ch 5

Introduction

behavioral counseling is recommended for sexually active adolescents and high-risk adults to reduce their risk

CDC Classifications of STIs

• Infections characterized by vaginal discharge

  • Vulvovaginal candidiasis

  • Trichomoniasis

  • Bacterial vaginosis

• Infections characterized by cervicitis

  • Chlamydia

  • Gonorrhea

• Infections characterized by genital ulcers

  • Genital herpes simplex

  • Syphilis

• Vaccine-preventable STIs

  • Hepatitis A, B, C

  • Human papillomavirus (HPV)

• Ectoparasitic infections

  • Pediculosis pubis

  • Scabies

Adolescents

• all states allow minors to consent for their own STI services, and no state requires parental consent for STI care

Risk Factors

• Due to biological and behavioral factors, adolescents are at high risk for STIs and their serious long-term consequences if left undiagnosed or untreated

• adolescent female columnar epithelial cells are more exposed and vulnerable to STIs (ex: chlamydia and gonorrhea) since the cells cover the vaginal side of the cervix (external os/orifice) where they are unprotected by cervical mucus

  • with age, these cells move to a more protected position

• High-risk factors: sex in early to middle adolescence, alcohol & substance use, male to male sex, detention center living, mood disorders, adverse childhood experiences (ex: maltreatment, sexual abuse), multiple or new sex partners or a partner with multiple partners and not using condoms

• Inexperience with condoms

  • do not store at a hot temp

  • hold condom while withdrawing

• Untreated STI → PID → infertility, adverse pregnancy outcomes, anogenital & cervical cancers

• Having other STIs raises the risk of transmitting and acquiring HIV, as skin breaks make it easier for the virus to enter the body

Nursing Assessment

• All states recognize chlamydia, gonorrhea, syphilis, chancroid, and HIV as notifiable conditions

  • federal law mandates HCP to report new cases of these to public health authorities

Nursing Management

Teaching Guidelines 5.1: Proper Condom Use

• Proper external condom use:

  • Use latex or polyurethane condoms

    • Polyurethane: more expensive, thinner, looser fit, breaks more often

      • just as effective as latex

      • not compatible with all the different kinds of lubricants (water, silicone, silicone hybrid, oil) so check each lubricant brand for compatibility

  • Ensure storage in a cool, dry place away from direct sunlight

    • no wallet, automobile, or anywhere it could be exposed to extreme temps

  • Check expiration date

  • Open carefully, no sharp objects

  • Do not use if it appears brittle, sticky, or discolored (signs of aging)

  • Put condom on before any genital contact (sperm is present in pre-ejaculate fluid)

  • Put condom on and withdraw after sex when penis is erect

  • Ensure it is placed so it will readily unroll; hold the tip of the condom while unrolling

  • Ensure there is a space at the tip for semen to collect, but make sure no air is trapped in the tip (pinch air out)

  • Ensure adequate lubrication during intercourse

    • use only water-based lubricants (K-Y Jelly) with latex condoms.

      • Oil-based or petroleum-based lubricants (body lotion, massage oil, cooking oil) weakens latex condoms

• Proper internal condom use:

  • Do not use an external condom with an internal condom.

  • thick inner ring with the closed end goes into the vagina (similar to inserting a tampon); the thin outer ring remains outside the body

  • Ensure condom is not twisted, and that the outer ring does not get pushed into the vagina

Table 5.2 • Guidelines: Barriers to Condom Use and Means to Overcome Them

Infections characterized by vaginal discharge

• Vaginitis: inflammation and infection of the vagina

  • causes: more often than not, by one of three organisms:

    • Candida, a fungus

    • Trichomonas, a protozoan

    • Gardnerella, a bacterium

Genital/Vulvovaginal Candidiasis

Genital/vulvovaginal candidiasis (VVC):

• one of the most common causes of vaginal discharge

• also referred to as yeast, monilia, and fungal infection

• NOT considered an STI because Candida is a normal constituent in the vagina and becomes pathologic only when the vaginal environment is altered

Therapeutic Management

• Treatment medications:

  • Miconazole (Monistat) - vaginal cream or suppository (OTC)

  • Clotrimazole (Gyne-Lotrimin) - vaginal tablet or cream (OTC)

  • Tioconazole (Monistat-1; Vagistat-1) - vaginal tablet or cream (OTC), single dose

  • Terconazole - vaginal ointment

  • Butoconazole (Gynazole-1) - vaginal cream, single dose

  • Fluconazole (Diflucan) - 150 mg oral tablet, usually 1 but possibly 2 doses

  • Ibrexafungerp (Brexafemme) - 150 mg oral tablet, two tabs given twice in 1 day; used in nonpregnant patients who cannot use fluconazole

• Topical azole preparations are an effective treatment

• untreated VVC during pregnancy → newborn oral thrush during birth, must be treated with a local azole preparation after birth

Nursing Assessment

• predisposing factors:

  • Pregnancy

  • oral contraceptives with high estrogen content

  • broad-spectrum antibiotics, steroid and immunosuppressive drugs

  • DM, obesity

  • HIV infection

  • Wearing tight, restrictive clothes and nylon underpants

  • Trauma to vaginal mucosa from chemical irritants or douching

• Typical symptoms, which can worsen just before menses, include:

  • Pruritus (itching)

  • Vaginal discharge (thick, white, curdlike)

  • Vaginal soreness

  • Vulvar burning

  • Erythema in the vulvovaginal area

  • Dyspareunia

  • External dysuria (felt at the outer opening of the genital area)

• Speculum examination will reveal white plaques on the vaginal walls

• Definitive diagnosis is made by a wet smear, which reveals the fungal characteristic when viewed under microscope

Nursing Management

preventive measures:

• Avoid douching

• Use condoms, limit sex partners

• Urinate with knees spread wide apart.

• Gently wash and dry the vulva with mild, unscented bar soap, avoiding liquid soaps and body washes.

• Avoid powders, bubble baths, and perfumed vaginal sprays.

• Change out of wet bathing suits ASAP

• Reduce dietary intake of simple sugars and soda.

• Wash underwear in hot water with unscented detergent and dry on high heat to kill yeast

• Avoid the use of superabsorbent tampons (use pads instead).

Trichomoniasis

• a flagellated protozoan that is a common parasite found in all sexes

• mainly sexually transmitted, but can also live on damp/wet surfaces (poorly cleaned/maintained hot tubs, drains, towels, bathing suits)

• females may or may not be symptomatic, males are often asymptomatic

• can cause preterm birth, PROM, low-birth-weight infants, PID, infertility

• infection doubles the risk of HIV susceptibility

• it IS an STI but is NOT nationally reportable

Therapeutic Management

single 2g oral dose of metronidazole (Flagyl), tinidazole (Tindamax), or secnidazole

• for both partners

• preferred treatment in females using metronidazole: multidose therapy, 500mg BID for 5-7 days

Nursing Assessment

• clinical manifestations:

  • heavy yellow/green, grayish frothy, or bubbly discharge

  • Vaginal pruritus and vulvar soreness; vaginal or vulvar erythema

  • Lower abdominal pain

  • Dyspareunia

  • A cervix that may bleed on contact

  • Dysuria

  • Foul vaginal odor

  • Petechiae on the cervix (“strawberry cervix”)

• confirming diagnosis:

  • nucleic acid amplification tests (NAATs) are highly accurate with sensitivity and specificity near 100%

  • Evaluation of vaginal pH and microscopy, where a motile flagellated trichomonad is visualized under the microscope, are are faster and more convenient but also less accurate

    • vaginal pH >4.5 is a typical finding

Nursing Management

• Instruct both patients to avoid sex until BOTH are cured (completed therapy & symptom-free)

• Follow-up testing is not indicated if symptoms resolve with treatment

Bacterial Vaginosis

• results from a shift in the balance of the vaginal microflora

  • cause: new or multiple sex partners, douching, not using condoms

• most prevalent cause of vaginal discharge or malodor

• most are asymptomatic

• IS an STI

  • bacterial imbalance is associated with sexual contact but is not usually spread through sex

• an associated inflammatory response is lacking

• can cause preterm labor, high risk of contracting HIV and other STIs, low birth weight, endometritis, and PID

Therapeutic Management

• Treatment: indicated for confirmed symptomatic BV patients or those having a gynecologic procedure involving the vagina

  • oral or vaginal metronidazole (Flagyl), clindamycin (Cleocin) cream

  • Treatment of the male sex partner is not indicated, however it can spread between female sex partners

Nursing Assessment

• Assess for clinical manifestations

• primary symptoms: thin white/grayish homogeneous vaginal discharge, pain, itching & burning in or around the vagina, burning when urinating, and a characteristic “stale fish” odor often recognized only after sexual intercourse

• diagnosis in which ¾ of the following four criteria must be met:

  • Thin, white/grayish vaginal discharge that adheres to the vaginal mucosa

  • Vaginal pH >4.5

  • Positive “whiff test” (secretion is mixed with a drop of 10% potassium hydroxide on a slide, producing a characteristic stale fishy odor)

  • presence of clue cells on wet-mount examination

Nursing Management

• primary prevention and education to limit recurrences

  • high risk behaviors: recent antibiotic use, douching, sexual activity with multiple partners, not using condoms

• reinforce importance of following medication instructions and finishing the entire course of prescribed antibiotics

Infections characterized by cervicitis

• Cervicitis: inflammation or infection of the cervix

• Ranges from symptomless erosions to an inflamed, bleeding cervix (on contact) with abnormal discharge containing unusual organisms

• usually caused by gonorrhea or chlamydia, as well as almost any pathogenic bacterial agent and a number of viruses

• highest incidence: young females aged 15-24 years & HIV-positive females

• treatment: targeted therapy for the specific organism causing it

• preventative measures: the ABC (abstinence, being monogamous, condom use) strategy

Chlamydia

• cause by Chlamydia trachomatis (bacterium)

  • intracellular parasite, cannot produce its own energy, depends on the host for survival

  • often difficult to detect

  • long-term consequences if left untreated

• most common risk factors: young age, history of a previous chlamydia infection, new sex partner or multiple sex partners in the past 3 months, lack of barrier contraception use, disadvantaged socioeconomic conditions, Black females

• being asymptomatic is common among both males and females

• untreated females → cervicitis, urethritis, PID → infertility, chronic pelvic pain, ectopic pregnancies

  • also increases the risk of transmitting the infection to partners

• untreated in pregnancy → PROM, preterm labor, and low-birth-weight newborns

• Newborns of infected moms may develop ophthalmia neonatorum, an acute conjunctivitis in the first month of birth

• CDC recommendation: yearly testing of all sexually active or pregnant females ages 25 and younger, as well as older or pregnant females with risk factors

Therapeutic Management

• diagnosis: nucleic acid amplification tests (NAATs) on the cervical or vaginal swabs and urine samples

• Antibiotics (patient AND partner)

  • doxycycline (preferred treatment) 100mg PO BID for 7 days

    • if doxycycline is contraindicated, like in pregnancy, use azithromycin (Zithromax) 1g PO single dose

• Retesting in 3 months to identify reinfection is suggested

• confirmed patients should be tested and treated for other STIs

Nursing Assessment

• significant risk factors:

  • age <24

  • multiple sex partners, new sex partner

  • unprotected vaginal, anal, or oral sex

  • oral contraceptive use

  • HIV-positive

  • Being pregnant

  • history of another STI

• majority of females are asymptomatic

• clinical manifestations (if symptomatic):

  • Mucopurulent vaginal discharge (a combination of mucus and pus)

  • Urethritis

  • Bartholinitis

    • infection & inflammation of the Bartholin's glands (located on either side of the vaginal opening producing mucus for lubrication)

  • Endometritis

  • Salpingitis

    • inflammation of one or both fallopian tubes due to an infection

    • a type of PID

  • Dysfunctional uterine bleeding

Nursing Management of Chlamydia and Gonorrhea

• treatment strategies, referral sources, and preventive measures

• Provide education about risk factors

• Emphasize the importance of seeking treatment, adhering to prescribed treatment regimens, informing sex partners, and receiving any recommended follow-up testing

• Stress that both of these STIs can lead to infertility and long-term sequelae

Gonorrhea

• a severe bacterial infection that can occur in the genitals, rectum, or throat

• cause: N. gonorrhoeae

• site of infection is the columnar epithelium of the endocervix (the cervical canal between the internal and external os)

• STI, almost exclusively transmitted by sexual activity

• association during pregnancy: chorioamnionitis, premature labor, spontaneous abortion, PROM, and low-birth-weight or small-for-gestational-age infants

• can also be transmitted to the newborn as ophthalmia neonatorum by direct contact during vaginal birth

  • highly contagious

  • untreated → blindness, corneal ulceration

• increases the risk of PID, infertility, ectopic pregnancy, chronic pelvic pain, other STIs, HIV acquisition and transmission

• can be difficult to cure due to antibiotic resistance

• asymptomatic common among females

  • major factor in the spread of it

• CDC recommends yearly testing for all sexually active or pregnant females ages 25 and younger, as well as older or pregnant females with risk factors

• pregnant patients should be screened during the 1st trimester and again in the 3rd trimester if at high risk for STIs

• Nucleic acid hybridization tests (GenProbe) are used for diagnosis

• spreads upward: endocervix → uterine endometrium → fallopian tubes → peritoneal cavity

  • peritoneum and ovary involvement = PID

• untreated → enters bloodstream → disseminated (widespread) gonococcal infection

  • can invade the joints (arthritis), the heart (endocarditis), the brain (meningitis), and the liver (toxic hepatitis)

Therapeutic Management

• treatment of choice: single IM high dose of ceftriaxone (Rocephin) 500mg for pregnant and nonpregnant females weighing less than 150kg (330lbs)

• If chlamydia has not been ruled out, proper treatment for chlamydia should be started

• Retesting in 3 months to identify reinfection is suggested

• ophthalmia neonatorum prevention: prophylactic agent (erythromycin ointment or azithromycin solution) instilled into the newborns eyes

Nursing Assessment

• risk factors: low education level, low socioeconomic status, single status, inconsistent use of barrier contraceptives, age under 25 years, being of an underrepresented ethnic population, substance misuse, history of previous gonorrhea, having a new sex partner, having multiple sex partners

• involves taking a health history that includes a comprehensive sexual history

• most females are asymptomatic

• Assess for clinical manifestations:

  • Mucopurulent vaginal discharge

  • Dysuria

  • Dyspareunia

  • Abnormal vaginal bleeding

  • Bartholin abscess

    • painful infection that develops when a Bartholin gland cyst becomes infected, leading to a buildup of pus

  • Abdominal or pelvic pain

Nursing Management of Chlamydia and Gonorrhea

• treatment strategies, referral sources, and preventive measures

• Provide education about risk factors

• Emphasize the importance of seeking treatment, adhering to prescribed treatment regimens, informing sex partners, and receiving any recommended follow-up testing

• Stress that both of these STIs can lead to infertility and long-term sequelae

Infections characterized by genital lesions

• Genital herpes & syphilis have been associated with an increased risk of HIV infection

• Not all genital ulcers are caused by STIs

Genital Herpes

• a recurrent, lifelong viral infection that has the potential for transmission throughout the lifespan

  • once infected, they remain infected for life

• characterized by painful, recurrent outbreaks of genital and anal lesions

• Infection during pregnancy → neonatal herpes disease, spontaneous abortion, preterm labor

• Two serotypes of HSV have been identified: HSV-1 and HSV-2

  • HSV-1: oral herpes (cold sores, fever blisters)

    • most infections are acquired during childhood

  • HSV-2: genital herpes; both types can cause outbreaks in either location.

• transmitted via direct mucous membrane contact or breaks in the skin

  • females are infected twice as much as males, partly due to prolonged exposure to semen during vaginal intercourse

  • kissing, sex (including oral), vaginal delivery

• Many have mild or unrecognized infections but still shed the herpes virus intermittently

• happens in this order: primary outbreak → virus remains dormant in the nerve cells for a lifetime → periodic recurrent outbreaks

  • Immunocompromised people = more frequent & severe recurrent outbreaks

• Potential psychosocial consequences: emotional distress, isolation, fear of rejection, depression, fear of transmission, altered perceptions of self-esteem

Therapeutic Management

• No cure exists

• antiviral drug therapy helps suppress symptoms, shedding, and recurrent episodes

  • treatment: acyclovir (Zovirax) 400mg PO TID for 7-10 days, famciclovir (Famvir) 250 mg PO TID for 7-10 days, or valacyclovir (Valtrex) 1g PO BID for 7-10 days

Nursing Assessment

• Assess for clinical manifestations (primary and recurrent episodes)

  • first/primary episode: most severe, viral shedding process takes up to 2 weeks to complete

    • systemic disease characterized by multiple painful vesicular lesions, mucopurulent discharge, superinfection with candida, fever, chills, malaise, dysuria, headache, genital irritation, inguinal tenderness, lymphadenopathy

    • lesions are frequently located on the vulva, vagina, and perineal areas

    • vesicles open and finally crust over, dry, and disappear without scar formation

  • recurrent episodes: milder, fewer lesions, shorter in duration

    • may occur 5-8x per year

    • Tingling, itching, pain, unilateral genital lesions, and a more rapid resolution of lesions

    • a localized disease

• Diagnosis: viral culture or polymerase chain reaction (PCR) (preferred diagnostic tests), based on clinical s&s

Nursing Management of Herpes and Syphilis

• Therapeutic management: counseling regarding the natural history of the disease, the risk of sexual and perinatal transmission, current treatment regimens, and the use of methods to prevent further spread

• Referral to a support group

• Address psychosocial aspects of these STIs by discussing appropriate coping skills, acceptance of the lifelong nature of the condition (herpes), and options for treatment and rehab

Syphilis

• a systemic, curable bacterial infection caused by the spirochete Treponema pallidum

• untreated → disability, death, hepatitis, CV issues, CNS damage

• episodes of active clinical disease are punctuated with periods of latency.

• Enters the lymph and bloodstream → systemic infection before any primary lesion appears

• site of entry may be vaginal, rectal, or oral

• Congenital syphilis can occur via transplacental transmission (virus can cross the placenta) or direct contact during birth

• can cause spontaneous abortion, low birth weight, prematurity, stillbirth, and multisystem problems of the bones, liver, pancreas, intestine, kidney, and spleen

• All pregnant patients should be screened at the first prenatal visit, with repeat testing at 28 weeks and before delivery for high-risk patients

  • Screen patients without symptoms who are considered high risk

Therapeutic Management

• injection of penicillin G can cure primary, secondary, or early latent syphilis

  • late latent syphilis: 3 doses at weekly intervals

  • Pregnant people should be treated with the same regimen for whichever stage they present with

  • give doxycycline if there’s a penicillin allergy

• reevaluated at 6 &12 months after treatment for primary or secondary syphilis with additional serologic testing

• Patients with latent syphilis should be followed up with clinically and serologically at 6, 12, and 24 months

Nursing Assessment

• has many nonspecific s&s

• Assess for clinical manifestations

• untreated → 5-stage lifelong infection progressing in order (primary, secondary, early latent, late latent, tertiary)

  • primary, secondary, and early latent stages being considered the most infectious (see below)

• Primary stage: presents as a chancre (painless ulcer) at the site of bacterial entry that will disappear within 3-6 weeks without intervention

  • painless bilateral adenopathy (swollen, enlarged lymph nodes)

• Secondary stage: appears 2-6 months after initial exposure, lasts about 2 years

  • manifestations: flulike symptoms (see below), a rash of the trunk, palms & soles, alopecia, adenopathy swollen, enlarged lymph nodes)

    • fever, sore throat, weight loss, myalgias, and fatigue

• early and late latent stages: no s&s, though serology is positive

  • can last as long as 20 years

• tertiary or late stages: life-threatening CV syphilis, gumma syphilis, and CNS syphilis

  • slowly destroys the heart and inflames the aorta, eyes, brain, CNS, and skin

• Serologic testing is evaluated using both nontreponemal and treponemal tests

  • Nontreponemal tests: measure IgM and IgG

    • most commonly used: the rapid plasma regain (RPR) & Venereal Disease Research Laboratory (VDRL)

    • less specific but commonly used for primary screening because they’re performed rapidly and inexpensive

  • Treponemal tests: detect treponema-specific IgA, IgM, and IgG antibodies

    • greater accuracy

    • preferred test: T. pallidum enzyme immunoassay

Nursing Management of Herpes and Syphilis

• Therapeutic management: counseling regarding the natural history of the disease, the risk of sexual and perinatal transmission, current treatment regimens, and the use of methods to prevent further spread

• Referral to a support group

• Address psychosocial aspects of these STIs by discussing appropriate coping skills, acceptance of the lifelong nature of the condition (herpes), and options for treatment and rehab

Pelvic Inflammatory Disease

• a spectrum of inflammatory disorders usually caused by an ascending infection of the genital tract from chlamydia or gonorrhea

• an inflammatory state of the upper female genital tract and nearby structures

• encompasses a broad category of diseases, including endometritis, salpingitis, salpingo-oophoritis, tubo-ovarian abscess, and pelvic peritonitis

• Long-term complications: ectopic pregnancies, infertility, chronic pelvic pain

• common risk factors: age <25, multiple sex partners, insertion of an IUD within the past 3 weeks, history of STIs in the patient or their partner, lack of barrier contraceptive use, previous episode of PID

Therapeutic Management

• treatment will be outpatient or inpatient based on clinical judgment and symptom severity

• Treatment: IV antibiotics, increased oral fluids to improve hydration, bed rest, and pain management

  • Broad-spectrum antibiotic therapy required for chlamydia, gonorrhea, or any anaerobic infection

    • ceftriaxone 1g IV once daily & doxycycline 100mg PO q12h & metronidazole 500mg PO or IV q12h

    • cefoxitin 2g IV q6h & doxycycline 100mg PO or IV q12h

    • cefotetan 2g IV q12h & doxycycline 100mg PO or IV q12h

  • Follow-up is needed to confirm the infection is gone and to prevent chronic pelvic pain

Nursing Assessment

• involves a complete health history and assessment of clinical manifestations, physical examination, and laboratory and diagnostic testing

  • current and past medical and sexual health history

Health History

• risk factors:

  • Adolescence or young adulthood

  • multiple sex partners

  • History of PID or STI

  • intercourse with a partner who has untreated urethritis

  • Recent insertion of an IUD

  • Lack of consistent condom use

  • Lack of contraceptive use

Physical Examination and Laboratory and Diagnostic Tests

• Assess for clinical manifestations

• Inspect for presence of fever or vaginal discharge

• Palpate abdomen, noting tenderness over the uterus or ovaries

• No single test is highly specific or sensitive

• criteria for diagnosis in sexually active females:

  • lower abdominal tenderness

  • adnexal tenderness (the structures that are adjacent to or near the uterus)

  • cervical motion tenderness

  • Additional supportive criteria:

    • Abnormal cervical or vaginal mucopurulent discharge

    • temp over 101°F (38.3°C)

    • N. gonorrhoeae or C. trachomatis infection

    • Abundant WBC’s on saline vaginal smear

    • Elevated erythrocyte sedimentation rate (inflammatory process)

    • Elevated C-reactive protein level (inflammatory process)

Nursing Management

• maintain hydration via IV fluids if necessary and administer analgesics PRN for pain

• Semi-Fowler positioning facilitates pelvic drainage

• educate to prevent recurrence

• Sexual counseling: practicing safer sex, limit sex partners, consistent use of barrier contraceptives, reconsider IUD use if sexually active with multiple partners, completing course of antibiotics as prescribed

• Ask the patient to have their partner go for evaluation and treatment to prevent a repeat infection

Teaching Guidelines 5.3 Preventing Pelvic Inflammatory Disease

• use condoms

• Discourage routine vaginal douching (may cause bacterial overgrowth)

• Encourage regular STI screenings

• Emphasize the importance of having each sexual partner receive antibiotic treatment if diagnosed with an STI

Human Papillomavirus (HPV)

• responsible for anogenital warts and several cancers (cervical, vaginal, vulvar, oropharyngeal, anal cancers)

  • Strong evidence has established the link between HPV and cervical cancer

• causes genital warts or condylomata (Greek for “warts”)

Therapeutic Management

• currently no medical treatment or cure

• focuses heavily on prevention through the use of the HPV vaccine, education, and treatment of lesions and warts caused by HPV.

• vaccine:

  • 9-valent vaccine is used in the US

  • recommend for routine administration to 11 & 12 year old children

    • as young as age 9

    • females between 11-26 years of age should receive the vaccination series

  • before 15th birthday = two doses for full protection

  • after age 15 = three doses for full protection

  • All are prophylactic

  • designed primarily for cervical cancer prevention, as well as cervical, vulvar, vaginal, penile, and anal cancers

• secondary prevention (if no vaccine): education about receiving regular Pap smears and, for female patients over age 30, including an HPV test

• goal of treatment: remove the warts and induce wart-free periods for the patient

• remove with a local agent during pregnancy

• c-section birth is not indicated to prevent transmission unless the pelvic outlet is obstructed by warts

Nursing Assessment

• complete health history, assessment of clinical manifestations, physical examination, and laboratory and diagnostic testing

  • symptoms: profuse, irritating vaginal discharge, itching, dyspareunia, bleeding after intercourse, “bumps” on their labia that may be painful, friable (easily pulverized or crumbled), and pruritic (itchy)

    • warts can occur on the external genitalia, cervix, vagina, urethra, anus, and mouth

  • Physical inspection of the external genitalia is important

Health history, physical examination, and laboratory and diagnostic tests:

• Most infections are asymptomatic

• Lesions can grow large during pregnancy which affects urination, defecation, mobility, and fetal descent

• large lesions exist in clusters and bleed easily

• Pap smears are now performed every 3-5 years for low-risk females starting at age 21

  • an HPV test should follow-up an an ambiguous Pap test

  • can detect high-risk HPV before visible cervical cell changes occur

  • positive high-risk type of HPV → patient should be referred for colposcopy (visual exam of the cervix and simple staining solutions) which is sometimes accompanied by a biopsy to confirm cervical abnormality

Nursing Management

• prevention education, vaccine and screening promotion

  • only way to prevent HPV is to refrain from any genital contact with another person

• latex condom use has been associated with a lower rate of cervical cancer

• educate that in most cases there are no s&s

• Strongly encourage females ages 9-26 to consider the HPV vaccine

• promote the importance of obtaining regular Pap smears for all female patients

• patients aged >30: suggest an HPV test

• Education and counseling:

  • Even after genital warts are removed, HPV may remain, and viral shedding may continue.

  • recurrence of genital warts within the first few months after treatment is common (recurrence, NOT reinfection)

• no current vaccine for hepatitis C

• Recommended hepatitis B screening includes females at risk and all pregnant people at their first prenatal visit and retesting near delivery for high-risk patients

• Recommended hepatitis C screening includes all females 18 years of age and older once in their lifetime

Ectoparasitic infections

• Ectoparasites: parasites that live on the outside of the body (host).

• common cause of skin rash and pruritus

• Overcrowding, weakened immune systems, global traveling, immigration, delayed diagnosis and treatment, and poor public education contribute to the prevalence of ectoparasites

• includes infestations of scabies and pubic lice

• Scabies

  • highly contagious intensely pruritic dermatitis caused by a mite

  • transmission: direct contact & overcrowded living conditions

  • Intense itching occurs weeks after the initial infection, especially at night

  • female mites burrows under skin and deposits eggs, which hatch

    • causes the appearance of linear burrows between the fingers, on the elbows, in the axillae, buttocks, and genitalia

  • lesions start as a small papule that reddens, erodes, and sometimes crusts

  • treatment: topical administration of a scabicidal agent (permethrin, crotamiton, ivermectin) plus an antibiotic if a secondary infection is present

• Lice

  • blood-sucking insects that can be found on people’s heads, bodies, or pubic areas

  • pediculosis pubis = pubic louse = public lice

  • s&s: pruritus, because of a rash brought on by skin irritation from scratching, or lice or nits in their pubic hair, axillary hair, abdominal and thigh hair, and sometimes in the eyebrows, eyelashes, and beards

  • usually asymptomatic until after a week or so, when bites cause pruritus and secondary infections from scratching

  • Diagnosis: presence of nits (small, shiny, yellow/white, oval, dewdroplike eggs) affixed to hair shafts or lice (a tan to grayish, short, wingless insect that appears crablike)

  • Treatment: medication (topical antilouse agents) & environmental control measures

    • Bedding & clothing:

      • wash in hot water, dry on hot setting in dryer

      • dry cleaning

      • seal clothes in plastic bags for 2 weeks to decontaminate them

    • Sex partners should be treated, as well as family members who live in close contact with the infected person

• Nursing care involves a three-tiered approach: eradicating the infestation with medication, removing the nits, and preventing spread or recurrence by managing the environment

Human Immunodeficiency Virus (HIV)

• HIV targets the immune system and weakens the body’s defense systems against infections and some types of cancer

• antiretroviral treatment halts the replication of the virus and ease symptoms, turning AIDS into a manageable chronic condition instead of a rapid terminal illness

• AIDS is a breakdown in the immune function caused by HIV, a retrovirus

• virus cannot live long outside the human body, cannot be transmitted via tears or sweat

• infection is the driving force behind CD4 T-cell depletion and progression to AIDS

• infected person develops opportunistic infections or malignancies that become fatal

• HIV transmission: sexual intercourse, body secretions, needle sharing/blood exposure, and perinatal transmission

  • breastfeeding is a method of transmission

• Females are more vulnerable to heterosexual transmission due to prolonged exposure to semen

• parent-to-child HIV transmission occur late in pregnancy or during delivery

  • ART therapy has decreased transmission to less than 1%

• recommended HIV screening: all females aged 13-64 years, all females who seek STI evaluation and treatment, and all pregnant people at first prenatal appointment and retest during the third trimester if at high risk

Clinical Manifestations

• HIV infection undergoes three distinct phases: acute seroconversion, chronic HIV without AIDS (without symptoms), AIDS

  • initial infection → 2-6 weeks after exposure, an acute primary infection occurs for about 3 weeks (fever, pharyngitis, rash, and myalgia) → HIV viral load drops quickly as the immune system controls infection

    • seroconversion occurs 3–12 months after initial exposure

      • pt is considered infectious during this time

  • After acute phase:

    • asymptomatic, but the virus begins to replicate

  • CD4 T-cell count <200 = AIDS

    • immune system continues to battle but falls behind over time

    • T cells have a viral reservoir that can store various stages of the virus

    • more present HIV virus = worse the person feels

    • opportunistic infections occur, qualifying the person for the diagnosis of AIDS

infants born to HIV positive moms will receive HIV medications for 2-6 weeks after birth to decrease the risk of transmission

Chapter 5 meds: