female reproductive system assessment
female reproductive system assessment
an evaluation of a patient's genital tract and breasts with an investigation of past and present disorders that may be factors in the individual's current gynecological condition. See also pelvic examination.
method In a relaxed professional interview the procedures to be conducted are explained and the patient is reassured that her privacy will be scrupulously maintained. The patient is interviewed to determine whether she has lower abdominal pain, cramps, vaginal bleeding, itching, swelling, redness, or a vaginal discharge that is mucoid, watery, frothy, or thick in consistency and white, yellow, greenish, bloody, or brown, or that has an odor. She is asked whether she experiences pain on intercourse and pain or burning on urination. Observations are recorded of her general appearance; vital signs; weight; breast symmetry, texture, and lumps or bumps; nipple color; and the presence of a serous, bloody, or purulent nipple discharge. The abdomen is examined for contour, symmetry, stretch marks, scars, lesions, and visible pulsations and peristaltic waves and is auscultated for bowel sounds in each quadrant. Carefully noted are edema or redness of the external genitalia, cervix, and perineum; lumps or lesions on the labia majora; the size of the urethral orifice; the presence or absence of the hymenal ring, hymenal tags, and perineal scars or excoriation; and a bloody, purulent, or odoriferous discharge. The normal mucoid secretion is distinguished from the thick, white, cheesy discharge typical of candidiasis; the frothy, yellow-green, watery liquid characteristic of trichomoniasis; and the thick, yellow-green or brown, and bloody drainage typical of upper genital tract infection. The patient's age at onset of menses; the duration, spacing, and regularity of cycles; the amount and character of the flow; the date of the last menstrual period; and associated symptoms such as pain and menorrhagia are investigated. The complications and outcome of each of the patient's pregnancies, the kind of delivery, the incidence and outcome of any abortion, and the date of menopause and associated symptoms, such as hot flashes and dry vaginal mucosa, are explored. It is determined whether the patient suffers from a sexually transmitted disease, constipation, hemorrhoids, hypothyroidism or hyperthyroidism, polycystic ovary syndrome, hypertension, or blood dyscrasias or has a history of gynecological or other major abdominal surgery or a serious illness, especially one related to the endocrine system. The patient's smoking habits, sexual activity, use of oral contraceptives or an intrauterine device; her experience with estrogen therapy; and family history of gynecological diseases and deaths are reported in the assessment. Diagnostic procedures indicated by the history may include a manual examination, Papanicolaou's (Pap) test, basal body temperature determination, culture of vaginal discharge, punch biopsy, endometrial biopsy, dilation and curettage, cold-knife conization, laparoscopy, ultrasound study, and tubal insufflation. Laboratory studies that may be performed include determinations of levels of human chorionic gonadotropin, serum luteinizing and follicle-stimulating hormones, 17-ketosteroids, and corticosteroids; tests for sexually transmitted diseases; and thyroid function tests such as the basal metabolic rate and protein-bound iodine level.
interventions The nurse conducts the interview, records observations of the patient, and collects the pertinent background information and the results of diagnostic procedures and laboratory studies. Throughout the assessment the nurse recognizes that the patient may be reluctant to discuss her symptoms and activities and may be sensitive about the necessary procedures.
outcome criteria A careful assessment of the patient's reproductive system is essential in establishing early diagnosis providing prompt treatment of abnormalities.