3. Complications affecting protective function: STDs. This NCLEX category measures applications of knowledge about conditions related to patient s capacity to maintain defenses and prevent physical and chemical trauma, injury, infection, and threats to health status.
   • Vaginitis - inflammation of vagina.
     1. Pathophysiology - local inflammatory reaction (redness, heat, irritation/tenderness, pain). May cause preterm labor in pregnancy.
     2. Etiology:
        • Common causative organisms:
          1. Bacteria - streptococci, Escherichiacoli, gonococci, chlamydia, bacterial vaginosis.
          2. Viruses - herpes type II, CMV, HPV
          3. Protozoa - Trichomonas vaginalis.
          4. Fungi - Candida albicans.
        • Atrophic changes - due to declining hormone level (postmenopausal women).
     3. Assessment: differentiate among common vaginal infections:
        • Vulvovaginal erythema.
        • Pruritus, dysuria, dyspareunia.
        • Vaginal discharge.
     4. Analysis/nursing diagnosis: pain related to inflammation, discharge.
     5. Nursing care plan/implementation:
        • Goal: emotional support.
        • Goal: health teaching. Instruct woman in self-care measures to promote comfort and healing:
          1. Perineal care.
          2. Sitz baths.
          3. Douching (as ordered). Not recommended during pregnancy.
          4. Exposing vulva to air.
          5. Cotton briefs.
          6. Proper insertion of vaginal suppository.
          7. Instruct patient on antibiotic use, as ordered.
        • Goal: prevent reinfection.
          1. Suggest sexual partner use condom until infection is eliminated - or abstain from intercourse.
          2. Recommend sexual partner seek examination and treatment.
        • Goal: medical consultation/treatment. Refer for diagnosis and treatment.
     6. Evaluation/outcome criteria:
        • Woman is asymptomatic; unable to recover organism from body fluids or tissue.
        • Woman avoids reinfection.
        • Woman carries pregnancy to term without complications.
   • Gonorrhea
     1. Pathophysiology:
        • Male - early infection usually confined to urethra, vestibular glands, anus, or pharynx. Untreated: ascending infection may involve testes, causing sterility.
        • Female - early infection usually confined to vestibular glands, endocervix, urethra, anus (vagina is resistant). May ascend to involve pelvic structures, e.g., PID: fallopian tubes, ovaries; scarring may cause sterility.
        • Pregnant female - may result in preterm rupture of membranes, amnionitis, preterm labor, postpartum salpingitis.
        • Sequelae (untreated):
          1. May develop carrier state (asymptomatic; organism resident in vestibular glands).
          2. Systemic spread may result in gonococcal:
             • Arthritis.
             • Endocarditis.
             • Meningitis.
             • Septicemia.
        • Newborn - ophthalmia neonatorum (gonococcal conjunctivitis). Untreated sequela: blindness.
     2. Etiology: gram-negative diplococcus (Neisseria gonorrhoeae).
     3. Epidemiology:
        • Portal of entry - oral or genitourinary mucous membranes.
        • Mode of transmission - usually sexual contact.
        • Incubation period: 2-5 days; may be asymptomatic.
        • Communicable period - as long as organisms are present; to 4 days after antibiotic therapy begun.
     4. Assessment:
        • History of known (or suspected) contact.
        • Male:
          1. Complaint of mucoid or mucopurulent discharge.
          2. Medical diagnosis - procedure: urethral discharge gram stain.
        • Female:
          1. Often asymptomatic; acute infection: severe vulvovaginal inflammation, venereal warts, greenish-yellow vaginal discharge.
          2. Medical diagnosis - procedure: en-docervical culture.
        • Gonococcal urethritis (male and female) - sudden severe dysuria, frequency, burning, edema.
        • Salpingitis/oophoritis - severe, sudden abdominal pain, fever (with or without vaginal discharge).
     5. Analysis/nursing diagnosis: impaired tissue integrity related to tissue inflammation.
     6. Nursing care plan/implementation:
        • Goal: emotional support.
        • Goal: health teaching to prevent transmission, sequelae, reinfection.
          1. Need for accurate diagnosis and effective treatment, follow-up examination in 7-14 days, and culture.
          2. All sexual partners need examination, treatment.
          3. Possible sequelae/complications (sterility, carrier state).
        • Goal: medical consultation/treatment.
          1. Determine allergy to antibiotics.
          2. Refer for diagnosis and treatment.
             • Diagnosis: culture.
             • Treatment - ceftriaxone IM, plus doxycycline PO. May use erythromycin or spectinomycin in pregnancy.
             • Follow-up culture before birth.
             • Notification of sexual partners.
     7. Evaluation/outcome criteria:
        • Verbalizes understanding of mode of transmission, prevention, importance of examination, treatment of sexual contacts.
        • Informs sexual contacts of need for examination.
        • Returns for follow-up examinations.
        • Successfully treated; weekly low-up cultures: negative on two successive visits.
        • Avoids reinfection.
   • Chlamydia trachomatis
     1. Pathophysiology:
        • Most common sexually transmitted disease in United States.
        • Initial infection mild in females; inflammation of cervix with discharge.
        • If untreated, may lead to urethritis, dysuria, PID, tubal occlusion, infertility.
     2. Etiology:
        • Chlamydia trachomatis has maternal-fetal effects.
        • Bacteria can exist only within living cells.
        • Transmission is by direct contact from one person to another.
     3. Assessment - maternal:
        • Inflamed cervix (may be asymptomatic).
        • Cervical congestion, edema.
        • Mucopurulent discharge.
     4. Assessment - fetal-neonatal:
        • Increased incidence of stillbirth.
        • Preterm birth may result.
        • Contact with infected mucus occurs during birth.
        • Newborn may be asymptomatic.
        • Conjunctivitis; may lead to scarring.
        • Chlamydial pneumonia.
     5. Analysis/nursing diagnosis:
        • Pain related to inflamed reproductive organs.
        • Fatigue related to inflammation.
        • Knowledge deficit related to mode of treatment, disease transmission.
     6. Nursing care plan/implementation:
        • Treatment with antibiotics, generally doxycycline or azithromycin. Erythromycin in pregnancy.
        • Provide pain relief, analgesics.
        • Counsel regarding use of condoms, spermicidal agents (containing nonoxynol-9) to prevent reinfection.
     7. Evaluation/outcome criteria:
        • Woman understands treatment and shows compliance.
        • Woman understands portal of entry and risk for reinfection.
   • Herpes genitalis
     1. Pathophysiology - initial infection: varies in severity of symptoms, may be local or systemic; duration: prolonged; morbidity: severe.
     2. Etiology - Herpes virus type II.
     3. Epidemiology:
        • Portal of entry - skin, mucous membranes.
        • Mode of transmission - usually sexual.
        • Incubation: 3-14 days.
        • Communicable period - while organisms are present.
     4. Assessment:
        • Lesions - painful, red papules; pustular vesicles that break and form wet ulcers that later crust; self-limiting (3 weeks).
        • Severe itching or tingling or pain.
        • Discharge - copious; foul smelling.
        • Dysuria.
        • Lymph nodes - enlarged, inflammatory, inguinal.
        • Pregnant female - vaginal bleeding, spontaneous abortion, fetal death.
        • May shed virus for 7 weeks.
        • Medical diagnosis: multinucleated giant cells in microscopic examination of lesion exudate; culture for herpes simplex virus (HSV).
     5. Analysis/nursing diagnosis:
        • Pain related to inflammation process.
        • Fear related to longevity of disease.
        • Fear related to no cure for disease.
        • Knowledge deficit related to transmission to future partners.
     6. Nursing care plan/implementation:
        • Goal: emotional support.
        • Goal: health teaching.
          1. Virus remains in body for life (dormant, noninfectious) in 25-30% of population; small percentage have symptoms.
          2. Recurrence probable; usually shorter and milder.
          3. Need for close surveillance during pregnancy; cesarean birth may be indicated if woman has active genital lesions or positive culture.
        • Goal: promote comfort.
        • Goal: accurate definitive treatment. Refer for diagnosis and treatment.
          1. Diagnosis - cervical smears, labial and vaginal smears.
          2. Treatment - acyclovir (Zovirax, but not in pregnancy), used for suppressive treatment only.
     7. Evaluation/outcome criteria:
        • Woman remains asymptomatic.
        • Pregnancy continues to term with no newborn effects.
   • Syphilis
     1. Pathophysiology:
        • Primary stage: nonreactive VDRL.
          1. Male: 3-4 weeks after contact, painless, localized penile/anal ulcer (chancre); lymph nodes - enlarged, regional.
          2. Female: often asymptomatic; labial, vaginal, or cervical chancre.
          3. Medical diagnosis - procedure: darkfield microscopic examination of lesion exudate.
        • Secondary stage: reactive VDRL.
          1. 6-8 weeks after infection.
          2. Rash-macular, papular; on trunk, palms, soles.
          3. Malaise, headache, sore throat, weight loss, low-grade temperature.
        • Latent stage: reactive serologic test for syphilis (STS). Asymptomatic; non-infectious.
        • Tertiary stage:
          1. Gumma formation in skin, cardiovascular system, or central nervous system.
          2. Psychosis.
     2. Etiology: Treponema pallidum (spirochete).
     3. Epidemiology:
        • Portal of entry - skin, mucous membranes.
        • Mode of transmission - usually sexual.
        • Incubation period - 9 days-3 months.
        • Communicable period - primary and secondary stages.
     4. Assessment:
        • Primary - chancre, when detectable. Medical diagnosis - procedure: dark-field examination of lesion exudate.
        • Secondary:
          1. Malaise, lymphadenopathy, headache, elevated temperature.
          2. Macular, papular rash on palms and soles; may be disseminated.
          3. Medical diagnosis—see d., below.
        • Tertiary:
          1. Subcutaneous nodules (gumma).
          2. Note: Gumma formation may affect any body system; symptoms associated with area of involvement.
        • Medical diagnosis - procedures: stages other than primary-STS: VDRL, rapid plasma reagin (RPR), T. pallidum immobilization (TPI), fluorescent treponemal antibody absorption (FTA). False-positive STS in: collagen diseases, infectious mononucleosis, malaria, systemic tuberculosis.
     5. Analysis/nursing diagnosis:
        • Pain related to inflammation process.
        • Knowledge deficit related to treatment and transmission of the disease.
     6. Nursing care plan/implementation:
        • Goal: emotional support
          1. Nonjudgmental.
          2. Caring, supportive manner.
        • Goal: health teaching.
          1. Need for accurate diagnosis and treatment, follow-up examinations.
          2. All sexual partners need examination and treatment.
        • Goal: medical consultation/treatment.
          1. Refer for diagnosis and treatment. Note: In pregnancy - treatment by 18th gestational week prevents congenital syphilis in neonate; however, treat at time of diagnosis.
          2. Treatment:
             • Primary, secondary - benzathine penicillin G, 2.4 million U.
             • Other stages - 7.2 million U over 3 weeks period.
             • Erythromycin or doxycycline for penicillin-allergic clients.
     7. Evaluation/outcome criteria:
        • If treated by 18th weeks of pregnancy, congenital syphilis is prevented.
        • Appropriate treatment after 18th weeks cures both mother and fetus; however, any fetal damage occurring before treatment is irreversible.
        • Follow-up VDRL: nonreactive at 1,3,6,9, and 12 months.
        • Tertiary - cerebrospinal fluid examination negative at 6 months and 1 year following treatment.
        • Verbalizes understanding of mode of transmission, potential sequelae without treatment, importance of examination/ treatment of sexual contacts, preventive techniques.
        • Informs contacts of need for examination.
        • Returns for follow-up visit.
        • Avoids reinfection.
   • PID
     1. Pathophysiology - ascending pelvic infection; may involve fallopian tubes (salpingitis), ovaries (oophoritis); may develop pelvic abscess (most common complication), pelvic cellulitis, pelvic thrombophlebitis, peritonitis.
     2. Etiology:
        • trachomatis.
        • Gonococci.
        • Streptococci.
        • Staphylococci.
     3. Assessment:
        • Pain: acute, abdominal.
        • Vaginal discharge: foul smelling.
        • Fever, chills, malaise.
        • Elevated white blood cell (WBC) count.
     4. Analysis/nursing diagnosis:
        • Pain related to occluded tubules.
        • Infertility related to permanent block of tubes.
        • Knowledge deficit related to transmission of disease.
        • Altered urinary elimination related to dysuria.
     5. Nursing care plan/implementation - for hospitalized woman:
        • Goal: emotional support.
        • Goal: limit extension of infection.
        1. Bed rest-position: semi-Fowler’s, to promote drainage.
        2. Force fluids to 3000 mL/days.
        3. Administer antibiotics, as ordered.
        • Goal: prevent autoinocculation/transmission.
          1. Strict aseptic technique (hand washing, perineal care).
          2. Contact-item isolation.
          3. Health teaching: if untreated: high risk of tubal scarring, sterility, or ectopic pregnancy; pelvic adhesions; transmission of disease.
        • Goal: promote comfort.
          • Analgesics, as ordered.
          • External heat, as ordered.
     6. Evaluation/outcome criteria:
        • Woman responds to therapy; uneventful recovery.
        • Woman avoids reinfection.