Reeves, Susan MSN, RN, WHNP-BC; Hellman, Ann N. MSN, RN
In today's fast-paced healthcare environment, many patients are admitted from physician's offices, clinics, or EDs with limited assessments performed by the referring healthcare provider. As a nurse, you have the opportunity to provide your female patients with an extensive assessment focusing on their specialized needs as women.
The healthcare market identifies women as “the primary healthcare decision makers in this country with 66 cents of every dollar spent on or by women.” Most healthcare marketing is geared toward women, but many women delay care for themselves. Delayed care seeking may be the result of women balancing multiple responsibilities—spouse or partner, mother, daughter, employee, and often caregiver of other family members such as aging parents. The demands of multiple responsibilities make it more difficult for women to make their own health a priority.
For this reason, we should view the admission of a female patient as an opportunity to address multiple issues related to women's health. We can make the most out of our female patient's healthcare experience by performing an extensive, yet time-efficient, assessment and providing education based on anticipating current and future needs.
This article will lead you through a comprehensive assessment of major body systems, with a special emphasis on attention to female needs. Additionally, special assessment considerations will be offered for the pregnant patient.
For several reasons, obtaining an adequate cardiac history from your female patient may be challenging. The first reason for this challenge is that women can present with different symptoms than men when experiencing a cardiac event. When you obtain a cardiac history from a female patient, ask about the occurrence of a hot or burning sensation in the chest, back, arms, or jaw instead of only focusing on chest pain or pressure. Secondly, it's only in the last few decades that cardiac disease in women has come into focus. You may find it difficult to determine what heart problems your female patient's family members have experienced in the past due to previous cardiac events going undiagnosed.
What cardiac complaints do women express? Women may report classic myocardial infarction (MI) symptoms such as crushing chest pain. However, they're more likely to experience other symptoms of an MI, such as jaw pain, nausea, dizziness, fatigue, and cold sweats. These symptoms often lead women to seek care later than men because they can be attributed to other issues, resulting in a lower survival rate for women who experience an MI.
It's important to remember that heart health isn't just for women over age 50. Young women may have cardiac issues related to genetic factors, lifestyle, and medications. The U.S. Preventive Services Task Force recommends screening for hypertension in all adults over age 18.
We all learned the basic cardiac assessment in nursing school: Listen over the aortic, pulmonic, tricuspid, and mitral areas and the apex of the heart. Health assessment textbooks often have illustrations featuring a thin man as the assessment model; obviously, women have different anatomy and require some adjustment to your technique. The landmarks are the same, but women may have obscured heart sounds because it's hard to listen through breast tissue.
In large-breasted women, you may have to move the breast to hear adequately. Using the back of your hand, gently lift the breast. This technique translates as a less intimate touch and may help your patient feel less violated than if you cup your hand around her breast. It's always a good practice to listen to the heart in the seated and supine positions. Finally, don't listen to the heart over the gown or clothing, and remember to make direct contact with the stethoscope to the skin.
If you aren't used to caring for pregnant patients on your medical unit, you may not readily recognize normal development changes for a pregnant woman. Due to the 40% to 50% increase in blood volume, resting heart rates tend to be more rapid—a resting pulse of 90 beats/minute isn't unusual. Be prepared to make slight adjustments in stethoscope placement during your assessment because the placement of the heart varies as the growing uterus displaces the heart upward and laterally (see Considerations for the pregnant patient).
The use of estrogen, both in oral contraceptives and hormone replacement therapy, increases the risk of cardiac events or blood clots. Once thought to be cardioprotective, the Women's Health Initiative concluded that the use of hormone replacement doesn't prevent heart problems and actually increases the risk of MI in 24% of menopausal women. In young women using hormonal contraceptives, there may be an increased risk of blood clots and pulmonary embolism. If your patient smokes and takes hormones, her risk of embolism increases further.
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The musculoskeletal assessment is often overlooked unless a musculoskeletal problem is the primary admitting diagnosis. However, we should be mindful that female patients constitute a high percentage of patients with underlying musculoskeletal concerns. According to one statistic, “more than two-thirds of the 44 million Americans suffering from osteoporosis are women.”
In addition to osteoporosis, women are more likely to have autoimmune disorders such as rheumatoid arthritis, which may affect mobility. Whether your patient is admitted with a musculoskeletal disorder or an unrelated problem, it's still necessary to assess a woman's strength and mobility. It's preferable to determine muscular weakness and deficits before your patient suffers an injury during hospitalization.
You can efficiently incorporate a musculoskeletal assessment while caring for your patient and performing tasks specific to her admission diagnosis. Assess your patient's range of motion when you ask her to lift her arm while listening to her lungs. Ask your patient to lift each leg slightly off the bed when you palpate for pedal pulses. Stand to the side and watch your patient ambulate in the room, to the restroom, and in the hallway. Watch for smoothness of gait, ability to navigate turns, and the ease with which she lifts each foot from the floor as she ambulates.
Female patients may have multiple genitourinary issues, ranging from abdominal or pelvic pain to urinary incontinence and changes brought on by fluctuating hormone levels. For those women in the hospital with abdominal or pelvic pain, a thorough history may provide some clues to the problem. Women who use recreational drugs may be at increased risk for sexually transmitted infections (STIs). Women who've had multiple STIs, especially if they haven't been adequately treated, run a higher risk of developing pelvic inflammatory disease and tubo-ovarian abscess. These problems increase the risk of ectopic pregnancy.
Most nurses don't find it easy to talk with patients about their sexual behavior. The Association of Reproductive Health Professionals (ARHP) reports that more than 50% of women have sexual concerns but less than half will be willing to bring up concerns to their healthcare provider. Additionally, the ARHP states that most women prefer that a healthcare provider brings up sexual topics.
In the hospital setting, a nurse has many more opportunities throughout the day to talk with a patient about sexual topics than the admitting provider. For some nurses, this is especially challenging if the female patient is lesbian or bisexual or has multiple partners. The key to navigating through these uncomfortable conversations is to set aside time to sit at the patient's bedside, then begin the conversation with a statement such as, “In order for us to better care for you, I need to ask you a few questions about your sexual history.” And, remember, after each question—listen.
Although the media paints a picture of our “senior” patients as having incontinence troubles, this may be a problem for women of any age. Young women who've recently delivered a baby or women who've delivered large babies may experience incontinence. Asking about urine loss during the health history may provide an opportunity to teach exercises to strengthen the pelvic floor. During the physical assessment, look for signs of prolapse from the vagina and the rectum.
Another symptom thought to be associated with menopause is vaginal dryness and atrophy. Be aware that women who are breastfeeding may also experience vaginal dryness, which may interfere with sexual relations or cause increased discomfort during pelvic exams and procedures.
Emotional states and intimate partner violence
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Intimate partner violence (IPV) is defined as “a pattern of coercive behaviors perpetrated by someone who is or was in an intimate relationship with the victim, such as a spouse, ex-spouse, boyfriend or girlfriend, ex-boyfriend or ex-girlfriend, or date” and ranges from assault, sexual assault, rape, and possibly even homicide. Unfortunately, IPV affects a large number of women. According to one statistic, “one out of every four American women will likely be victimized by an intimate partner.” We shouldn't assume that our patient's intimate partner is a spouse or a member of the opposite sex; we must be open to including homosexual partners and roommates.
The absence of bruises can't reassure us that our patient isn't a victim of IPV. It's our obligation to determine if she's being abused. The most important step in performing an assessment of IPV is to provide a time of privacy so that you can easily ask sensitive questions pertaining to the subject. Assure your patient that the hospital is a safe environment and that visitors can be restricted for her highest possible safety. Before asking sensitive questions, establish a relationship with your patient. Inquire who lives in her home and with whom she's in frequent contact, ask about hobbies and activities that she's involved in during her free time, and financial stability. Suitable questions to gather information about IPV include: “Do you feel safe in your home?” “Do you ever feel threatened?” “Does anyone in your life make you feel afraid or tearful?” and “Does anyone in your life ever hit, slap, or kick you or make you feel that you are about to be hit, slapped, kicked, or physically harmed in some way?”
As you ask these sensitive questions, watch for nonverbal signs exhibited by your patient, such as avoiding making direct eye contact with you as she answers, dropping her head and avoiding your gaze when you begin questioning her, and appearing to withdraw into herself when questioned. Additional signs that your patient may be the victim of IPV are untreated previous injuries and stories explaining injuries that don't match the nature of the injury. As you perform the history portion of the assessment, try to get a clear and accurate record of all your patient's previous injuries and the events leading to those injuries.
In addition to assessing for IPV, the nurse has an opportunity to assess for depression and anxiety. This assessment is especially relevant in women because an estimated 21% of women will develop a major depressive disorder. Women are also more likely to seek care for depressive symptoms even if they don't identify the symptoms as depression. In some cases, depression or anxiety may be considered a normal response to a loss the patient is experiencing, such as the loss of health or function or a poor prognosis.
Although we're extremely busy on a medical-surgical unit, the time spent communicating with our female patients and educating them in self-care activities is always beneficial.
In the PINK
Caring for a woman within a medical setting can be an opportunity for a thorough exam and patient education. As a direct care nurse on a medical-surgical unit, it's possible to keep your assessment of female patients in the PINK. And now you know how!
Considerations for the pregnant patient
Admittance of a pregnant patient to a medical-surgical unit
You may have a pregnant patient admitted with a diagnosis unrelated to her pregnancy and, therefore, she may be admitted to a general medical-surgical floor. A mnemonic to assist you in performing important assessment elements for these patients is FETUS.
* F: Document fetal heart tones every shift. To assess fetal heart tones, use a handheld Doppler ultrasound and place it in an area corresponding to uterine height. For example, for a patient who's less than 20 weeks' pregnant, the most likely area to find fetal heart tones is at the pubic hairline or the symphysis pubis. For a patient whose pregnancy is more advanced, such as at 24 weeks, the fetal heart rate can most probably be heard midline between the symphysis pubis and the umbilicus. As the pregnancy advances in weeks, fetal heart tones can be heard closer to and possibly above the umbilicus.
* E: Provide emotional support. Pregnant women who are experiencing unexpected medical conditions are at a high level of anxiety worrying how the current medical problem may affect the fetus. You should take extra care to alleviate and reduce your patient's anxiety by explaining all medications and treatments. Additionally, be prepared to listen for fetal heart tones anytime the patient requests it to further reduce her worry and reassure her that the fetus is doing well.
* T: Measure maternal temperature. Because your patient's core body temperature is higher than you can detect through oral or tympanic thermometers, be alert to the presence of a fever. A high maternal temperature can lead to fetal tachycardia and distress. An order for antipyretics on admission to ensure their quick availability will be a prudent request you should make to the admitting physician.
* U: Ask about uterine activity or contractions. Make it a normal part of your routine to ask about any type of uterine pain, tightening, or discomfort throughout your shift. Be aware that early contractions often present as lower back pain. Don't attribute complaints of lower back pain to the hospital bed. If your patient reports any unusual activity, take care to softly palpate the lower abdomen for periods of greater than 2 minutes while conversing with her. Watch for subtle changes of facial expression while simultaneously detecting a change in uterine tone. If contractions are suspected, your patient will need to be monitored with continuous fetal monitoring in the labor and delivery unit.
* S: Assess for the presence of and changes in sensations of fetal movement. After 20 weeks' gestation, all women should be able to report feeling the fetus move. This is an important assessment to perform and document at least every shift, easily accomplished by asking “How often are you feeling the baby move?” By asking this as an open-ended question, you'll receive more information about the quantity of fetal movement such as, “I haven't felt the baby move as much as usual today.” If you had asked the question “Have you felt the baby move?” your patient may have responded with a simple “yes” rather than providing you with the information that prompts you to perform further assessment.
Admittance of a postpartum patient to a medical-surgical unit
There are times when a woman may be hospitalized during the postpartum period for a medical condition. When this occurs, she'll most likely be placed on a general medical-surgical unit. Her admission will cause you to ask: “What's normal during the weeks following the birth of a baby?”
* Breasts. Within the first 24 hours postpartum, colostrum appears and is followed by breast milk within the first 72 hours. Breast engorgement is most likely to occur around day 4 postpartum. The engorged breast will appear full, taut, and even shiny. Although this is normal, it may be very uncomfortable for your patient. In contrast, a woman with mastitis will usually run a fever higher than 100° F, report feeling “ill,” and have one breast that's affected (firm, inflamed, swollen, and exquisitely tender to touch). If your patient is breastfeeding her newborn, she'll require a breast pump. Depending on the medications ordered, the milk may need to be disposed of and not used for the baby.
* Lochia. Sometimes women will experience lochia (vaginal discharge) until the time of their 6-week postpartum visit. Immediately after delivery, the lochia is red and heavy enough to require a pad change every 1 to 2 hours. By 7 days postpartum, the lochia should be lighter in color (pink to red) and amount, requiring a pad change every 4 hours. Lochia that becomes heavier, has a foul odor, and is accompanied by pelvic pain isn't a normal finding and requires immediate intervention.
* Perineal care. For the first 2 weeks following delivery, patients will need to perform perineal hygiene as taught during the immediate postpartum period. This may include perineal water rinses following elimination using warm water or medicinal rinses, use of sitz baths, and comfort medications to the perineal and anal area.
* Cesarean section. If your patient delivered her baby via cesarean section, continued assessment of the surgical incision is warranted for the first 2 to 3 weeks postpartum. Redness and warmth around the incision, excessive bruising around the incision, or incisional drainage requires immediate intervention. If the surgeon used staples to close the incision, they're usually removed approximately 5 days postdelivery.
Remember, the hospitalized postpartum patient is likely to be very emotional. Not only will she be experiencing the normal hormonal fluctuations of the postpartum period, she'll also likely be distraught at leaving her newborn at home and feeling that she's missing bonding time with her child. Visitation between the mother and her infant may be very limited to minimize the infant's risk of infection, but visits should be arranged if at all possible.
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