Assessment and Health Promotion

Chapter 3


Assessment and Health Promotion


Ellen Olshansky



Care of the well woman is focused on health promotion and illness prevention, recognizing that a woman is a bio-psycho-social-spiritual being, requiring a holistic approach to nursing care. To encourage appropriate health-promotion activities, it is important to conduct systematic health assessments and screenings. This chapter presents an overview of the nurse’s role in encouraging health promotion and illness prevention in women. It provides guidelines for how to conduct a complete history and physical examination. This chapter also includes a schedule of screening tests recommended for women at different stages of their lives. As background to understanding assessment, a review of female anatomy and physiology as well as the menstrual cycle is presented. Facilitators and barriers to women to enter the health care system and risk factors for women’s health across the life cycle are described. Anticipatory guidance suggestions, including nutrition and stress management, are included. Violence against women, particularly intimate partner violence (IPV) and battering of women, is discussed because it is often in the health care setting that the woman is able to acknowledge being in an abusive relationship. Examples of health-promotion efforts in the community are presented in an effort to emphasize community health approaches to care, especially since much of well woman care occurs in the community.



Female Reproductive System


The female reproductive system consists of external structures visible from the pubis to the perineum and internal structures located in the pelvic cavity. The external and internal female reproductive structures develop and mature in response to estrogen and progesterone. This process starts in fetal life and continues through puberty and the childbearing years. Reproductive structures atrophy with age or in response to a decrease in ovarian hormone production. A complex nerve and blood supply supports the functions of these structures. The appearance of the external genitalia varies greatly among women. Heredity, age, race, and the number of children a woman has borne influence the size, shape, and color of her external organs.



External Structures


The external genital organs, or vulva, include all structures visible externally from the pubis to the perineum. These include the mons pubis, labia majora, labia minora, clitoris, vestibular glands, vaginal vestibule, vaginal orifice, and urethral opening. The external genital organs are illustrated in Fig. 3-1.



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 that develop hair on the outer surfaces 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. There are no hair follicles on the labia minora, but many sebaceous follicles and a few sweat glands are present. The interior of the labia minora comprises connective tissue and smooth muscle and is supplied with extremely sensitive nerve endings. Anteriorly, the labia minora fuse to form the prepuce (the hoodlike covering of the clitoris) and the frenulum (the 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 discussed 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 that surrounds the vaginal opening, can be perforated during strenuous exercise, insertion of tampons, masturbation, and vaginal intercourse. Bartholin glands lie under the constrictor muscles of the vagina and are located posteriorly on the sides of the vaginal opening, although the ductal opening usually is not visible. During sexual arousal, the glands secrete 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 muscles and ligaments form a sling that supports the pelvic organs.



Internal Structures


The internal structures include the vagina, uterus, fallopian tubes, and ovaries. The description of these structures follows.


The vagina is a fibromuscular, collapsible, tubular structure that lies between the bladder and rectum and extends from the vulva to the uterus. 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 limited. 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. Anterior, posterior, and lateral pockets called fornices (singular: fornix) 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: cardinal, uterosacral, round, and 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. 3-2). The fundus is the dome-shaped top of the uterus and is the site at which the uterine tubes (fallopian tubes) enter the uterus. The isthmus, or 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 is also responsible for cyclic menstruation.


The uterine wall is made up of three layers: the endometrium, the myometrium, and part of the peritoneum. 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. 3-3). 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 that 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 squamo-columnar junction, where the two types of cells meet, is usually located just inside the cervical os. This junction is also called the transformation zone and is the most common site for neoplastic changes. Cells from this site are scraped for the Papanicolaou (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 provide a passage between the ovaries and the uterus for the movement of the ovum. The infundibulum has fimbriated (fringed) ends, which pull the ovum into the tube. The ovum is pushed along the tubes to the uterus by rhythmic contractions of muscles of the tubes and by the current 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 are 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. The two innominate (hip) bones (consisting of ilium, ischium, and pubis), the sacrum, and the coccyx make up the four bones of the pelvis (Fig. 3-4). Cartilage and ligaments form the symphysis pubis, 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. 3-5). 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. Variations that occur in the size and shape of the pelvis are usually related to age, race, and sex. Pelvic ossification is complete at about 20 years of age.




Breasts


The breasts are paired mammary glands located between the second and sixth ribs (Fig. 3-6). About two thirds of the breast overlies the pectoralis muscle, between the sternum and midaxillary line, with an extension to the tail of Spence. The lower one third of the breast overlies the serratus anterior muscle. The breasts are attached to the muscles by connective tissue or fascia.



The breasts of the healthy, mature woman are approximately equal in size and shape but often are not absolutely symmetric. The size and shape vary with 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 size of the glands. 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 reported differences from previous descriptions (Geddes, 2007; Love and Barsky, 2004; Ramsay, Kent, Hartmann, et al., 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. 3-6). 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, Montgomery tubercles, directly beneath the skin. 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.


The vascular supply to the mammary gland is abundant. In the nonpregnant state there is no obvious vascular pattern in the skin. 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. The lymphatics form a rich network in the deeper portions of the breasts. The primary deep lymphatic pathway drains laterally toward the axillae.


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


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, 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 alternations in breast size and activity reach their minimum level about 5 to 7 days after menstruation stops. Therefore breast self-examination (BSE) (systematic palpation of breasts to detect signs of breast cancer or other changes) is best carried out during this phase of the menstrual cycle (see Guidelines box). Although monthly BSE used to be recommended to all women, the current guidelines recommend BSE as an option (American Cancer Society, 2012b), mostly because they believe that many unnecessary biopsies and other procedures result. However, breastcancer.org (2012) continues to recommend that all women perform BSE monthly (see the Critical Thinking Case Study).



image Guidelines


Breast Self-Examination


If you choose to perform a breast self-examination, the best time is when breasts are not tender or swollen.


How to examine your breasts:



1. Lie down and put a pillow under your right shoulder. Place your right arm behind your head (Fig. 1).


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2. Use the finger pads of your three middle fingers on your left hand to feel for lumps or thickening. Your finger pads are the top third of each finger. Use circular motions of the finger pads to feel the breast tissue.


3. Press firmly enough to know how your breast feels. Use light pressure to feel the tissue just under the skin, medium pressure for a little deeper, and firm pressure to feel the breast tissue close to the chest and ribs. A firm ridge in the lower curve of the breast is normal.


4. Move around the breast in a set way, such as using an up-and-down or vertical line pattern (Fig. 2). Go up to the collar bone and down to the ribs and from your underarm on the side to the middle of your chest. Use the same technique every time. It will help you to make sure that you have gone over the entire breast area and to remember how your breast feels.


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5. Now examine your left breast using the finger pads of your right hand.


6. You may want to check your breasts while standing in front of a mirror. See if there are any changes in the way your breasts look: dimpling of the skin, changes in the nipple, or redness or swelling.


7. Checking the area between the breast and the underarm and the underarm itself is important. Examine the area above the breast to the collarbone and to the shoulder while you are standing or sitting up with your arms slightly raised.


8. If you find any changes, see your health care provider right away.


Adapted from American Cancer Society: Breast awareness and self-exam, 2013, www.cancer.org.




Menstruation


Menarche and Puberty


Although young girls secrete small, rather constant amounts of estrogen, a marked increase occurs between 8 and 11 years of age. 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 13 years of age.


Initially, menstrual periods are irregular, unpredictable, painless, and anovulatory (no ovum is 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 the ovary) periods tend to be regular, with estrogen dominating the first half of the cycle and progesterone dominating the second half of the cycle.


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: endometrial, hypothalamic-pituitary, and ovarian. The average length of a menstrual cycle is 28 days, but variations are normal. The first day of bleeding is designated as day 1 of the menstrual cycle, or menses (Fig. 3-7). The average duration of menstrual flow is 5 days (with a range of 3 to 6 days) and the average blood loss is 50 mL (with a range of 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. A woman’s age, physical and emotional status, and environment influence the regularity of her menstrual cycles.



Endometrial Cycle


The four phases of the endometrial cycle are (1) the menstrual phase, (2) the proliferative phase, (3) the secretory phase, and (4) the ischemic phase (see Fig. 3-7). During the menstrual phase, shedding of the functional two thirds of the endometrium (the compact and spongy layers) is initiated by periodic vasoconstriction in the upper layers of the endometrium. The basal layer is always retained, and regeneration begins near the end of the cycle from cells derived from the remaining glandular remnants or stromal cells in this layer.


The proliferative phase is a period of rapid growth lasting from about the fifth day to the time of ovulation. The endometrial surface is completely restored in approximately 4 days, or slightly before bleeding ceases. From this point on, an eightfold to tenfold thickening occurs, with a leveling off of growth at ovulation. The proliferative phase depends on estrogen stimulation derived from ovarian follicles.


The secretory phase extends from the day of ovulation to about 3 days before the next menstrual period. After ovulation, large amounts of progesterone are produced. An edematous, vascular, functional endometrium is now apparent. At the end of the secretory phase, the fully matured secretory endometrium reaches the thickness of heavy, soft velvet. It becomes luxuriant with blood and glandular secretions—a suitable protective and nutritive bed for a fertilized ovum.


Implantation of the fertilized ovum generally occurs about 7 to 10 days after ovulation. If fertilization and implantation do not occur, the corpus luteum, which secretes estrogen and progesterone, regresses. With the rapid decrease in progesterone and estrogen levels, the spiral arteries go into spasm. During the ischemic phase, the blood supply to the functional endometrium is blocked and necrosis develops. The functional layer separates from the basal layer, and menstrual bleeding begins, marking day 1 of the next cycle (see Fig. 3-7).



Hypothalamic-Pituitary Cycle


Toward the end of the normal menstrual cycle, blood levels of estrogen and progesterone decrease. Low blood levels of these ovarian hormones stimulate the hypothalamus to secrete gonadotropin-releasing hormone (GnRH). In turn, GnRH stimulates anterior pituitary secretion of follicle-stimulating hormone (FSH). FSH stimulates development of ovarian graafian follicles and their production of estrogen. Estrogen levels begin to decrease, and hypothalamic GnRH triggers the anterior pituitary to release luteinizing hormone (LH). A marked surge of LH and a smaller peak of estrogen (day 12) (see Fig. 3-7) precede the expulsion of the ovum from the graafian follicle by about 24 to 36 hours. LH peaks at about day 13 or 14 of a 28-day cycle. If fertilization and implantation of the ovum have not occurred by this time, regression of the corpus luteum follows. Levels of progesterone and estrogen decline, menstruation occurs, and the hypothalamus is once again stimulated to secrete GnRH. This process is called the hypothalamic-pituitary cycle.



Ovarian Cycle


The primitive graafian follicles contain immature oocytes (primordial ova). Before ovulation, from 1 to 30 follicles begin to mature in each ovary under the influence of FSH and estrogen. The pre-ovulatory surge of LH affects a selected follicle. The oocyte matures, ovulation occurs, and the empty follicle begins its transformation into the corpus luteum. This follicular phase (pre-ovulatory phase) (see Fig. 3-7) of the ovarian cycle varies in length from woman to woman. Almost all variations in ovarian cycle length are the result of variations in the length of the follicular phase. On rare occasions (i.e., 1 in 100 menstrual cycles), more than one follicle is selected and more than one oocyte matures and undergoes ovulation.


After ovulation, estrogen levels drop. For 90% of women, only a small amount of withdrawal bleeding occurs, and it goes unnoticed. In 10% of women, there is sufficient bleeding for it to be visible, resulting in what is termed midcycle bleeding.


The luteal phase begins immediately after ovulation and ends with the start of menstruation. This postovulatory phase of the ovarian cycle usually requires 14 days (range 13 to 15 days). The corpus luteum reaches its peak of functional activity 8 days after ovulation, secreting the steroids estrogen and progesterone. Coincident with this time of peak luteal functioning, the fertilized ovum is implanted in the endometrium. If no implantation occurs, the corpus luteum regresses and steroid levels drop. Two weeks after ovulation, if fertilization and implantation do not occur, the functional layer of the uterine endometrium is shed through menstruation.




Prostaglandins


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


PGs are produced in most organs of the body, including the uterus. Menstrual blood is a potent PG 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. PGs play an important role in many physiologic, pathologic, and pharmacologic reactions. PGF, PGE4, and PGE2 are most commonly used in reproductive medicine.


PGs affect smooth muscle contractility and modulation of hormonal activity. Indirect evidence indicates 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 miscarriage and induced abortion, and onset of labor (term and preterm).


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


PGs may play a key role in ovulation. If PG levels do not rise 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 the uterine cavity (from ejaculated semen) increases the motility of uterine musculature, which may assist the transport of sperm through the uterus and into the oviduct.


PGs produced by the woman cause regression of the corpus luteum and regression 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 may also be involved in dysmenorrhea (see Chapter 4) and preeclampsia/eclampsia (see Chapter 12).



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 Latin mensis, month, and Greek pauses, to cease) refers only to the last menstrual period. However, unlike menarche, 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.



Sexual Response


The hypothalamus and anterior pituitary glands in females regulate the production of FSH and LH. The target tissue for these hormones is the ovary, which produces ova and secretes estrogen and progesterone. A feedback mechanism between hormone secretion from the ovaries, the hypothalamus, and the anterior pituitary aids in the control of the production of sex cells and steroid sex hormone secretion.


Although the first outward appearance of maturing sexual development occurs at an earlier age in females, both females and males achieve physical maturity at approximately 17 years of age; however, individual development varies greatly. Anatomic and reproductive differences notwithstanding, women and men are more alike than different in their physiologic response to sexual excitement and orgasm. For example, the glans clitoris and the glans penis are embryonic homologs. Little difference exists between female and male sexual response; the physical response is essentially the same whether stimulated by coitus, fantasy, or masturbation. Physiologic sexual response can be analyzed in terms of two processes: vasocongestion and myotonia.


Sexual stimulation results in increase in circulation to circum-vaginal blood vessels (lubrication in the female), causing engorgement and distention of the genitals. Venous congestion is localized primarily in the genitalia, but it also occurs to a lesser degree in the breasts and other parts of the body. Arousal is characterized by myotonia (increased muscular tension), resulting in voluntary and involuntary rhythmic contractions. Examples of sexually stimulated myotonia are pelvic thrusting, facial grimacing, and spasms of the hands and feet (carpopedal spasms).


The sexual response cycle is classically divided into four phases: excitement, plateau, orgasmic, and resolution, according to the seminal work of Masters and Johnson (1966). The four phases occur progressively, with no sharp dividing line between any two phases. The time, intensity, and duration for cyclic completion also vary for individuals and situations. Other researchers have suggested different models to explain sexual response. Leeman and Rogers (2012) emphasize the need to address sexuality and possible sexual difficulties with women in the postpartum period. Specific issues related to this period (and prior procedures such as episiotomy) must be considered in counseling to promote healthy sexuality during the postpartum period. Despite these alternate models of sexual response, it is still common to describe the classic four stages in which specific body changes take place in sequence, and this description is useful in educating and talking with women who may have concerns about possible sexual dysfunction. Table 3-1 compares male and female body changes during each of the four phases of the sexual response cycle.



TABLE 3-1


FOUR PHASES OF SEXUAL RESPONSE

































REACTIONS COMMON TO BOTH SEXES FEMALE REACTIONS MALE REACTIONS
Excitement Phase
Heart rate and blood pressure increase. Nipples become erect. Myotonia begins. Clitoris increases in diameter and swells. External genitalia become congested and darken. Vaginal lubrication occurs; upper two thirds of vagina lengthens and extends. Cervix and uterus pull upward. Breast size increases. Erection of the penis begins; penis increases in length and diameter. Scrotal skin becomes congested and thickens. Testes begin to increase in size and elevate toward the body.
Plateau Phase
Heart rate and blood pressure continue to increase. Respirations increase. Myotonia becomes pronounced; grimacing occurs. Clitoral head retracts under the clitoral hood. Lower one third of vagina becomes engorged. Skin color changes occur—red flush may be observed across breasts, abdomen, or other surfaces. Head of penis may enlarge slightly. Scrotum continues to grow tense and thicken. Testes continue to elevate and enlarge. Preorgasmic emission of two or three drops of fluid appears on the head of the penis.
Orgasmic Phase
Heart rate, blood pressure, and respirations increase to maximum levels. Involuntary muscle spasms occur. External rectal sphincter contracts. Strong rhythmic contractions are felt in the clitoris, vagina, and uterus. Sensations of warmth spread through the pelvic area. Testes elevate to maximum level. Point of “inevitability” occurs just before ejaculation and an awareness of fluid in the urethra. Rhythmic contractions occur in the penis. Ejaculation of semen occurs.
Resolution Phase
Heart rate, blood pressure, and respirations return to normal. Nipple erection subsides. Myotonia subsides. Engorgement in external genitalia and vagina resolves. Uterus descends to normal position. Cervix dips into seminal pool. Breast size decreases. Skin flush disappears. Fifty percent of erection is lost immediately with ejaculation; penis gradually returns to normal size. Testes and scrotum return to normal size. Refractory period (time needed for erection to occur again) varies according to age and general physical condition.


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Barriers to Entering the Health Care System


Financial Issues


Access to care varies greatly, 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 to the promotion of health and comprehensive care, despite the fact that people are discharged earlier from hospitals, requiring more care in homes and community settings.


In the United States, disparity among races and socioeconomic classes affects many facets of life including health. Limited finances is associated with lack of access to care, delay in seeking care, few prevention activities, and little accurate information about health and the health care system. Women use health care services more often than men but are more likely than men to have difficulty in financing the services. Many poor women have traditionally been underinsured or uninsured, but rules about health insurance and who and what are covered are undergoing a transition with the Affordable Care Act (healthcare.gov, 2012). People will not be denied insurance because of pre-existing conditions, and various preventive health services will be covered under health insurance. However this legislation is far from decided and its impact on the American people will not be known for years.


With a greater focus on preventive health care services and with 32 million formerly uninsured patients having access to health care, nurses, advanced practice nurses, including nurse practitioners, midwives, and clinical nurse specialists, are critical to the provision of high quality, safe, effective, and accessible health care (see the Community Focus box).




Cultural Issues


We live in a multicultural society with constantly changing demographics, and for nursing care of women to be optimal, cultural differences must be addressed with great sensitivity and competency. Nurses are in excellent positions to be responsible for providing culturally sensitive and competent health care (Escallier, Fullterton, and Messina, 2011). A variety of reasons are given to explain some of the differences in accessing care when financial barriers are adjusted. Some women experience racial discrimination or disrespectful, disillusioning, or discouraging encounters with community service providers such as social services and health care providers. Many women do not seek care from the health care system because of lack of trust (Yang, Matthews, and Hillemeier, 2011). A lack of cross-cultural communication also presents problems. Desired health outcomes are best achieved when the health care provider has knowledge of and understanding about the culture, language, values, priorities, and health beliefs of those in various ethnic groups. Conversely, members of these various groups should understand the health goals to be achieved and the methods proposed to do so. Language differences can produce profound barriers between patients and providers. Even with an interpreter, misinformation can occur on both sides of the communication.


Providers must consider culturally based differences that could affect the treatment of diverse groups of women, and the women themselves must share practices and beliefs that could influence their responses to treatment or willingness to adhere to treatment. 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 plan of care, as with birth control measures or blood transfusions. Some cultural groups prefer folk medicine, homeopathy, or prayer to traditional Western medicine; and others attempt combinations of some or all practices. Nurses can integrate into their own practice various holistic approaches to care, in accordance with Dossey’s (2010) Theory of Integral Nursing. It is critically important to be sensitive to cultural differences and at the same time not stereotype and assume that a woman has certain beliefs because of her ethnic background. Although the amount of health information on the Internet is increasing, information in languages other than English is limited and not all information on the Internet is accurate, making health literacy an important issue in culturally competent care.



Gender Issues


Gender influences provider-patient communication and may influence access to health care in general. 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 do men and, some believe, more effectively. The gender of the provider plays a role. The concept of “gender concordance,” in which the patient’s gender matches the health care provider’s gender, was found to be important for women seeking Pap tests (McAlearney, Oliveri, Post, et al., 2011). McAlearney et al. found that women were more comfortable having a Pap test performed by a female physician and having a female nurse present.


Sexual orientation may produce another barrier. Nurses need to understand the specific health care needs and issues related to sexual orientation (Brennan, Barnsteiner, de Leon Siantz, et al., 2012). Some lesbians may not disclose their sexual 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). Lesbians themselves may hold beliefs that are incorrect (e.g., that they have immunity to human immunodeficiency virus [HIV], sexually transmitted infections [STIs], and certain cancers [e.g., cervical]). The perceived lack of risk can result in lesbians avoiding health care, as well as in health care providers giving incorrect advice or not providing appropriate 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 not different from that of the heterosexual woman. To offset stereotypes, it is necessary for providers to develop an approach that does not assume that all patients are heterosexual. More content related to this issue needs to be included in nursing curricula.



Caring for the Well Woman Across the Life Span: The Need for Health Promotion and Disease Prevention


Maintaining optimal health is a goal for all women. Essential components of health maintenance are the identification of unrecognized problems and potential risks and the education and health promotion needed to reduce them. Current trends in the health care of women have expanded beyond a reproductive focus. A holistic approach to women’s health care goes beyond simple reproductive needs and includes a woman’s health needs throughout her lifetime, with attention to physical, mental/emotional, social, and spiritual health. Women’s health is considered to be part of the primary health care delivery system with assessment and screening focusing on a multisystem evaluation that emphasizes the maintenance and enhancement of wellness. Prevention of cardiovascular disease, promotion of mental health, and prevention of cancers beyond just reproductive-related cancers are all components of well-woman care. It is important to consider all aspects of women’s health, particularly in light of the fact that the leading causes of death in women in the United States include more than just reproductive health conditions (Box 3-1).



Even when focusing on reproductive health, it is critical to take a holistic approach to the health of women. This is especially important for women in their childbearing years because conditions that increase a woman’s health risks are related not only to her well-being but also to the well-being of both mother and baby in the event of a pregnancy. Prenatal care is an example of prevention that is practiced after conception. However, prevention and health maintenance are needed before conception because many of the mother’s risks can be identified and eliminated, or at least modified.


As a female progresses through developmental ages and stages, she is faced with conditions that are age related. An overview of conditions and circumstances that increase health risks in women across the life span is presented in the next section.



Adolescents


All teens undergo progressive development of sex characteristics. They experience the developmental tasks of adolescence such as establishing identity and sexual orientation, emancipating from family, and establishing career goals. Some of these processes can produce great stress for the adolescent, and the health care provider should treat her very carefully. Female teenagers who enter the health care system usually do so for screening or because of a problem such as episodic illness or accidents. Previous guidelines recommended that young women should be screened with Pap tests at age 18 or when they become sexually active. Guidelines suggest that Pap tests begin at age 21, but controversy exists about the evidence to support these new guidelines, with some health care providers providing evidence for earlier testing (Zhao, Kalpos-Novak, and Austin, 2011). Gynecologic problems are often associated with menses (either bleeding irregularities or dysmenorrhea), vaginitis or leukorrhea, STIs, contraception, or pregnancy. The adolescent is also at risk for use of street drugs, for eating disorders, and for stress, depression, and anxiety.


Many women first enter the health care delivery system for a Pap test or for 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, infertility, pain, abnormal bleeding, or vaginal discharge. Recently the availability of the human papillomavirus (HPV) vaccine has created another reason for young women to enter the health care system (Saraiya, Rosser, and Cooper, 2012).



Teenage Pregnancy


Most young women begin having sex in the mid- to late teens. At age 15, 13% of teens have had sex, but by age 19, 70% of teens have had sexual intercourse (Guttmacher Institute, 2012). A sexually active teen who does not use contraception has a 90% chance of pregnancy within 1 year. The United States has the highest teen pregnancy rate in the industrialized world. By age 20, one third of all American girls get pregnant; most of these pregnancies are unintended (CDC, 2012).


Effective educational programs about sex and family life are imperative to control the rate of teen pregnancy and STIs (Box 3-2). The nurse can provide information regarding the need for child spacing, methods of family planning that are consistent with religious and personal preferences, non-contraceptive benefits of certain methods, the appropriate use of methods selected, and the protection of future fertility when so desired.



Pregnancy in the teenager who is 16 years of age or younger often introduces additional stress into an already stressful developmental period. The emotional level of such teens is commonly characterized by impulsiveness and self-centered behavior, and they often place primary importance on the beliefs and actions of their peers. In attempts to establish a personal and independent identity, many teens do not realize the consequence of their behavior; their thinking processes do not include planning for the future.


Teenagers usually lack the financial resources to support a pregnancy and may not have the maturity to avoid teratogens or have prenatal care and instruction or follow-up care. Children of teen mothers may be at risk for abuse or neglect because of the teen’s inadequate knowledge of growth, development, and parenting. Implementation of specialized adolescent programs in schools, communities, and health care systems is demonstrating continued success in reducing the birthrate in teens.



Young and Middle Adulthood


Because women ages 20 to 40 years have a need for contraception, pelvic and breast screening, and pregnancy care, they may prefer to use their gynecologic or obstetric provider as their primary care provider. During these years the woman may be “juggling” family, home, and career responsibilities, with resulting increases in stress-related conditions. Health maintenance includes not only pelvic and breast screening but also promotion of a healthy lifestyle (i.e., good nutrition, regular exercise, no smoking, moderate or no alcohol consumption, sufficient rest, stress reduction, and referral for medical conditions and other specific problems). Common conditions requiring well-woman care include vaginitis, urinary tract infections, menstrual variations, obesity, sexual and relationship issues, and pregnancy.





Approaches to Care at Specific Stages of a Woman’s Life


There are certain specific approaches to care of women at different stages of their lives. Several of these approaches are described in the next section.



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 care guides couples on how to avoid unintended pregnancies, identify and manage risk factors in their lives and their environment, and identify healthy behaviors that promote the well-being of the woman and her potential fetus. It has been estimated that 31% of pregnant women experience some complications of pregnancy, including mental health issues (mostly depression) and factors that lead to the need for cesarean birth (HealthyPeople.gov, 2012b). In addition, 12% of births result in preterm infants and 8.2% result in low-birth-weight infants (HealthyPeople.gov, 2012a).


Activities that promote healthy mothers and babies must be initiated 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. These hazards include drugs, viruses, and chemicals. In many instances, counseling can promote behavior modification before damage is done or the woman can make an informed decision about her willingness to accept potential hazards.


Preconception care is important for women who have had a problem with a previous pregnancy (e.g., miscarriage or preterm birth). Although causes are not always identifiable, in many cases problems can be discovered and treated and do not recur in subsequent pregnancies. Preconception care is also important to minimize fetal malformations. For example, the offspring of women who have type 1 diabetes mellitus have significantly more congenital anomalies than do children of mothers without diabetes. The rate of malformation is greatly reduced when the insulin-dependent woman with diabetes has excellent blood glucose control at the time she becomes pregnant and maintains euglycemia (normal blood sugar level) throughout the period of organ development in the fetus. The incidence of neural tube defects such as spina bifida and anencephaly is decreased significantly with the intake of 400 mcg of supplemental folic acid.


The components of preconception care such as health promotion, risk assessment, and interventions are outlined in Box 3-3.



Box 3-3   Components of Preconception Care




Risk Factor Assessment




• Chronic diseases



• Infectious diseases



• Reproductive history



• Genetic or inherited conditions (e.g., sickle cell anemia, Down syndrome, cystic fibrosis)


• Medications and medical treatment



• Personal behaviors and exposures



• Environmental (home, workplace) conditions





Pregnancy


A woman’s entry into health care is often associated with pregnancy, for either diagnosis or actual prenatal care. Early entry into prenatal care (i.e., within the first 12 weeks) allows for identification of the woman at risk for complications and initiation of measures to prevent problems or treat them if they arise. The U.S. Department of Health and Human Services (2012) has emphasized the importance of early and consistent prenatal care to improve outcomes for both mother and infant. Major goals of prenatal care are listed in Box 3-4 and should be addressed in the first visit. Extensive discussion of pregnancy is found in Unit 3.




Fertility Control and Infertility


More than half of the pregnancies in the United States each year are unintended (Taylor, Levi, and Simmonds, 2010), and the majority of these occur in women who either do not use contraception or who experienced a contraceptive failure. 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 5).


Women also enter the health care system because of their desire to become pregnant. 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 factors that affect fertility negatively (including age-related infertility for the woman). In addition, 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.


Infertility can cause emotional pain for many couples, and the inability to produce offspring sometimes results in feelings of failure and places inordinate stress on the couple’s relationship. Much time, money, and emotional investment can be used for testing and treatment in efforts to build a family.


Steps toward prevention of infertility should be undertaken as part of ongoing routine health care, and information about how women may prevent some causes of infertility 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 5.

Sep 16, 2016 | Posted by in NURSING | Comments Off on Assessment and Health Promotion

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