents and young adults who engage in sexual intercourse at earlier and earlier ages. Adolescents report many reasons for wanting to be sexually active, among which are peer pressure, desire to love and be loved, experimentation, enhancing self-esteem, and having fun. However, many teens do not have the decision-making or values-clarification skills needed to take this important step at a young age, and they lack the knowledge base regarding contraception and STIs. They also do not believe that becoming pregnant or getting an STI will happen to them.

Although some STIs can be cured with antibiotics, many can cause significant problems. Possible sequelae include infertility, ectopic pregnancy, neonatal morbidity and mortality, genital cancers, acquired immunodeficiency syndrome (AIDS), and even death (CDC, Workowski, & Berman, 2006). The incidence of STIs is increasing rapidly and reaching epidemic proportions. Choice of contraception has an effect on the risk of contracting an STI; however, no method of contraception offers complete protection. (See Chapter 7 for discussion of STIs and Chapter 8 for contraception.)

Medical Conditions

Most women of reproductive age are relatively healthy. Heart disease; lung, breast, colon, and gynecologic cancers; stroke; chronic lung disease; and diabetes are among the leading causes of death in adult women (Heron & Tejada-Vera, 2008) (Box 4-6). Certain medical conditions present during pregnancy can have deleterious effects on both the woman and the fetus. Of particular concern are risks from all forms of diabetes, urinary tract disorders, thyroid disease, hypertensive disorders of pregnancy, cardiac disease, and seizure disorders. Effects on the fetus vary and include intrauterine growth restriction, macrosomia, anemia, prematurity, immaturity, and stillbirth. Effects on the woman also can be severe. These conditions are discussed in later chapters.

Gynecologic Conditions

Women are at risk throughout their reproductive years for pelvic inflammatory disease, endometriosis, STIs and other vaginal infections, uterine fibroids, uterine deformities such as bicornuate uterus, ovarian cysts, interstitial cystitis, and urinary incontinence related to pelvic relaxation. These gynecologic conditions may contribute negatively to pregnancy by causing infertility, miscarriage, preterm labor, and fetal and neonatal problems. Gynecologic cancers also affect women’s health, although the risk for most cancers is low in pregnancy. Risk factors depend on the type of cancer. The effect of developing a gynecologic problem or cancer in women and their families is shaped by a number of factors including the specific type of problem or cancer, the implications of the diagnosis for the woman and her family, and the timing of the occurrence in the woman’s and family’s lives. These conditions are discussed in Chapters 6, 7, and 11.

Environmental and Workplace Hazards

Environmental hazards in the home, the workplace, and the community can contribute to poor health at all ages. Categories and examples of health-damaging hazards include the following: (1) pathogenic agents (viruses, bacteria, fungi, parasites); (2) natural and synthetic chemicals (natural toxins from animals, insects, and plants; consumer and industrial products such as pesticides and hydrocarbon gases; medical and diagnostic devices; tobacco; fuels; and drug and alcohol abuse); (3) radiation (radon, heat waves, sound waves); (4) food substances (added components that are not necessary for nutrition); and (5) physical objects (moving vehicles, machinery, weapons, water, and building materials).

Environmental hazards can affect fertility, fetal development, live birth, and the child’s future mental and physical development. Environmental hazards are discussed throughout other chapters as they are identified as specific risks to women’s and infants’ health.

Violence Against Women

Violence against women is a major health care problem in the United States, affecting millions of women each year and costing millions of dollars in annual medical costs. Women of all races and of all ethnic, educational, religious, and socioeconomic backgrounds are affected. Pregnancy is often a time when violence begins or escalates. The magnitude of the problem is far greater than the statistics indicate because violent crimes against women are the most underreported data as a result of fear, lack of understanding, and stigma surrounding violent situations. Maternity and women’s health nurses, by the very nature of their practice, are in a unique position to conduct case finding, provide sensitive care to women experiencing abusive situations, engage in prevention activities, and influence health care and public policy toward decreasing the violence. For further discussion of violence against women, see Chapter 5.

Interview

The contact with the woman usually begins with an interview. This interview should be conducted in a private, comfortable, and relaxed setting (Fig. 4-8). The woman is addressed by her title and name (e.g., Mrs. Gonzalez), and the nurse introduces herself or himself by using name and title. It is important to phrase questions in a sensitive and nonjudgmental manner. Body language should match verbal communication. The nurse is cognizant of a woman’s vulnerability and assures her of strict confidentiality. For many women, fear, anxiety, and modesty make the examination a dreaded and stressful experience. Many women are uninformed, misguided by myths, or afraid they will appear ignorant by asking questions about sexual or reproductive functioning. The woman is assured that no question is irrelevant. The history begins with an open-ended question such as, “What brings you in to the office/clinic/hospital today? Anything else? Tell me about it.”

Additional ways to get women to share information include the following:

Direct questions may be necessary to elicit specific details. These should be worded in language that is understandable to the woman and expressed neutrally, so that the woman will not be led into a specific response. The nurse asks about one item at a time and proceeds from the general to the specific (Seidel, Ball, Dains, Flynn, Soloman, & Stewart, 2011).

Women with Special Needs

History

At a woman’s first visit, she is often expected to fill out a form with biographic and historic data before meeting with the examiner. This form aids the health care provider in completing the history during the interview. Most forms include information about the following categories:

Box 4-8 describes a complete health history and review of systems based on the above categories.

Physical Examination

In preparation for the physical examination, the woman is instructed on undressing and given a gown to wear during the examination. She is usually given the opportunity to undress privately. Objective data are recorded by system or location. A general statement of overall health status is a good way to start. Findings are described in detail.

Laboratory and Diagnostic Procedures

The following laboratory and diagnostic procedures are ordered at the discretion of the clinician, considering the woman and her family history: hemoglobin, fasting plasma glucose, total blood cholesterol, lipid profile, urinalysis, syphilis serology (Venereal Disease Research Laboratory [VDRL] or rapid plasma reagin [RPR]) and other screening tests for sexually transmitted infections, mammogram, tuberculosis skin testing, hearing, visual acuity, electrocardiogram, chest X-ray, pulmonary function, fecal occult blood, flexible sigmoidoscopy, and bone mineral density scan. Results of these tests may be reported in person, by phone call, or by letter. Tests for HIV and drug screening may be offered with informed consent in high risk populations. These test results usually are reported in person.

Nutrition

To maintain good nutrition, women should be counseled to include recommended servings from the major food categories of MyPyramid. Recommended servings from the food groups also provide adequate vitamins, minerals, iron, and fiber. Fluid intake is not included in the food pyramid, but individuals should be encouraged to drink at least six to eight glasses of water every day in addition to other fluids such as juices. Coffee, tea, soft drinks, and alcoholic beverages should be used in moderation..

Folic acid helps reduce high levels of homocysteine, an amino acid that damages the heart and blood vessels and increases the risk of heart disease, stroke, and dementia. Folic acid is present in citrus fruits, broccoli, spinach, asparagus, peas, lettuce, beans, whole grains, and orange juice. It is in many fortified grains and pasta or can be taken as a daily vitamin supplement (USDHHS & USDA, 2010).

Antioxidants are thought to be effective in helping to prevent oxidative damage in the body such as cancer, heart disease, and stroke; however, more research is needed in this area. Vitamins C and E; selenium (a mineral); and a group known as beta-carotenes (carotenoids) can be found in a diet containing fruits, vegetables, and whole grains.

Most women do not recognize the importance of calcium to health, and their diets are insufficient in calcium. Women who are unlikely to have enough calcium in the diet may need calcium supplements in the form of calcium carbonate with vitamin D, which contains more elemental calcium than do other preparations.

Vitamin D is essential for strong bones and a healthy immune system. Recent epidemiologic studies have shown a relationship between low vitamin D levels and multiple disease states such as increased cardiovascular mortality, cancer incidence, diabetes, osteoporosis, chronic pain and autoimmune diseases such as multiple sclerosis (Kulie, Groff, Redmer, Hounshell, & Schrager, 2009). Women can fulfill their vitamin D requirements by ingesting vitamin D and vitamin D–enhanced foods or being exposed to the sun for enough time to produce adequate amounts. It has been postulated that exposure of the arms and legs for 5 to 30 minutes between the hours of 10 am and 3 pm twice a week can be adequate to prevent vitamin D deficiency (Holick, 2007). With concerns about skin cancer, most women are cautious about sun exposure. Sources of natural vitamin D include egg yolks, shitake mushrooms, tuna, mackerel, sardines, salmon, and cod liver oil. Vitamin D–enhanced foods include milk, orange juice, infant formulas, yogurt, butter, margarine, cheese, and breakfast cereals. Researchers continue to investigate the optimum levels of vitamin D needed by healthy adults; most experts agree that less than 20 ng/ml represents deficiency (Kulie et al.).

The diet can be assessed by using a standard assessment form—​a 24-hour recall is adequate and quick—​and then food likes and dislikes, including cultural variations and typical food portions and dietary habits should be discussed and incorporated into counseling (see Chapter 14).

Exercise

Physical activity and exercise counseling for women of all ages should be undertaken at schools, worksites, and primary care settings. American Heart Association (AHA) (2010) recommendations include 30 to 60 minutes of moderate to vigorous activity on most days of the week. Activities do not need to be strenuous to bring health benefits. What is important is to include activities as part of a regular health routine. Activities that are especially beneficial when performed regularly include brisk walking, hiking, stair climbing, aerobic exercise, jogging, running, bicycling, rowing, swimming, soccer, and basketball. Few Americans exercise as often as they should, and physical activity is known to decrease with age, especially during adolescence and early adulthood.

The nurse should stress the importance of daily exercise throughout life for weight management and health promotion, suggesting exercises that are enjoyable to the individual (Fig. 4-15). Physical activity builds healthy bones, muscles, and joints and reduces the risk of colon and breast cancer. It also reduces feelings of depression and anxiety and improves mood and promotes a feeling of well-being. Many women who are sedentary during leisure time can benefit from gradually increasing their physical activity. They may be encouraged to exercise with their children or in groups with friends. Programs such as Curves for women, worksite fitness programs, or community-based programs such as the AHA’s Choose To Move are increasingly available. Young women can be involved in fitness centers, cheerleading, gymnastics, sports teams, or individual competitive sports.

For women who are sedentary or are not able to exercise vigorously, even moderate- and low-intensity activities, when performed daily, can have long-term health benefits such as lowering the risk of cardiovascular disease. Regular physical activity can reduce or eliminate some of these risk factors by lowering blood pressure, maintaining a reasonable weight or facilitating weight loss, and lowering cholesterol levels to less than 200 mg/dl.

Home maintenance, yard work, and gardening are other activities that promote health and a sense of well-being, especially for older adults. Attention to safety factors and wearing clothing and shoes appropriate to each activity are advised. Care should be taken not to aggravate existing conditions or create muscle and joint discomfort by an overly aggressive approach to exercise.

Stress Management

Because it is neither possible nor desirable to avoid all stress, women must learn how to manage stress. The nurse should assess each woman for signs of stress by using therapeutic communication skills to determine risk factors and the woman’s ability to function. See Box 4-5 for identifying symptoms of stress.

Women are twice as likely as men to have depression, anxiety, or panic attacks (NWHRC, 2009). Nurses must be alert to the symptoms of serious mental disorders, such as depression and anxiety. Women having major life changes such as divorce and separation, bereavement, serious illness, and unemployment need special attention.

For many women, the nurse is able to provide comfort, reassurance, and advice concerning helping resources, such as support groups. Many centers offer support groups to help women prevent or manage stress. The nurse can help women become more aware of the relationship between good nutrition, rest, relaxation, and exercise, and diversion, and their ability to deal with stress. In the case of role overload, determining what needs immediate attention and what can wait is important. Practical advice includes having regular breaks, taking time for friends, developing interests outside of work or the home, setting realistic goals, and learning self-acceptance. Discussing how women can maintain meaningful relationships is important. Social support and good coping skills can improve a woman’s self-esteem and give her a sense of mastery. Anticipatory guidance for developmental or expected situational crises can help her plan strategies for dealing with potentially stressful events.

The abundant literature on stress management interventions includes role-playing, relaxation techniques, biofeedback, meditation, desensitization, imagery, assertiveness training, yoga, diet, exercise, and weight control, techniques nurses can include in their repertoire of helping skills. Insufficient time prevents one-on-one assistance in many situations, but the more nurses know about these interventions, the better able they are to intervene, counsel, and direct women to appropriate resources.

Some women must be referred for counseling or other mental health therapy. Careful follow-up of all women experiencing difficulty in dealing with stress is important.

Substance Use Cessation

All women of all ages will receive substantial and immediate benefits from smoking cessation. However, this task is not easy, and most people stop several times before they accomplish their goal (Box 4-9). Many are never able to do so. Those who wish to stop smoking can be referred to a smoking-cessation program where individualized methods can be implemented. At the very least, individuals should be guided to self-help materials available from the March of Dimes, the American Lung Association, and the ACS. During pregnancy, women seem to be highly motivated to stop or at least to limit smoking. Insult to the fetus can be reduced or even prevented if cessation is accomplished by the end of the first trimester (Bernstein, Mongeon, Badger, Solomon, Heil, & Higgins, 2005).

New approaches to increase cessation among smokers and to discourage smoking among young women—especially in adolescence and during pregnancy—​are needed. Health care providers can have a positive effect on smoking behavior and should attempt to motivate smokers to stop.

Counseling women who appear to be drinking alcohol excessively or using drugs may include promoting strategies to increase self-esteem and teaching new coping skills to resist and maintain resistance to alcohol abuse and drug use. Appropriate referrals should be made, with the health care provider arranging the contact and then following up to be sure that appointments are kept. General referral to sources of support also should be provided. National groups that provide information and support for those who are chemically dependent have local branches or contacts that are listed in the local telephone book.

Anticipatory guidance includes teaching about the health and safety risks of alcohol and mind-altering substances and discouraging drug experimentation among preteen and high school students, because the use of drugs at an early age tends to be a predictor of greater involvement later.

Sexual Practices That Reduce Risk

Prevention of STIs is predicated on the reduction of high risk behaviors by educating toward a behavioral change. Behaviors of concern include multiple and casual sexual partners and unsafe sexual practices. The abuse of alcohol and drugs also is a high risk behavior and results in impaired judgment and thoughtless acts. Specific self-management measures to reduce risk are described in Chapter 7.

In addition to the prevention of STIs, women of childbearing years need information regarding contraception and family planning (see Chapter 8).

Health Screening Schedule

Periodic health screening includes history, physical examination, education, counseling, immunizations, and selected diagnostic and laboratory tests. This regimen provides the basis for overall health promotion, prevention of illness, early diagnosis of problems, and referral for appropriate management. Such screening should be customized according to a woman’s age and risk factors. In most instances it is completed in health care offices, clinics, or hospitals; however, portions of the screening are now being carried out at events such as community health fairs. An overview of health screening recommendations and immunizations for women 18 years and older is provided in Table 4-3.

Health Risk Prevention

Simple safety factors often are forgotten or perceived not to be important, yet injuries continue to have a major effect on the health status of all age-groups. Being aware of hazards and implementing safety guidelines will reduce risks. The nurse should frequently reinforce the following common-sense concepts that will protect the individual:

Health Protection

Nurses can make a difference in stopping violence against women and preventing further injury. Educating women that abuse is a violation of their rights and facilitating their access to protective and legal services constitutes a first step. Encouraging health care institutions to implement appropriate domestic violence screening programs also is of great value (see Chapter 5). Other helpful measures for women to discourage their entry into abusive relationships include promoting assertiveness and self-defense courses; suggesting support and self-help groups that encourage positive self-regard, confidence, and empowerment; and recommending educational and skills development classes that will enhance independence and self-care.

Numerous national and local organizations provide information and assistance for women in abusive situations. All nurses who work in women’s health care should become familiar with local services and legal options.

• Culture, religion, socioeconomic status, personal circumstances, individual preference, and stage of development are among the factors that influence a woman’s desire for care and her response to the health care system.

• The changing status and roles of women affect their health, needs, and ability to cope with problems.

• Anticipatory guidance is enhanced in a private, safe environment in which the interaction is culturally competent, nonjudgmental, and confidential.

• Preconception counseling allows identification and possible remediation of potentially harmful personal and social conditions, medical and psychologic conditions, environmental conditions, and barriers to care before conception.

• Conditions that increase a woman’s health risks also increase risks for her offspring.

• Periodic health screening, including history, physical examination, immunizations, and diagnostic and lab tests, provide the basis for overall health promotion, prevention of illness, early diagnosis of problems, and referral for management.

• Physical Activity Guidelines for Americans include 2½ hours a week of moderate intensity or 1¼ hours per week of vigorous-intensity exercise, or a combination of both (USDHHS, 2008).

• Health promotion and prevention of illness assists women in actualizing health potential by increasing motivation, providing information, and incorporating recommendations for accessing specific resources.