Nur 201 test iii study guide by Jennifer Cook

Jennifer Cook

Nursing 201 Test III Study Guide

2015

Mental Health & Reproductive System Alterations

NUR 201 Test III Study Guide Mental Health         

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Colonial America – Witchcraft 1st Hospital for Mentally ill – in Philadelphia Benjamin Rush – Father of American Psychiatry o 1st Humane TX for Mentally ill in U.S. Hippocrates – 4 Humors: blood, black bile, yellow bile, and phlegm. Dorothea Dix – Former School Teacher o Successfully lobbied for state mental hospitals Linda Richards – 1st American Psychiatric Nurse o Helped establish 1st school of psychiatric nursing @ McLean Asylum in Massachusetts Psychiatric Nursing – Not included in curriculum until 1955 1946 National Mental Health Act – funds for the education of psychiatrists, psychologists, social workers, and psychiatric nurses. Maslow Hierarchy of Needs o Physiological Needs o Safety & Security o Love & Belonging o Self Esteem; Esteem of Others o Self-Actualization Robinson – The Successful Adaptation Cultural Influences o Incomprehensibility – inability of general population to understand the motivation behind the behavior. o Cultural Relativity – “normality” of behavior is determined by the culture. Mental Illness – Maladaptive responses to stressors from the internal or external environment AEB thoughts, feelings, and behaviors that are incongruent w/the local and cultural norms. o Interferes w/individual’s social, occupational, or physical functioning. o Not a Sufficient Cause of Violence Stress – May be viewed as an individual’s reaction to any change that requires an adjustment or response. o Physical, Mental, or Emotional o Roy  Adaptive Response – Healthy; maintains integrity  Maladaptive Response – Unhealthy; interrupts integrity; person does not bend, so they break o Hans Selye – General Adaptation Syndrome  Alarm Reaction Stage – Fight or Flight

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 Stage of Resistance – attempting to adapt to stress  Stage of Exhaustion – prolonged exposure to stress Anxiety – diffuse apprehension; feelings of uncertainty and helplessness o Peplau – 4 Levels of Anxiety  Mild – Good for us; Day to Day Living  Moderate – Decreased attention span and ability to concentrate  Severe – Inability to complete the simplest task; confusion; dread; horror  Panic – Unable to focus; can be life threatening o Coping Defense Mechanisms  Compensation – Covering up weaknesses  Denial – Refusal to acknowledge situation  Displacement – Transferring feelings toward something less threatening  Identification – Acquiring traits of admired person  Intellectualization – Logic, Reasoning, Analyzing to express emotions  Introjection – Integrating beliefs and values of another; loss of self  Isolation – Separating thought/memory from emotion  Projection – Passing blame or feelings onto another person  Rationalization – Make excuses  Reaction Formation – Exaggerate the opposite  Regression – Behaving @ earlier level of development  Repression – Involuntary blocking of unpleasant feelings/experiences  Sublimation – Rechanneling drives/impulses into constructive activities  Suppression – Voluntary blocking of unpleasant feelings/experiences  Undoing – Symbolically cancelling out unpleasant experiences Freud – Father of Psychiatry o Psychoanalytic Theory – Personality Organization; clinical method for treating psychopathology.  Relevance to Nurses – assist in assessment of developmental level in clients; and assist in creating change. o Structure of Personality  ID – Self-Centered; present at birth  Ego – Learns what to do; 4 to 6 mos.; balances ID and Superego  Superego – Rationalizes why one should or should not do something; 3 to 6 yrs.; assists Ego in controlling ID impulses. o Typography of the Mind  The Conscious – Awareness; Controlled by Ego; Smallest  The Preconscious – Memories buried but recallable  The Unconscious – Memories unable to bring to conscious awareness o Dynamics of Personality  Psychic Energy – Originated in ID  Cathexis  Anticathexis

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Development of Personality  Oral Stage – Birth to 18 mos.; Oral gratification  Anal Stage – 18 mos. to 3 yrs.; Excretory function  Phallic Stage – 3 to 6 yrs.; Genital organs  Latency Stage – 6 to 12 yrs.; Sexual repression  Genital Stage – 13 to 20 yrs.; Sexuality reawakens Sullivan – Interpersonal Theory (direct result of interpersonal relationships) o Relevance to Nurse – Relationship development; helps assist clients in achieving interpersonal security and a sense of well-being. o Major Concepts  Anxiety – Arises over inability to satisfy needs or security  Satisfaction of Needs – Meeting physiochemical needs (O2, food, water, etc.)  Self-System – Protects against anxiety o Personality Development Stages  Infancy – Birth to 18 mos.; gratification of needs  Childhood – 18 mos. – 6 yrs.; delayed gratification  Juvenile – 6 to 9 yrs.; relationships  Preadolescence – 9 to 12 yrs.; collaboration  Early Adolescence – 12 to 14 yrs.; identity  Late Adolescence – 14 to 21 yrs.; intimate relationship st Piaget – 1 Psychologist to study Cognitive Development o Biological adaptation; psychological adaptation to the environment. o Relevance to Nurses – Cognitive therapy; cognitive therapy focuses on changing “automatic thoughts.” Helps clients identify distorted thought patterns. o Stage of Cognitive Development  Sensorimotor – Birth to 2 yrs.; basic needs  Preoperational – 2 to 6 yrs.; egocentrism; wild imaginations; believes objects are alive  Concrete Operations – 6 to 12 yrs.; concrete thinkers; begin to logic; interact w/others; understands established rules  Formal Operations – 12 to 15 yrs.; reason in abstract terms; problem solvers; distinguish reality Kohlberg – Theory of Moral Development o Stages are not closely tied to specific age groups; determined by individual motivation; every step must be completed to progress to next stage. o Relevance to Nurses – Critical thinking; behave and treat others; clients to higher developmental maturity o 3 Major Levels of Moral Development  Pre-Conventional Level – 4 to 10 yrs.; fear of punishment; instrumental relativism; egocentrism

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Conventional Level – 10 to 13 yrs. and into adulthood; interpersonal concordance; personal respect for authority; rules; laws  Post-Conventional Level – Adolescence and on; legalistic orientation; respect for universal laws and moral principles; honor, justice, and respect for human dignity and guided by conscious Ethical Dilemmas – happens when there are 2 opposing courses of action Ethical Principles – fundamental guidelines that influence decision making. o Autonomy – right to self determination o Beneficence – duty to promote good of others; client advocacy o Nonmaleficence – do no harm o Justice – right to equality o Veracity – duty to be truthful Model for Making Ethical Decisions - APPIE o Assessment o Problem Identification o Plan o Implementation o Evaluation Patient Bill of Rights o The right to refuse treatment o The right to refuse medication o The right to the least restrictive treatment alternative Legal Considerations o Confidentiality and Right to Privacy o Doctrine of Privileged Communication o Exception: Duty to Warn to protect 3rd party o Informed Consent – written permission  Exceptions – Incompetent and TX necessary to preserve life or avoid serious harm; endangers life or health of another; emergency; if client is a child  Make sure there is knowledge; competency; and free will o Restraints and Seclusion  Must be D/C’d ASAP  RX must be renewed a minimum of q 4 hrs. for 18 and older; q 2 hrs. for children and adolescents 9 to 17  Max time is 24 hrs.  Must be assessed by practitioner within 1 hour  Healthcare workers can be charged with False Imprisonment Communication – transaction between the sender and the receiver, both person participate simultaneously. 70 to 80% is nonverbal. o Therapeutic – used to enhance development of a therapeutic nurse-client relationship. o Nontherapeutic – barriers to open communication between nurse and client.

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Active Listening – SOLER (***KNOW***) o S – Sit squarely facing client o O – Observe and open posture o L – Lean forward toward the client o E – Establish eye contact o R – Relax ANA Standards of Practice for Mental Health - ADOPIPE o Assessment o Diagnosis o Outcomes o Planning o Implementation o Psychotherapy o Evaluation Types of Groups w/Nurse Participation o Supportive/Therapeutic o Group Therapy o Self-Help Groups Therapeutic Groups: Curative Factors o Hope, Universality, Learn, Support, Sharing, Social Techniques, Desired Traits, Insight, Belonging, Expression, Responsibility Bowen’s Theory on Family Dynamics o Family Projection Process o Multigenerational Transmission Process (Traditions) o Sibling Position: Predictable Traits  1st Born – Perfectionist; reliable  Middle – Indpendent; loyal, intolerable of conflict  Youngest – Charming; precocious; enjoy others  Only Child – Over confident; don’t handle conflict well Milieu Therapy – Surroundings or Environment; In Psychiatry = Therapeutic Community o Learn; Hospital Experience; Owns; Peer Pressure; Discussed; Temporary Isolation o Physiological Needs; Physical Facilities; Self-Government; Responsibilities; Activities; Facilitate Discharge o Care directed by an interdisciplinary team w/a comprehensive treatment plan that is updated regularly. o Relevance to Nurse – Manage; Nursing process; Evaluation; Needs met; Medication; one-to-one; Setting limits; Education Crisis Characteristics o Personal; acute; potential for psychological growth or deterioration Phases in Development of Crisis o Precipitating stressor

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o Anxiety o Resolve o Breaking point o Major disorganization o Depends on 3 factors – Perception; supports; adequate coping mechanisms Types of Crisis o Dispositional Crisis; Anticipated Life Transitions; Traumatic Stress; Maturational/Developmental Crises; Crises Reflecting Psychopathology; Psychiatric Emergencies Crisis Intervention – Resolve; Restore; Enhance Relevance to Nurse – APIE o Assessment; Planning; Intervention; Evaluation Anger/Aggression o Anger – emotional state; physiological and biological changes  Frowning, clenched fists, easily offended, yelling, low-pitched verbalization forced through clenched teeth, etc. o Aggression – behavior; “to go against;” assault; attack  Pacing, restlessness, tense facial expression, loud voice, use of obscenities, threats of homicide or suicide, increased agitation, panic anxiety, etc. o Best Intervention is Prevention o Breset Violence Checklist – Scoring of behaviors and de-escalation techniques (***KNOW***)  Score 1 point for each behavior observed. At a score of > 2, begin de-escalation techniques.  Behaviors:  Confusion, irritability, boisterousness, physical threats, verbal threats, attacks on objects  De-escalation Techniques:  Calm voice, walk, identify consequences, group participation, open hands, nonthreatening posture, allow phone call, express concern, relaxation, reduce stimulation and loud noise, reduction in demands, verbal redirection and limit setting, etc.  If De-escalation Techniques Fail:  Suggest PRN medications  Time-out or unlocked seclusion, which can progress to locked seclusion o Suicide – Behavior and not a diagnosis (***KNOW***)  Facts:  Cry for someone to save them. May give subtle clues.  Only suicidal for limited time. Can be saved.  Most suicides happen within 3 months of improving (when depression lifts) when they have the energy to do it.

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 Not inherited.  Not necessarily psychotic or caused by mental illness Pavlov – Dog experiement: unconditioned and conditioned responses Behavior Therapy – Operant Conditioning o Positive Reinforcer – Messy room, child cleans, child gets allowance o Negative Reinforcer – Messy room, child cleans, child does not get scolded for not cleaning o Aversive Stimulus or Punisher – Messy room, child does not clean, child gets scolded Techniques for Modifying Client Behavior o Shaping – small steps o Modeling – new behaviors o Premack Principle – positive reinforcement o Extinction – gradual decrease o Contingency Contracting o Token Economy o Time Out o Reciprocal Inhibition – more adaptable behavior o Overt Sensitization – Unpleasant consequences; antabuse is an example o Covert Sensitization – imagine negative consequences o Systematic Desensitization – slow encounter to overcome phobias o Flooding – flooding w/mental images to overcome phobias ECT – Produces Grand Mal Seizure o Only absolute contraindication – Intracranial Pressure (***KNOW***) o Most common adverse effect -Temporary memory loss and confusion o Results in significant increase of serotonin, norepinephrine, and dopamine o Prior to TX – void, dentures, eyeglasses/contacts off, jewelry, hairpins o Atropine sulfate or glycopyrrolate 30 minutes before TX Delirium – Disturbance in attention and awareness and a change in cognition that develops rapidly over a short period of time NCD o Major NCD – formerly called Dementia o Primary NCD – Not related to any other illness; example is Alzheimer’s disease o Secondary NCD – Symptoms are caused by or R/T another disease (example: HIV) o Impairment in abstract thinking o Types of NCD  Vascular – worst prognosis  Frontotemporal – shrinking of frontal/temporal anterior lobes, behavioral/personality changes, speech/language problems  Traumatic Brain Injury  Lewy Body – early onset, visual hallucinations, then Parkinson’s S/S  Parkinson’s – tremors 1st, then S/S of Dementia

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 HIV Disease  Substance/Medication Induced  Huntington’s – hereditary  Prion Disease – mad cow disease, protein in brain  General medical condition o Medications (***KNOW Generic Names***)  Cognitive Impairment  Aricept (Donepezil): 5 – 10 mg/day  Exelon (Revastigmine): 6 – 12 mg/day  Namenda (Memantine): 5 – 20 mg/day  Agitation  Zyprexa (Olanzapine): 5 – 20 mg/day  Geodon (Ziprasidone): 40 – 160 mg/day  Seroquel (Quetiapine): 25 mg titrate slowly to 300 to 400 mg/day  Haldol (Haloperidol): 1 – 4 mg/day  Depression  Zoloft (Sertraline): 50 – 100 mg/day  Paxil (Paroxetine): 10 – 40 mg/day  Anxiety  Ativan (Larozepam): 1 – 2 mg/day  Serax (Oxazepam): 10 – 30 mg/day Panic – sudden overwhelming feeling of terror or impending doom Panic Disorder – recurrent panic attacks Generalized Anxiety Disorder – chronic, unrealistic, and excessive anxiety and worry Phobias – excessive fear OCD – recurrent obsessions (thoughts) or compulsions (actions) MAOI Side Effect – Ex. Trazodone: 0 aged cheese or meats/Tyramine – increases B/P

Reproductive System Alterations         

Rectocele – Bulging of rectum into the vagina Fistulas – Abnormal passage between 2 organs Cervical Polyps – Small, finger-like growths originating from the surface of the cervix that hang from a stalk and protrude through the cervical opening (the os). Menarche – First menstrual cycle Hematuria – Blood in the urine Dysmenorrhea – Painful menstruation; cramps Amenorrhea – Absence of menstruation Endometriosis – Endometrial tissue outside of uterine cavity Vaginitis – Inflammation of the vagina

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Cystocele – Inflammation of the vulva Cystocele – Protrusion of urinary bladder into the vagina PMS – Symptoms that disrupt quality of life during the luteal phase (after ovulation) o How to Relieve Symptoms of PMS (***KNOW***)  Diet  Reduce Caffeine (irritability)  Avoid simple sugars (hypoglycemia)  Decrease salty foods (fluid retention)  Drink at least 2 L water/day  Eat 6 small meals/day  Eat well balanced diet  Avoid alcohol  Exercise  Stress Management  Sleep and Rest Menopause – end of menstruation o Climacteric – “Change of Life” Endometriosis – occurs when endometrial tissue implantation outside the uterine cavity o Chocolate Cyst – area of endometriosis on the ovary o Scarring can lead to infertility o Gets better during pregnancy and menopause Vulvovaginitis – Inflammation of the lower genital tract from a disturbance of the balance of hormones and flora in the vagina and vulva o How to Manage Infection (***KNOW***)  Risk increases if you have sex w/more than one person  Do not have sex, if you have a vaginal infection, or make sure partner wears condom  Sex partners need to be treated for infection, as well  The only way to identify what infection you have is to be examined w/lab tests by HCP  Take medication as prescribed, not just until symptoms go away. Toxic Shock Syndrome – Small number of cases are fatal o Tampon use mainly, but can be from surgical wound infection, other infections, Diaphragm, and contraceptive sponges o Menstrual blood provides a medium for the growth of Staph o Exotoxins produced by the bacteria spread to blood stream from micro-abrasions from tampon insertion or tampon that is left for to long. o CPK = Twice the Norm (Norm = 10 – 120, it would be 240) (***KNOW***) o Low Platelets (Thrombocytopenia) – < 150 (Norm = 150 – 450) Uterine Prolapse – Downward placement of the uterus o Can cause bladder, rectum, and small intestine to protrude through the vaginal walls

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Cystocele – protrusion of the bladder through the vaginal wall leading to stress incontinence and UTI’s (***KNOW***)  Surgical = Anterior Repair (***KNOW***) o Rectocele – protrusion of the rectum through the weakened vaginal wall (***KNOW***)  Surgical = Posterior Repair (***KNOW***) Fistulas – abnormal openings between two adjacent organs or structures o Types  Urethro-vaginal – urethra and vagina  Vesico-vaginal – bladder and vagina  Recto-vaginal – vagina and rectum o Embarrassing to client; be kind and compassionate o Symptoms Include – urine leakage, flatus, feces into vagina, unpleasant odor in vagina, irritation or excoriation of vulva and vaginal tissues Benign Neoplasms o Ovarian Cyst – Functional ovarian cysts can occur in women of any age but rare after menopause  Often disappear over time; may be painful; if unrelated to menstrual cycle, need further investigation to R/O Cancer o Uterine Leiomyoma (Fibroids) – Benign, slow growing solid tumors of the uterine myometrium  Classification  Intramural – Uterine wall  Submucosal – Protrude into uterine cavity  Subserosal – Protrude through outer surface of uterine wall and may extend to broad ligament and press on other organs  Sometimes in cervix  Chance of having increases w/age  Risk increases if never been pregnant  Occurs more often in African-Americans  HgB - < 12 (Norm = 12 – 15.5 for women) (***KNOW***) Endometrial Cancer – Cancer of the inner lining of the uterus o Most common GYN Cancer in the U.S. ** o Has good prognosis d/t it being slow growing o 80% are adenocarcinoma o Increased Risk Factors Include  Tamoxifen (decreases breast cancer, but increases risk of endometrial cancer) (***KNOW***) o Assessment Remember  Postmenopausal Bleeding  Watery bloody vaginal discharge

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 Transvaginal Ultrasound and Endometrial Biopsy  Enlarged uterus indicates advanced disease o Interventions  Surgical  Stage I – Total Hysterectomy w/bilateral salpingectomy-oophorectomy w/fluid cytology exam  Stage II – Radical Hysterectomy w/bilateral pelvic node dissection and removal of upper 3rd of vagina  Non-Surgical  Radiation and Chemotherapy postop  Brachytherapy – Internal Intra-Cavity Radiation used w/Stage II to prevent recurrence of vaginal cancer o Best Practice Health Teaching – Teach client to report any of these S/S to the HCP immediately. Not radioactive between treatments and there are no restrictions on her interactions w/others. (***KNOW S/S***)  Heavy vaginal bleeding  Urethral burning for more than 24 hrs.  Blood in urine  Extreme fatigue  Severe diarrhea  Fever over 100  Abdominal pain  External – used to treat any stage in combination w/surgery. TX lasts 4 to 6 weeks. Avoid sunbathing and do not wash markings  Chemotherapy – palliative TX for Stage III or IV; Adriamycin, Platinol, and Taxol  Hormone Therapy – for cancer dependent tumors and palliative therapy Cervical Cancer o Pap test screens for this o Usually takes years to transform from normal to premalignant to invasive o Pre-Invasive – limited to cervix o Invasive – spread to other pelvic organs o Risks Include – HPV infection, African American, HX of STD’s, Lower socioeconomic status, sex partner had previous partner with cervical cancer, younger than 18 at 1st intercourse o Health Promotion  Gardasil (HPV vaccine) – before onset of intercourse is best  Yearly pelvic exams o Assessment  Pre-invasive – usually asymptomatic

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 Invasive – painless vaginal bleeding  Dark Foul-smelling vaginal discharge  Leg pain (late symptom or recurrent disease)  Flank pain (late symptom) Ovarian Cancer – Epithelial tumors that grow on the surface of the ovaries o Grows rapidly and spreads quickly o Leading cause of death from reproductive cancers in women (***KNOW***) o Low survival rate d/t detected in late stages o IMPORTANT – Teach women older than 40 “think ovarian” if they have vague abdominal and GI symptoms. (***KNOW***) o Has a High Recurrence Rate (***KNOW***) Fallopian Tube Cancer (Tubular Cancer) o Rare as primary cancer; usually from other type of cancer Vulvar Cancer – located in genitals outside of female body o Primarily disease of older women, but increasing in women younger than 50 years R/T HPV o S/S – Vulvar irritation or itching; sore that won’t heal; bleeding is late symptom; lesions appear white/red. o Major Nursing Focus Post Op – Wound healing and pain control Vaginal Cancer o Rare as primary cancer o Usually an extension of cervical, endometrial, or vulvar cancer o Staging Determines TX  Limited to Surface – Remove lesion and small margin  Localized Lesion – Surgical removal local wide excision  Invasive – Partial or total vaginectomy with reconstruction o Topical form of Chemotherapy to lining of vagina can be used. Sexually Transmitted Diseases (STD) o Which ones are Reportable (***KNOW***)  Chlamydia  Gonorrhea  Syphilis  Chancroid (Bacterial) causing painful sores on genitalia  HIV  AIDS o Incubation – Interval before symptoms; period between the time somebody is infected w/disease and the appearance of its 1st symptoms o Syphilis (Treponema Pallidum) – transmitted by close body contact and kissing  Gram-Negative Bacteria  Stages  Primary

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Highly Infectious Stage (***KNOW***) Assessment (***KNOW***)  Starts as small papule  Painless, indurated, smooth, weeping lesion  Lymph nodes enlarge, feel firm, but are not painful  Even without TX, chancre usually disappears within 6 weeks  Continues to spread through body  Secondary o 6 weeks to 6 mos. after onset of primary stage o Wear Gloves (***KNOW***)  Latent o Early – 1st year of infection, infectious lesions can recur o Late – greater than 1 yr. following infection; not infectious except to fetus of pregnant woman o May or may not have reactive VDRL  Tertiary o Occurs after a period of 4 to 20 years o Develops d/t untreated cases o Benign lesions (gummas); Cardiovascular syphilis; Neurosyphilis (CNS changes, partial paralysis)  Interventions o Keep all patients receiving PCN 30 minutes following injection to observe for allergy (***KNOW***) o Jarisch-Herxheimer Reaction – May follow treatement for syphilis; caused by rapid release of products from the organism Genital Herpes – Caused by Herpes Simplex Virus  Most common STD in U.S.  Incubation – 2 to 20 days  Can have no symptoms and still be infectious  Care of Genital Herpes (***KNOW***)  Administer oral and local analgesics  Ice packs or warm compresses to lesions  Sitz baths 3 or 4 times/day  Increase fluid intake to replace what is lost through lesions  Encourage frequent urination/catheterize PRN  Water over genitalia while voiding; or void in shower  Encourage genital hygiene  Wash hands/towels that have had contact w/lesions  Wear gloves  Avoid sexual activity when lesions are present and wear condoms

 Educate client on side effects/risks vs. benefits of antiviral agents  Advise to discuss DX w/current and new partners Condylomata Acuminata – Genital Warts  Caused by HPV – primary risk for development of cervical cancer  Incubation 2 to 3 months  Focus on removing warts and treating symptoms  Recurrence likely (especially in 1st 3 mos.); no current therapy eliminates HPV  Drugs – Condylox (podoflox), Aldara (imiquimod), Pododerm (podophyllin) Gonorrhea – sexually transmitted bacterial infection  Symptoms – 3 to 10 days after being infected, or may not have any symptoms  Highest in 15 to 4 yr. olds, as well as men having sex w/men  Antibiotics – Rocephin, Doxycycline, Zithromax Chlamydia  Incubation – 1 to 3 weeks, but can be present for mons. without symptoms  Highest Risk – African American women between 16 and 24 years  Antibiotics – Zithromax, Doxycycline Pelvic Inflammatory Disease (PID) – infectious process in which the organisms of the lower genital tract migrate from the endocervix upward through the uterine cavity into the fallopian tubes.  STD’s and other organisms are linked to PID – Chlamydia, Gonorrhea, Gardnerella Vaginalis, Haemophilus Influenze, Staph, Strep, E-Coli  Leading cause of infertility **  R/T ectopic pregnancy  Irreversible scarring and strictures  May or may not have symptoms AIDS  Prevent Infection (when WBC is low) (***KNOW***)  Avoid crowds  Do not share personal toilet articles  Bathe daily  Clean toothbrush at least weekly  Wash hands thoroughly with antimicrobial soap before eating or drinking, after touching pet, after shaking hands, as soon as home from outing, and after using toilet  Avoid eating salads, raw fruit and veggies, undercooked meat, fish, and eggs, and pepper and paprika  Wash dishes between use  Do not drink anything that has been standing for longer than one hour  Do not reuse cups or glasses without washing  Do not change pet litter boxes, if unavoidable, use gloves  Avoid turtles and reptiles as pets

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Do not feed pets raw or undercooked meat Take temp q day Report to HCP immediately o Temp > 100 o Persistent cough o Pus or foul-smelling drainage from open sores o Presence of boil or abcess o Urine that is cloudy or foul smelling, or burning on urination Take all medication Do not dig in garden or work w/houseplants Condom use Avoid travel to areas of world w/poor sanitation or < adequate health care facilities

Benign Breast Disorders o Fibroadenoma – mass of connective tissue that is unattached to surrounding breast tissue  Most common benign tumor in women during reproductive years  Risk of cancer is small  Oval, freely movable, and rubbery o Fibrocystic Breast Condition  Involves lobules, ducts, and stromal tissues  Most often seen in premenopausal women between 20 and 50 years  Caused by imbalance in estrogen to progesterone ratio  Two Main Features  Fibrosis – Firm hard areas  Cysts – Fluid filled  Symptoms fade after menstruation and recur before the next menstrual period  Can use Danazol (Danocrine), but has severe side effects. Only used if FBC is recurrent and severe.  Reduce fat and caffeine intake, diuretics for engorgement, supportive bra, limit salt intake before mensus, etc. o Ductal Ectasia – breast duct dilation and wall thickening causing ducts to become blocked, resulting in inflammatory response.  Usually seen in women approaching menopause  Greenish brown nipple discharge  Hard mass w/irregular boarders that is tender  Redness and edema over site of mass  Hard to distinguish from breast cancer  Microscopic exam of nipple discharge and excision of affected area is required o Intraductal Papilloma – overgrowth of the epithelial lining of the breast duct forming a pedunculated papilloma

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Occurs most often in women 40 to 55 years old As it progresses, erosion occurs in duct causing bloody or serous nipple discharge o Gynecomastia – benign condition of breast enlargement in men  “Female breasts”  Symptom, not a disease  Always R/O cancer  Abnormal growth of breast glandular tissue  Underlying disease causing estrogen excess (malnutrition, liver disease, and hyperthyroidism)  Androgen deficiency from age, chronic kidney disease, or alcoholism Breast Cancer o Most commonly diagnosed cancer in women o Early detection is vital o Categories  Noninvasive – (20%) remains in the mammary ducts  In situ – in the original position; confined to the site of origin  Ductal Carcinoma in situ (DCIS) – an early noninvasive form of breast cancer; not harmful at this stage but should be treated to prevent spread to tissue surrounding the ducts.  Lobular Carcinoma in situ (LCIS) – usually diagnosed accidentally during biopsy for another problem; does not show up as calcified area on mammogram; commonly affects both breasts  Invasive – (80%) penetrates the tissue surrounding the ducts  Most common type; infiltrating ductal carcinoma  Originates in mammary ducts  Inflammatory breast cancer – as tumor spreads it can invade lymphatic system blocking lymph drainage causing breast to have edema, redness, warmth, and peau d’orange.  Common sites of metastisis – bone, lungs, brain, and liver o High Risk Factors  Age > 65  Inherited mutations  2 or more 1st degree relatives w/breast cancer at early age (mother, sister, daughter) o Moderate Risk Factors  1 1st degree relative with breast cancer  Atypical hyperplasia  High postmenopausal bone density o Low Risk Factors  Nulliparity

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 1st child born after age 30  Early menstruation; late menopause  Oral contraceptives  HRT  Obesity o Other Risk Factors  Alcohol – 2 drinks/day may increase risk by 21%  High socioeconomic status  Jewish Heritage Health Promotion o Mammography – annually staring at age 40 o BSE  Monthly 1 week after menstrual period  Post-Menopausal/Post-Hysterectomy – same day every month Surgical o Modified Radical Mastectomy – breast tissue, nipple lymph nodes are removed and muscles left intact o Simple Mastectomy – breast tissue and nipple removed, lymph noeds left intact o Lumpectomy w/Node Dissection – Only the tumor and lymph nodes are removed o Mastectomy Post-Op Care (***KNOW***)  Assess incision and flap for S/S of infection  Assess incision and falp for S/S of poor tissue perfusion  Avoid pressure on the flap and suture lines by positioning the patient on nonoperative side; avoid tight clothing  Monitor and measure drainage  Teach to return to usual activity level gradually; avoid heavy lifting  Avoid sleeping in prone position  Avoid participation in contact sports or other activity that could cause trauma  Minimize pressure on breast during sexual activity  Refrain from driving until advised by HCP  Ask for 6 week postop visit to ask when full activity can be resumed  Optimal appearance may not occur for 3 to 6 mons. postop.  If implants, method of breast massage to enhance expansion and prevent capsule formation

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 Breast self-awareness, review BSE technique  Importance of f/u visits  Types of Breast Resoncstruction o Breast Expanders – tissue expander under pectoralis muscle; NS injected weekly for 6 to 8 weeks; exchanged for permanenet implant o Autologous Reconstruction – uses patient’s own skin, fat, and muscle  Flap Donor Sites  Back, TRAM (Abdomen) flap, Buttock Precocious Puberty – when someone’s body begins changing from a child into an adult too soon; puberty that begins before age 8 for girls and before age 9 for boys. o Appear older than chronological age Family Planning o Advantages and Disadvantages of Most Common Contraceptive Methods (Pg. 737 – 738 – Mckinney Table 31.1) (***KNOW***) Infertility – the inability to conceiver after one year of unprotected regular sexual intercourse. o Pregnancy wastage – conceive but repeatedly abort before old enough to survive o Affects approximately 10 20% of U.S. women