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NURSE PROTOCOLS FOR
WOMEN’S HEALTH
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Division of Public Health
Nurse Protocols for Registered Professional Nurses
for 2008
TABLE OF CONTENTS
WOMEN’S HEALTH
World Health Organization Medical Eligibility Criteria for Contraceptive Use
Combined Oral Contraceptives
Abnormal Lipid Tests While Taking Oral Contraceptives
Hypertension While Taking Oral Contraceptives
Spotting or Breakthrough Bleeding While Taking Oral Contraceptives
Progestin-Only Pill
Emergency Contraceptive Pills
Implanon: Insertion
Implanon: Removal
IUD Insertion: Copper T380A
IUD Insertion: Mirena LNG IUD
IUD-Related Dysmenorrhea
Lost IUD Strings
IUD-Related Menorrhagia
Pregnancy With IUD In Place
IUD Removal
IUD Complications and Actions
Medroxyprogesterone Acetate Injectable Contraceptive
Ortho Evra Patch
NuvaRing
Diaphragm
Norplant Removal
Amenorrhea (Primary and Secondary)
Bacterial Cystitis
Dysmenorrhea
Ectopic Pregnancy
Nurse Protocol for Prophylactic Therapy with Folic Acid for
Reproductive-Age Women
Iron Deficiency Anemia In Non-Pregnant and Non-Lactating Women 18
and Over
Osteoporosis in Women
Sexual Abstinence Counseling
Local Estrogen Therapy
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Nurse Protocols for Registered Professional Nurses
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World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use
Third Edition, 2004
CONDITION
TYPE OF
CONTRACEPTIVE
CATEGORY
CLARIFICATIONS/
I=Initiation
EVIDENCE
C=Continuation
Condition
Clarifications and
Condition classified from
evidence regarding the
1 to 4
classification
The categories for
fertility awarenessbased methods and
surgical sterilization are
described at the
beginning of the
relevant section.
NA denotes a condition for which a ranking was not given by the Working Group but for which
clarifications have been provided.
Classification of categories
Each condition was defined as representing either an individual's characteristics (e.g., age,
history of pregnancy) or a known pre-existing medical/pathological condition (e.g., diabetes,
hypertension). It is expected that national and institutional health and service delivery
environments will decide the most suitable means for screening for conditions according to
their public health importance. Client history will often be the most appropriate approach.
The conditions affecting eligibility for the use of each contraceptive method were classified
under one of the following four categories:
1.
2.
3.
4.
A condition for which there is no restriction for the use of
the contraceptive method.
A condition where the advantages of using the method
generally outweigh the theoretical or proven risks.
A condition where the theoretical or proven risks usually
outweigh the advantages of using the method.
A condition which represents an unacceptable health risk if
the contraceptive method is used.
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Nurse Protocols for Registered Professional Nurses
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Using the categories in practice
Categories 1 and 4 are self-explanatory. Classification of a method/condition as category 2
indicates the method can generally be used, but careful follow-up may be required. However,
provision of a method to a woman with a condition classified as category 3 requires careful
clinical judgment and access to clinical services; for such a woman, the severity of the
condition and the availability, practicality, and acceptability of alternative methods should be
taken into account. For a method/condition classified as category 3, use of that method is not
usually recommended unless other more appropriate methods are not available or
acceptable. Careful follow-up will be required.
Where resources for clinical judgment are limited, such as in community-based services, the
four-category classification framework can be simplified into two categories. With this
simplification, a classification of Category 3 indicates that a woman is not medically eligible
to use the method.
CATEGORY
1
2
3
4
WITH CLINICAL
JUDGMENT
WITH LIMITED
CLINICAL JUDGMENT
Use method in any
circumstances
Yes (Use the method)
Generally use the method
Use of method not usually
recommended unless
other more appropriate
methods are not available
or not acceptable
No (Do not use the
method)
Method not to be used
ABBREVIATIONS:
COC – Combined oral contraceptive
CIC – Combined injectable contraceptive
P/R – Patch/Ring
POP – Progestin-only pill
DMPA – Depot medroxyprogesterone acetate
NET-EN – Norethinsterone enantate
LNG/ETG – Levonorgestrel/Etonorgestrel (Norplant & Jadell/Implanon
Cu IUD – Copper IUD (ParaGard)
LNG IUD – Levonorgestrel IUD (Mirena)
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NURSE PROTOCOL FOR
COMBINED ORAL CONTRACEPTIVES (OCs)
DEFINITION
Combined oral contraceptives work primarily before fertilization. The
progestins in all combined hormonal contraceptives provide most of the
birth control activity by:

Thickening cervical mucus to prevent sperm penetration into the
upper genital tract.

Blocking the lutenizing hormone (LH) surge prohibiting ovulation.

Inhibiting capacitation of the sperm which may delay sperm
transport.
Some progestin effects additionally alter the environment that
would be required for embryogenesis to proceed by:

Disrupting transport of the fertilized ovum.

Inducing endometrial atrophy, changing underlying vascular
function and structure and altering the metalloproteinase in the
endometrium which may inhibit implantation.
SUBJECTIVE
OBJECTIVE
1.
Desires OCs as choice of contraception.
2.
Has detailed health history (includes menstrual, sexual,
contraception, personal health and family history) that does not
reveal a condition representing an unacceptable health risk
according to the product prescribing information and the World
Health Organization (WHO) Medical Eligibility Criteria for
Contraceptive Use.
3.
If breastfeeding, has been breastfeeding at least 6 weeks,
but, preferably six months or more after childbirth, to ensure that
breastfeeding has been well established.
4.
If age 35 or older, client does not smoke.
Physical examination and laboratory tests according to programmatic
guidelines.
OR
Physical exam deferred up to 3 months.
Document reason for deferral on chart. Document on Request for and
Consent to Family Planning Services (form 3700) that client agreed to
have physical exam delayed.
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ASSESSMENT
Patient has no condition representing an unacceptable risk for taking
OCs.
PLAN
DIAGNOSTIC STUDIES
1.
Lipid profile beginning by age 45. Consider screening
women age 20-44 in the presence of high-risk factors for
CVD. Rescreen every 5 years or more often depending on
test results and high-risk factors. For Recommended Tests
and Immunizations for Women with High-Risk Factors refer to
www.womenshealth.gov.
2.
Blood glucose beginning by age 45. Consider screening
women at an earlier age in the presence of high-risk factors
for diabetes. Rescreen every 3 years or more often
depending on test results and high risk factors. For
Recommended Tests and Immunizations for Women with
High-Risk Factors refer to www.womenshealth.gov.
3.
Screen women for colorectal cancer according to district
policy/procedure for colorectal cancer screening.
THERAPEUTIC
PHARMACOLOGIC
1.
If the patient can take a pill with estrogen, give one tablet
daily PO of any FDA approved <35 mcg oral contraceptive.
2.
If the patient has been successfully taking OCs that are not
available in the clinic, select pill with comparable
composition or phone order to pharmacy.
3.
Start patient on lowest acceptable dose with acceptable
level of side effects.
4.
For patients not receiving physical exam prior to first 3month supply, a physical exam must be performed to
dispense additional OCs.
5.
If patient is currently taking OCs or took previously without
problems, may dispense appropriate number of cycles until
next exam is to be performed.
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PATIENT EDUCATION/COUNSELING
1.
Counsel patient according to the seven basic elements of
informed consent (BRAIDED).







2.
Benefits of the method.
Risks of the method (both major risks and all common
minor ones), including consequences of method failure.
Alternatives to the method (including abstinence and no
method).
Inquiries about the method are the patient’s right and
responsibility.
Decision to withdraw from using the method without penalty
is the patient’s right at any time.
Explanation of the method is owed the patient, in a format
that is understandable to the patient.
Documentation that the care-giver has ensured
understanding of each of the preceding six points, usually
by use of a consent form.
Instructions in OC use:
a.
b.
c.
d.
e.
f.
Take pills at the same time every day.
Use back-up birth control for the first 7 days of OCs.
Sunday-start, first day of menses start or quick start (refer
to Contraceptive Technology, p. 420).
Taking a pill more than a few hours late increases the risk
of pregnancy; missing more than 2 pills in a row greatly
increases the risk.
When finishing one pack, take the first pill in the next
packet on the very next day.
Discuss medications that may reduce effectiveness.
3.
Side effects and danger signs (ACHES).
4.
Effectiveness and back-up methods.
5.
Advise patient if she misses a pill(s) to refer to her pill package
insert for missed pills instructions.
6.
Counsel on the use of condoms to reduce the risk of STD/HIV.
7.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
8.
Emphasize importance of keeping immunizations current; assess
client’s immunization status and administer vaccines
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indicated according to the current Advisory Committee on
Immunization Practices (ACIP) childhood or adult immunization
schedule. If client declines vaccination, document refusal. See
the Georgia Immunization Program Manual, Recommended
Schedule and Guidelines, for current ACIP schedules and
administration guidelines for each vaccine. The Georgia
Immunization Manual may be accessed online at
http://www.health.state.ga.us/programs/immunization/publications.
asp.
FOLLOW-UP
1.
Return as scheduled for evaluation or contact clinic if side effects
or danger signs develop. Outside of clinic hours, seek physician
or emergency care if danger signs develop.
2.
If patient did not receive a physical exam, have her return within 3
months for an exam and reassessment.
3.
Established patients should return for evaluation at the end of the
current supply of pills, or sooner if side effects or danger signs
develop.
CONSULTATION/REFERRAL
1.
Development of any danger signs:
a.
b.
c.
d.
e.
f.
g.
Abdominal pain (severe).
Eye problems (vision loss or blurring).
Speech problems.
Chest pain (severe), coughs, shortness of breath.
Severe leg pain (calf or thigh).
Severe headaches that start or become worse after
beginning to take OCs.
Dizziness, weakness, numbness or depression.
2.
Any serious health concern expressed by patient.
3.
If patient is under the supervision of medical doctor(s) for a health
problem (e.g., hypertension).
4.
Abnormal initial laboratory values or development of abnormal
laboratory values or physical findings that indicate oral
contraceptives should not be continued.
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5.
To nutritionist if patient has poor dietary intake, is overweight or
underweight, is anemic or has any chronic disease related to poor
nutrition.
REFERENCES
1.
2.
3.
4.
5.
6.
American Society of Health-Systems Pharmacists. American Hospital Formulary
Service, Bethesda, MD, 2007, pp. 3072-3086.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co., New York, 2004. (Current)
World Health Organization, Medical Eligibility Criteria for Contraceptive Use, Third
Edition, 2004, <http:www.who.int/reproductive-health/publications/mec/> (March 15,
2005).
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
"Preventive Screenings and Immunizations," U. S. Department of Health and
Human Services, Office of Women's Health,
<http://www.womenshealth.gov/screeningcharts/highrisk/>.
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NURSE PROTOCOL FOR
ABNORMAL LIPID TESTS
WHILE TAKING ORAL CONTRACEPTIVES (OCs)
DEFINITION
Increased blood cholesterol levels are causally related to an increased
risk of coronary heart disease. Coronary risk rises progressively with
cholesterol levels, particularly when total cholesterol levels rise above
200 mg/dL. Borderline total cholesterol levels are 200-239 mg/dL and
high levels are >240 mg/dL. Desirable levels of low-density lipoprotein
cholesterol (LDL) are <130 mg/dL. Desirable levels of high-density
lipoprotein cholesterol (HDL) are >40 mg/dL and are as significant as
total cholesterol levels.
Ethinyl estradiol increases HDL cholesterol and reduces LDL cholesterol.
Progestins diminish the magnitude of the favorable impact; the more
androgenic formulations have a more pronounced negative effect.
Although triglyceride levels increase somewhat with estrogen-containing
contraception, there is little concern because those remnants are not
atherogenic. However, estrogen-containing contraceptives should be
avoided if their use will be anticipated to raise triglycerides levels to
>350 mg/dL and place the woman at risk for pancreatitis.
SUBJECTIVE
OBJECTIVE
Patient may have:
1.
Family history of cardiovascular disease prior to age 50.
2.
History of hypertension.
3.
History of smoking cigarettes.
4.
Diabetes or gestational diabetes.
1.
BMI of 27 or greater.
1.
Total cholesterol 200 mg/dL or greater.
AND/OR
High-density lipoprotein cholesterol (HDL) <40 mg/dL.
AND/OR
Low-density lipoprotein cholesterol (LDL) >130 mg/dL.
AND/OR
Triglycerides >150mg/dL.
2.
3.
4.
ASSESSMENT
Elevated Cholesterol and/or Triglycerides (hypertriglyceridemia).
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PLAN
DIAGNOSTIC STUDIES
Fasting total cholesterol and lipid profile (to include HDL, LDL) and
triglycerides. Assessment cannot not be made on screening total
cholesterol only.
THERAPEUTIC
PHARMACOLOGIC
Change to OC containing either desogestrol (Desogen, OrthoCept), norgestimate (Ortho-Cyclen, Ortho-Tricyclen), lowest dose
norethindrone (Ovcon-35, Brevicon, Modicon) or drospirenone
(Yasmin) or progestin-only OC.
PATIENT EDUCATION/COUNSELING
1.
Discuss risk factors associated with smoking, hypertension,
diabetes and obesity.
2.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
3.
Discuss lifestyle changes such as diet modifications to
lower blood cholesterol, diet low in fat, high in fiber (plenty
of whole grains, vegetables and fruits).
4.
Advise patient to increase exercise and/or physical activity.
5.
Lower dose OCs probably do not adversely affect lipid levels in
most women.
FOLLOW-UP
Recheck lipid profile in 3–6 months.
CONSULTATION/REFERRAL
Refer to physician:
1.
If total cholesterol is 240 mg/dL or greater, HDL <40 mg/dL,
LDL>160 mg/dL, and/or Triglycerides >200 mg/dL. Must have MD
approval to continue OCs.
2.
To nutritionist for dietary counseling as needed.
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REFERENCES
1.
2.
3.
4.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co., New York, 2004. (Current)
Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III), Executive Summary, NIH, Publication No. 01-3670 National
Heart, Lung, and Blood Institute, US Department of Health and Human Services,
Bethesda, MD, May, 2001. (Current)
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
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NURSE PROTOCOL FOR
HYPERTENSION WHILE TAKING ORAL CONTRACEPTIVES
DEFINITION
Women who use oral contraceptives (OCs) rarely develop hypertension.
However, the probability of developing hypertension increases with age.
Hypertension may appear at any time and is not limited to the first
months of use. OC-related hypertension is usually mild to moderate (a
rise over baseline of 10-20 mmHg diastolic and/or 20 to 40 mmHg
systolic). The hypertension is usually reversible within one to three
months after discontinuing OCs. Only a few cases progressing to
malignant hypertension have been reported.
ETIOLOGY
Variables such as previous toxemia of pregnancy or previous renal
disease do not predict whether a woman will develop hypertension while
using OCs. The mechanism for an effect of OCs on blood pressure is
thought to involve the renin angiotensin system.
SUBJECTIVE
1.
May or may not have past history of hypertension.
2.
Is currently taking OCs and hypertension has developed since
starting pills.
OBJECTIVE
Blood pressure, measured according to Nurse Protocol for Primary
Hypertension in Adults, shows:
1.
2.
Systolic blood pressure ≥ 140 mmHg on three or more separate
occasions.
OR
Diastolic blood pressure ≥ 90 mmHg on three or more separate
occasions.
NOTE: See Nurse Protocol for Primary Hypertension in Adults
ASSESSMENT
Hypertension, possibly related to oral contraceptives.
PLAN
THERAPEUTIC
PHARMACOLOGIC
Change to another contraceptive method that is not
combined hormonal.
NON-PHARMACOLOGIC MEASURES
Review the following lifestyle modifications with all clients,
as applicable:
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1.
Counsel regarding the Dietary Approaches to Stop
Hypertension (DASH), Reduced Sodium Diet.
2.
Achieve/maintain desirable body weight or Body Mass
Index of 18.5-24.9 kg/m2.
3.
Reduction of dietary sodium (1500 mg to no more than
2400 mg/day).
4.
Reduction of dietary fats and cholesterol.
5.
Moderation of alcohol intake (less than one ounce
[30mL] ethanol/day for men and less than 0.5 oz [15mL]
for women). One ounce of ethanol equals 24 oz Beer,
10 oz wine, or 3 oz 80-proof whiskey.
6.
Adequate dietary potassium intake (if renal function is
normal and not taking drugs known to raise potassium,
such as angiotensin-converting enzyme Inhibitors) of
3500 mg/day.
7.
Regular aerobic physical activity at least 30 minutes
per day, most days of the week.
8.
If smoker or tobacco user, refer to local cessation
program and/or Georgia Quit Line 1-877-270-STOP
(7867).
9.
Adequate intake of calcium, 1000-1500 mg/day.
PATIENT EDUCATION/COUNSELING
1.
Educate patient on lifestyle changes that may help lower blood
pressure.
a.
b.
c.
d.
e.
g.
h.
i.
Limit sodium intake to no more than 1500-2000 mg/day.
Eat a diet rich in vegetables, fruits and low-fat dairy
products such as low-fat milk and yogurt.
Exercise and/or increase physical activity.
Quit smoking
Decrease intake of caffeine and alcohol.
Avoid over-the-counter-oral decongestants and diet pills.
Attain and maintain optimal weight
Attain and maintain adequate calcium.
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2.
Discuss possible risks and complications of hypertension.
FOLLOW-UP
Monitor blood pressure monthly, for 3 months.
REFERRAL/CONSULTATION
1.
For uncontrolled blood pressure consistently >140 mmHg systolic,
or >90 mmHg diastolic.
2.
To nutritionist for diet counseling about optimal food intake to
attain/maintain normal blood pressure, Na intake and weight.
3.
Systolic pressure ≥210 mmHg or diastolic pressure ≥120 mmHg
on any occasion.
REFERENCES
1.
2.
3.
4.
5.
American Society of Health-Systems Pharmacists, American Hospital Formulary
Service, Bethesda, MD, 2007, pp. 3072-3091.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co., New York, 2004. (Current)
Leon Speroff and Marc Fritz, Clinical Gynecologic Endocrinology and Infertility, Seventh
Edition, Lipincott Williams & Wilkins, Philadelphia, 2005.
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
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NURSE PROTOCOL FOR
SPOTTING OR BREAKTHROUGH BLEEDING
WHILE TAKING ORAL CONTRACEPTIVES
DEFINITION
Breakthrough bleeding (BTB) is bleeding that requires use of a pad or
tampon during the cycle of oral contraceptives (OCs). A lesser amount
of bleeding while taking OCs is called spotting.
Light bleeding between menses for the first few months on OCs is
generally not a sign of any serious problems and is common (30-50% of
women) in the first few months of OC use. BTB generally resolves by
the third or fourth month of OC use. There is no evidence that the onset
of bleeding is associated with decreased efficacy, no matter what oral
contraceptive formulation is used, even the lowest dose products.
SUBJECTIVE
1.
May have a recent history of missed OCs or incorrect usage.
2.
Intermenstrual spotting/bleeding for several months.
3.
May have recent history of GI problems such as
vomiting or diarrhea.
4.
May have history of taking antiseizure medications (phenobarbital,
phenytoin, carbamazepine, or promidone), rifampin, topiramate or
griseofulvin. Herbal substances such as St. John’s Wort may
increase metabolism of estrogen and cause side effects and/or
decreased effectiveness.
5.
May have history of abnormal vaginal discharge.
6.
May have history of dyspareunia or pelvic pain.
OBJECTIVE
Pelvic exam is negative for other causes of bleeding.
ASSESSMENT
Spotting or breakthrough bleeding while on OCs.
PLAN
DIAGNOSTIC STUDIES
1.
Urine dip stick if indicated.
2.
Gonorrhea and chlamydia tests, if indicated.
3.
Pregnancy test if indicated.
4.
Hemoglobin/hematocrit if indicated.
5.
Wet prep if indicated.
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THERAPEUTIC
1.
For women with persistent irregular bleeding after 2-3 months,
consider changing to other formulations, although no research
indicates any specific OC is best at eliminating spotting or
bleeding.
2.
If spotting or bleeding before completion of active OCs, increase
the progestin content of OC either by changing to a different
monophasic formulation or by switching to a triphasic formulation
that increases the progestin level of active OCs.
OR
3.
If spotting continues after withdrawal bleed, increase the estrogen
in each tablet or decrease the progestin in the early pills
(especially with triphasic formulation).
OR
4.
For mid-cycle spotting/bleeding, increase both estrogen/progestin
mid-cycle with OCs such as Triphasil and Tri-Levlen.
PATIENT EDUCATION/COUNSELING
1.
Reassure new OC users that breakthrough bleeding
decreases dramatically over the first 3-4 months of pill use.
2.
Reinforce proper usage of OCs, especially taking pills at the same
time each day.
3.
Counsel on use of alternate method if OCs are discontinued.
4.
Counsel on use of condoms to reduce the risk of STDs/HIV.
5.
Breakthrough bleeding occurs at a higher rate in women who
smoke.
6.
If smoker, refer to local cessation program and/or Georgia
Tobacco Quit Line, 1-877-270-STOP (7867).
FOLLOW-UP
Reassess in 3 months depending on the acuity of the problem.
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REFERRAL/CONSULTATION
1.
If problem continues.
2.
Pelvic pathology.
3.
Abnormal diagnostic tests.
REFERENCES
1.
2.
3.
4.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co., New York, 2004. (Current)
Leon Speroff and Marc Fritz, Clinical Gynecologic Endocrinology and Infertility,
Seventh Edition, Lippincott Williams & Wilkins, Philadelphia, 2005.
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
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NURSE PROTOCOL FOR
PROGESTIN-ONLY PILL (MINIPILL)
DEFINITION
The minipill is an oral contraceptive (OC) pill that contains only progestin.
The amount of progestin in the minipill is less than what is found in the
lowest-dose combination oral contraceptives.
Progestin-only pills prevent pregnancy by: inhibiting ovulation,
thickening and decreasing cervical mucus preventing sperm penetration,
suppressing mid-cycle peaks of LH and FSH, inhibiting progesteronereceptor synthesis, reducing number/size of endometrial glands
associated with a thin atrophic endometrium, reducing activity of the cilia
in the fallopian tubes, arresting movement of the blastocyst, and
premature luteolysis (diminished function of the corpus luteum).
Minipills do not suppress the milk supply once breastfeeding is well
established and studies have found no adverse effects on infant health.
The minipill is often used after a woman has experienced one of the
estrogen-excess side effects with use of combination pills.
Because minipills often cause irregular bleeding, undiagnosed abnormal
vaginal bleeding is one of the more important contraindications to their
use. Also, minipills do not protect against ectopic pregnancy as
effectively as they protect against intrauterine pregnancy.
SUBJECTIVE
OBJECTIVE
1.
May complain of estrogen-excess side effects while taking
combined oral contraceptives, such as headaches, leg pain,
weight gain, nausea.
2.
Breastfeeding patients must give a history of no unprotected
intercourse within the prior two weeks.
3.
May want lowest-dose oral contraceptive available.
4.
Has detailed health history (includes menstrual, sexual,
contraception, personal health and family health) that does not
reveal a condition representing an unacceptable health risk
according to the product prescribing information and the World
Health Organization (WHO) Medical Eligibility for Contraceptive
Use.
1.
Physical examination and laboratory tests according to
programmatic guidelines.
OR
2.
Physical exam deferred up to 3 months.
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Document on Request for and Consent to Family Planning
Services (form 3700) that client agreed to have physical exam
delayed.
3.
Pregnancy test, if indicated, is negative.
ASSESSMENT
Patient has no condition representing an unacceptable risk if taking minipills.
PLAN
DIAGNOSTIC STUDIES
1.
Lipid profile beginning by age 45. Consider screening
women age 20-44 in the presence of high-risk factors for
CVD. Rescreen every 5 years or more often depending on
test results and high-risk factors. For Recommended Tests
and Immunizations for Women with High-Risk Factors refer to
www.womenshealth.gov.
2.
Blood glucose beginning by age 45. Consider screening
women at an earlier age in the presence of high-risk factors
for diabetes. Rescreen every 3 years or more often
depending on test results and high risk factors. For
Recommended Tests and Immunizations for Women with
High-Risk Factors refer to www.womenshealth.gov.
3.
Screen women for colorectal cancer according to district
policy/procedure for colorectal cancer screening.
THERAPEUTIC
PHARMACOLOGIC
1.
Order any FDA approved progestin-only OC.
2.
If breastfeeding, wait until breastfeeding well established
(usually at six weeks postpartum) before starting mini pills.
May begin on first day of menses or on any day that
pregnancy has been ruled out.
3.
Always take one pill every day at the same time. Taking a
pill more than a few hours late increases the risk of
pregnancy, and missing two or more pills in a row greatly
increases the risk. When one packet is finished, take the
first pill from the next packet on the very next day. All pills
are active, hormonal pills. There is no wait between
packets.
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4.
With missed pills or more than three hours late taking the
pills, use a barrier method or avoid sex for two days. Take
the last missed pill as soon as possible and continue taking
one pill each day as usual.
5.
If pills were not taken on schedule and patient has had
unprotected sex in the past 72 hours, may want to use
emergency contraceptive pills (ECP) to reduce the risk of
pregnancy (See Nurse Protocol for Emergency
Contraceptive Pills).
6.
For patients not receiving physical exam prior to first
supply, a physical should be performed prior to
dispensing additional OCs.
7.
If patient currently taking OCs or took previously
without problems, may dispense appropriate number
of cycles until next exam is to be performed.
PATIENT EDUCATION/COUNSELING
1.
Counsel patient according to seven basic elements of informed
consent (BRAIDED – Benefits Risks Alternatives Inquiries
Decision Explanation Documentation).
2.
The minipill may cause irregular bleeding or amenorrhea.
3.
Danger signs:
a.
Abdominal pain may be due to an ovarian cyst or ectopic
pregnancy.
b.
A delayed period after several months of regular cycles
may be a sign of pregnancy.
c.
Repeated, very severe headaches.
4.
The minipills must be taken at about the same time every day.
The margin for error is less with minipills than with combined OCs.
5.
There appear to be no significant metabolic effects and there is an
immediate return to fertility upon discontinuation of the minipill.
6.
Counsel patient on use of condoms to reduce the risk of
STDs/HIV.
7.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
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9.
Emphasize importance of keeping immunizations current; assess
client’s immunization status and administer vaccines
indicated according to the current Advisory Committee on
Immunization Practices (ACIP) childhood or adult immunization
schedule. If client declines vaccination, document refusal. See
the Georgia Immunization Program Manual, Recommended
Schedule and Guidelines, for current ACIP schedules and
administration guidelines for each vaccine. The Georgia
Immunization Manual may be accessed online at
http://www.health.state.ga.us/programs/immunization/publicatio
ns.asp.
FOLLOW- UP
1.
Return as scheduled for evaluation, or contact clinic if side effects,
danger signs or symptoms of possible pregnancy. Outside of
clinic hours, seek physician or emergency care if danger signs
develop.
2.
If patient did not receive a physical exam, have her return within 3
months for an exam and reassessment.
3.
Established patients should return for an evaluation at the end of
the current supply of pills, or sooner if side effects or danger signs
develop.
CONSULTATION/REFERRAL
1.
Development of danger signs.
2.
To nutritionist if patient has poor dietary intake, is overweight or
underweight, is anemic or has any chronic disease related to poor
nutrition.
3.
Extremely heavy bleeding.
4.
Suspected pregnancy (e.g., missed menses after several regular
cycles), especially if she has signs of ectopic pregnancy such as
abdominal pain or tenderness, or fainting.
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REFERENCES
1.
2.
3.
4.
5.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York. 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co. New York, 2004. (Current)
American Society of Health-Systems Pharmacists, American Hospital Formulary
Service, Bethesda, MD, 2007, pp. 3086 - 3091.
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
"Preventive Screenings and Immunizations," U. S. Department of Health and
Human Services, Office of Women's Health,
<http://www.womenshealth.gov/screeningcharts/highrisk/>.
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NURSE PROTOCOL FOR
EMERGENCY CONTRACEPTIVE PILLS (ECPs)
DEFINITION
For the average fertile couple, the probability of conception is about 20%
each cycle, which means there is an 80% probability that conception will
not occur.
There are many steps in the process of reproduction that potentially
could be affected by emergency contraception:

Follicle maturation, egg maturation and the ovulatory process.

Sperm migration and function.

Fertilization.

Zygote, morula, and blastocyst development, and transport in the
fallopian tube and uterine cavity.

Development of receptive uterine lining.

Maintenance of necessary hormone levels by the corpus luteum.
The effect of treatment depends on when in the woman’s cycle
emergency contraception is used.
SUBJECTIVE
1.
Patient requests postcoital contraception as an emergency
measure only (not as ongoing routine contraception). Patient has
had unprotected intercourse within the last 120 hours.
NOTE: Emergency Contraceptive is most effective if given within
72 hours of unprotected intercourse. The sooner ECPs are
initiated, the more effective treatment is.
2.
Precautions:
When dispensing Plan B®:
a.
History of hypersensitivity to any component
of progestin only pills.
b.
Undiagnosed vaginal bleeding.
c.
Known or suspected pregnancy.
Contraindications when dispensing combined OCs:
a.
Known or suspected pregnancy.
b.
Hypersensitivity to any component of
combined OCs.
c.
Acute migraine headaches at the time patient plans to take
the OCs.
d.
History of thromboembolic disease or
pulmonary embolus (Use Plan B®).
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OBJECTIVE
1.
2.
Negative pregnancy test.
Pelvic exam, if indicated.
ASSESSMENT
Patient requests emergency contraception: no contraindications.
PLAN
THERAPEUTIC
PHARMACOLOGIC
1.
Brand
Manufacturer
Plan B® (dedicated
WCC
product)
Alesse®
Wyeth-Ayerst
Emergency contraceptive pills, one dose as soon as
possible within 120 hours after unprotected intercourse,
and another dose 12 hours later.
Number of Pills
per Dose
Ethinyl
Estradiol per
Dose (µg)
Levonorgestrel
per Dose
(mg)
Antinausea
Rx Recommended
1 white pill
0
0.75
No
5 pink pills
100
0.50
Yes
Aviane™
Duramed
5 orange pills
100
0.50
Yes
Levlen®
Burlex
4 light orange pills
120
0.60
Yes
Levlite™
Burlex
5 pink pills
100
0.50
Yes
Levora®
Watson
4 white pills
120
0.60
Yes
Low-Ogestrel®
Watson
4 white pills
120
0.60
Yes
Lo/Ovral®
Wyeth-Ayerst
4 white pills
120
0.60
Yes
Nordette®
Wyeth-Ayerst 4 light orange pills
120
0.60
Yes
Ogestrel®
Watson
2 white pills
100
0.50
Yes
Ovral®
Wyeth-Ayerst
2 white pills
100
0.50
Yes
Seasonale
Barr
4 pink pills
120
0.60
Yes
Tri-Levlen®
Berlex
4 yellow pills
120
0.50
Yes
Triphasil®
Wyeth-Ayerst
4 yellow pills
120
0.50
Yes
2.
For preventing or treating nausea:
NOTE: Antiemetics not needed with Plan B.®
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Non-prescription (Adult Dose)
a.
b.
c.
Meclizine HCl 25mg (OTC available as Dramamine
II® or Bonine® , by prescription Antivert® 25mg and
50mg), 25-50mg PO taken one hour prior to dose.
Meclizine HCl has a 24 hour duration.
OR
Cyclizine hydrochloride (Marezine®) 50 mg tablets,
one tablet PO a half hour before taking ECPs;
repeat every 4 to 6 hours prn, up to 200 mg/day.
OR
Diphenhydramine hydrochloride (e.g., Benadryl®) 25
mg tablets, 1-2 tablets PO 1 hour before taking
ECPs; repeat every 4-6 hours prn. Maximum dose
300 mg/day.
OR
To order and/or dispense (Adult Dose)
d.
e.
f.
g.
Trimethobenzamide hydrochloride (Tigan®) 300 mg
capsule, one capsule PO one hour before taking
ECPs; repeat every 6 to 8 hours prn.
OR
Tigan 200 mg rectal suppository, insert one
suppository one hour before taking ECPs; repeat
every 6 to 8 hours prn.
OR
Promethazine hydrochloride (Phenergan®) 25 mg
tablets, one tablet PO a half hour before taking
ECPs; repeat every 4 hours prn.
OR
Promethazine hydrochloride (Phenergan®) 25 mg
rectal suppository inserted a half hour before taking
ECPs; repeat every 4 hours prn.
NOTE: Medication used to prevent or treat nausea may
cause drowsiness. Therefore, caution the patient who is
driving or operating dangerous equipment. Caution on
alcohol use. (Medication is not as likely to be effective if
already nauseated.)
3.
If patient wants to use OCs, as an ongoing method, initiate
a new pack of OCs according to manufacturers directions
at the next menstrual cycle, or begin taking OCs one tablet
daily the day after ECP treatment is complete. If taking
Levlen, Lo/Ovral, Low-Ogestrel, Nordette or Portia for
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ECPs, continue taking one pill per day from the same pack.
If using other OC brands, begin a new pack the day after
ECP treatment is complete. Use condoms as back-up for 7
days if OCs started immediately.
PATIENT EDUCATION/COUNSELING
1.
Exact directions for taking medication.
2.
Risks of nausea and emesis.
a.
b.
c.
d.
The nausea is usually mild and should stop within a day or
so after treatment.
If severe gastrointestinal side effects occur after the first
dose of combined ECPs, patient may need additional
medication.
If patient vomits within one hour after either dose, take an
additional dose.
If patient vomits more than two hours after taking the pills,
additional pills are not recommended.
3.
The next menstrual period should begin sometime within next 2 or
3 weeks. If no menses in 3 weeks advise patient to return to clinic
for pregnancy test.
4.
Strongly encourage patient to choose an acceptable, ongoing
method of birth control.
5.
Counsel on the use of condoms to reduce the risk of STDs/HIV.
6.
Extensive information about emergency contraception is available
in English/Spanish by calling 1-888-NOT-2-LATE.
7.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
FOLLOW-UP
1.
If period has not started in 3 weeks, or if next menses is unusually
light or unusually painful, return to clinic.
2.
Return to clinic for long-term birth control method if not provided at
visit.
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CONSULTATION/REFERRAL
1.
Immediately, if nausea/vomiting cannot be controlled.
2.
Development of any serious side effects of combined OCs.
REFERENCES
1.
2.
3.
4.
5.
American Society of Health-Systems Pharmacists, American Hospital Formulary
Service, Bethesda, MD, 2007, pp. 2935-2939, 2557-2559.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised
Edition, Ardent Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co. New York, 2004. (Current)
Leon Speroff et al., Clinical Gynecologic Endocrinology and Infertility, Seventh Edition,
Lipincott Williams and Wilkins, Baltimore 2005.
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
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NURSE PRACTITIONER PROTOCOL FOR
CONTRACEPTIVE IMPLANT INSERTION: IMPLANON
DEFINITION
The subdermal contraceptive implant (Implanon®) is an etonogestrelimpregnated 4 cm plastic rod. It is placed under the skin of the upper
arm. Implanon does not contain estrogen. It prevents pregnancy
primarily by inhibiting ovulation. Other contraceptive effects include
thickening cervical mucus and thinning the endometrial lining. The
implant must be removed at the end of the third year of use and may be
replaced with a new implant if continued contraception is desired.
SUBJECTIVE
1.
Desires an implant as method and long-term
contraception.
2.
Has detailed health history (includes menstrual, sexual,
contraception, personal health and family history) that does not
reveal a condition representing an unacceptable health risk
according to the product prescribing information and to the World
Health Organization (WHO) Medical Eligibility Criteria for
Contraceptive Use.
1.
Physical exam and laboratory tests according to programmatic
guidelines.
OBJECTIVE
OR
2.
ASSESSMENT
Physical exam deferred up to 3 months. Document reason for
deferral on chart. Document on Request for and Consent to
Family Planning Services (form 3700) that client agreed to have
physical exam delayed.
Patient has no condition representing an unacceptable risk if using
Implanon.
PLAN
DIAGNOSTIC STUDIES
1.
Pregnancy test if indicated to rule out pregnancy before inserting
Implanon.
2.
Lipid profile beginning by age 45. Consider screening women age
20-44 in the presence of high-risk factors for CVD. Rescreen
every 5 years or more often depending on test results and highrisk factors. For Recommended Tests and Immunizations for
Women with High-Risk Factors refer to www.womenshealth.gov.
3.
Blood glucose beginning by age 45. Consider screening women
at an earlier age in the presence of high-risk factors for diabetes.
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Rescreen every 3 years or more often depending on test results
and high-risk factors. For Recommended Tests and
Immunizations for Women with High-Risk Factors refer to
www.womenshealth.gov.
4.
Screen women for colorectal cancer according to district
policy/procedure for colorectal cancer screening.
PHARMACOLOGIC
1.
Local anesthesia with 1% lidocaine should be injected
under the skin and along the insertion track.
2.
Insert Implanon per manufacturer’s directions. May be
inserted any time in the cycle as long as pregnancy has
been ruled out and manufacturer’s instructions regarding
backup contraception are followed.
NOTE: Before insertion, the patient must read and sign
the consent form provided by the manufacturer in addition
to the program’s method specific consent form.
3.
IMPORTANT: Organon, the manufacturer of Implanon,
requires practitioners to attend an Implanon-specific clinical
training program before insertion privileges are granted.
For information, call 1-877-467-5266.
NON-PHARMACOLOGIC MEASURES
1.
Take precautions to avert a vasovagal reaction
(syncope/fainting). Allow the patient to lie still several
minutes after insertion. Ask about pain or feeling faint. If
the patient says she feels like she can sit up, have her sit
up slowly while being supported. If no problems in 1-2
minutes, allow her to stand.
2.
Treat signs of vasovagal reaction (pallor/cyanosis, pinchedface look, dilated pupils, weak and rapid pulse, rapid
shallow breathing, hypotension) according to the
Emergency Protocols and Procedures section of this
manual.
3.
Ice to insertion area for discomfort.
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PATIENT EDUCATION/COUNSELING
1.
Counsel patient according to seven basic elements of informed
consent (BRAIDED – Benefits Risks Alternatives Inquiries
Decision Explanation Documentation).
2.
In addition to the manufacturer’s consent form, the packaging also
includes a User Card. The User Card should be filled out and
given to the patient after Implanon insertion so she will have a
record of the location of Implanon and when Implanon should be
removed.
3.
Teach patient how to check for Implanon.
a.
The implant should be palpated by both the clinician and
patient before patient goes home to ensure proper
placement.
b.
The patient may confirm placement at any time by
palpating her inner upper arm.
c.
If patient cannot feel the implant, she should use another
method of contraception (e.g., condoms or abstinence) and
return to the clinic.
4.
Review warning signs and symptoms of possible insertion site
problems: redness, swelling, or purulent discharge at insertion
site.
5.
Menstrual irregularities (spotting, light bleeding, prolonged
bleeding, no bleeding) are common.
6.
Take over-the-counter ibuprofen or acetaminophen and/or apply
ice to insertion area for discomfort.
7.
Use condoms to reduce the risk of STDs, including HIV.
8.
Outside of clinic hours, seek physician or emergency care if
warning signs develop.
9.
Implanon is approved for use for 3 years.
10.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
11.
Emphasize importance of keeping immunizations current; assess
client’s immunization status and administer vaccines indicated
according to the current Advisory Committee on Immunization
Practices (ACIP) childhood or adult immunization schedule. If
client declines vaccination, document refusal. See the Georgia
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Immunization Program Manual, Recommended Schedule and
Guidelines, for current ACIP schedules and administration
guidelines for each vaccine. The Georgia Immunization Manual
may be accessed online at
http://health.state.ga.us/publications/manuals.asp.
FOLLOW-UP
1.
Return as scheduled for evaluation or contact clinic if side effects
or danger signs develop.
2.
If patient did not receive a physical exam, have her return within 3
months for an exam and reassessment.
3.
After an Implanon has been in place for 3 years, check with
manufacturer regarding possible approval for a longer time.
CONSULTATION/REFERRAL
1.
Difficult Implanon insertion or removal.
2.
Suspected ectopic pregnancy.
3.
Other complications related to implant use.
REFERENCES
1. Robert Hatcher et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
2. Implanon Etonogestrel Subdermal Contraceptive Implant, Physician Prescribing
Information, Organon, July 2006.
3. World Health Organization, Medical Eligibility Criteria for Contraceptive Use, Third
Edition, 2004, <http:www.who.int/reproductive-health/publications/mec/>(May 31,
2007).
4. U. S. Department of Health and Human Services, Office of Women's Health,
http://www.womenshealth.gov/screeningcharts/highrisk/.
5. American Society of Health-Systems Pharmacists. American Hospital Formulary
Service, Bethesda, MD, 2007, pp 3086-3091.
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NURSE PRACTITIONER PROTOCOL FOR
IMPLANON® REMOVAL
DEFINITION
Removal of Implanon® at the patient's request, due to clinical findings
such as pregnancy or side effects, or per guidelines that Implanon® must
be removed after 3 years.
SUBJECTIVE
1.
Patient desires Implanon® removal.
2.
May be pregnant.
3.
Complains of severe side effects.
4.
Three years may have elapsed since insertion.
1.
Positive pregnancy test.
2.
Clinical findings of severe side effects or a
contraindication for continuing with Implanon®.
OBJECTIVE
ASSESSMENT
Removal of Implanon® is desired or recommended.
PLAN
DIAGNOSTIC STUDIES
Implant palpable under skin and exact position localized. If implant is not
palpable, do not attempt to begin removal process. Implant must be
localized with ultrasound using a high frequency linear array transducer
(≥10 mHz) or MRI. Only remove a non-palpable implant once the location
of the implant has been established. If imaging methods fail, call the
manufacturer, Organon, at 1-877-467-5266 for further instructions.
THERAPEUTIC
Per manufacturer’s instructions, remove the Implanon® capsule through
a very small incision over the tip that is closest to the elbow.
1.
Per manufacturer’s removal instructions:
a.
Inject local anesthetic under the distal tip of the implant.
b.
Make a 2-3 mm incision just above the tip of the rod.
c.
Gently push the tip of the implant through the incision and
grasp with a hemostat or forceps for removal.
d.
Place bandage over incision.
2.
If implant is not palpable but has been localized by ultrasound and
is found to be deeply inserted, referral to a specialist with
expertise in deep removals is highly recommended. This
specialist should have a good understanding of the vessels and
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nerves of the arm. Any adverse events associated with removal
should be reported to Organon at 1-877-467-5266.
PATIENT EDUCATION/COUNSELING
1.
Provide patient with instructions for care. Take over-the-counter
ibuprofen or acetaminophen for discomfort if needed.
2.
Discuss alternative contraceptive method, if desired.
3.
Menses may be delayed or irregular for a month or more after
removal.
4.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
6.
Emphasize importance of keeping immunizations current; assess
client’s immunization status and administer vaccines indicated
according to the current Advisory Committee on Immunization
Practices (ACIP) childhood or adult immunization schedule. If
client declines vaccination, document refusal. See the Georgia
Immunization Program Manual, Recommended Schedule and
Guidelines, for current ACIP schedules and administration
guidelines for each vaccine. The Georgia Immunization Manual
may be accessed online at
http://health.state.ga.us/publications/manuals.asp.
FOLLOW-UP
Return, as needed, for contraception or yearly exam.
CONSULTATION/REFERRAL
1.
Difficult/failed removal.
2.
Successful removal, patient pregnant.
3.
Persistent side effects.
REFERENCES
1. Robert Hatcher et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
2. Implanon Etonogestrel Subdermal Contraceptive Implant, Physician Prescribing
Information, Organon, July 2006.
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3. World Health Organization, Medical Eligibility Criteria for Contraceptive Use, Third
Edition, 2004, <http:www.who.int/reproductive-health/publications/mec/>(May 31,
2007).
4. U. S. Department of Health and Human Services, Office of Women's Health,
http://www.womenshealth.gov/screeningcharts/highrisk/.
5. American Society of Health-Systems Pharmacists. American Hospital Formulary
Service, Bethesda, MD, 2007, pp 3086-3091.
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NURSE PRACTITIONER PROTOCOL FOR
IUD INSERTION: COPPER T380A
DEFINITION
The Copper T380A (ParaGard®) intrauterine device, is a copper-bearing
contraceptive device. It prevents pregnancy by immobilizing sperm,
inhibiting fertilization and preventing implantation due to local
inflammatory responses and endometrial effects.
SUBJECTIVE
1.
Desires an IUD as method and long-term contraception.
3.
Not at high risk for sexually transmitted infections.
4.
Has detailed health history (includes menstrual, sexual,
contraception, personal health and family history) that does not
reveal a condition representing an unacceptable health risk
according to the product prescribing information and to the World
Health Organization (WHO) Medical Eligibility Criteria for
Contraceptive Use.
1.
Normal pelvic exam at the time of insertion.
2.
Negative pregnancy test at the time of insertion.
3.
Laboratory tests:
OBJECTIVE
a.
b.
c.
d.
Pap smear in last 12-15 months which rules out cervical
malignancy.
Negative gonorrhea and chlamydia tests within last 60
days.
Wet mount if indicated.
Normal hemoglobin or hematocrit within last 60 days.
ASSESSMENT
Patient has no condition representing an unacceptable risk if using a
Copper T380A.
PLAN
DIAGNOSTIC STUDIES
1.
Blood glucose beginning by age 45. Consider screening
women at an earlier age in the presence of high-risk factors
for diabetes. Rescreen every 3 years or more often
depending on test results and high risk factors. For
Recommended Tests and Immunizations for Women with
High-Risk Factors refer to www.womenshealth.gov.
2.
Screen women for colorectal cancer according to district
policy/procedure for colorectal cancer screening.
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PHARMACOLOGIC
1.
May give an over-the-counter (OTC) nonsteroidal antiinflammatory agent 30-60 minutes before the procedure to
reduce discomfort.
2.
Insert Copper T380A per manufacturer’s directions. May
be inserted any time in the cycle as long as pregnancy has
been ruled out.
NOTE: Before insertion, the patient must read and sign
the consent form if provided by the manufacturer in addition
to the program’s method specific consent form.
3.
If hemoglobin below 12.0 g/dL for non-smoker or below
12.3 g/dL for smoker or hematocrit below 35.7% for nonsmoker or below 36% for smoker, treat according to
appropriate nurse protocol for age for iron deficiency
anemia.
NON-PHARMACOLOGIC MEASURES
1.
Take precautions to avert a vasovagal reaction
(syncope/fainting) caused by uterine manipulation and
sounding. After IUD insertion, allow the patient to lie still
for at least 30 seconds (while explaining how to check for
strings). Ask about pain or cramping. If the patient says
she feels okay, have her sit up slowly while being
supported. If no problems in 30 seconds, allow her to
stand.
2.
Treat signs of vasovagal reaction (pallor/cyanosis, pinchedface look, dilated pupils, weak and rapid pulse, rapid
shallow breathing, hypotension) according to the
Emergency Protocols and Procedures section of this
manual.
3.
Heat to pelvic area for discomfort.
PATIENT EDUCATION/COUNSELING
1.
Counsel patient according to seven basic elements of informed
consent (BRAIDED – Benefits Risks Alternatives Inquiries
Decision Explanation Documentation).
2.
Teach patient how to check for IUD strings.
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a.
b.
c.
d.
e.
The IUD can be expelled without being noticed.
Check for the strings frequently during the first months,
then after each menses and any time there is abnormal
cramping while menstruating.
Inspect tampons on removal for IUD.
If patient cannot feel the strings, or if the plastic part is felt,
use another method of contraception and return to the
clinic.
Most likely cause of IUD failure is expulsion with risk
highest during the first year, particularly within the first
3 months after insertion.
3.
Review warning signs and symptoms of possible problem:
abdominal pain, discharge, or missing string.
4.
There is a small increased risk of PID, which is most likely to
occur within the first 2-3 weeks after insertion.
5.
Menstrual irregularities (spotting, light bleeding) are common
in the first 3-6 months after insertion.
6.
Take over-the-counter ibuprofen or naproxen sodium and/or apply
heat to pelvic area for discomfort.
7.
Should strongly consider changing to another contraceptive
method if behavior puts client at risk for PID (multiple partners,
partner with multiple partners).
8.
Use condoms to reduce the risk of STDs, including HIV.
9.
Outside of clinic hours, seek physician or emergency care if
warning signs develop.
10.
The T380A is approved for use for 10 years.
11.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
12.
Emphasize importance of keeping immunizations current; assess
client’s immunization status and administer vaccines
indicated according to the current Advisory Committee on
Immunization Practices (ACIP) childhood or adult immunization
schedule. If client declines vaccination, document refusal. See
the Georgia Immunization Program Manual, Recommended
Schedule and Guidelines, for current ACIP schedules and
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administration guidelines for each vaccine. The Georgia
Immunization Manual may be accessed online at
http://www.health.state.ga.us/programs/immunization/publications.
asp.
FOLLOW-UP
1.
Re-examine and evaluate the patient shortly after the first postinsertion menses, but no later than three months afterwards.
2.
If patient had a low hemoglobin or hematocrit, recheck after
completion of at least 4–6 weeks of iron therapy:
a.
b.
If hemoglobin drops >2 g/dL or hematocrit drops >6%,
strongly consider removal and treat according to
appropriate nurse protocol for age for iron deficiency
anemia. If hemoglobin <9 g/dL or hematocrit <27%,
strongly consider removal and treat according to protocol.
If IUD removed for the above reasons:
1)
Repeat hemoglobin/hematocrit in 1-2 months.
2)
Provide an alternate method of contraception.
3.
If evidence of pelvic inflammatory disease, see Nurse Protocol for
Pelvic Inflammatory Disease (PID). IUD removal is not necessary
unless no improvement after 2-3 days of antibiotic treatment.
4.
If pregnancy occurs, counsel patient that IUD should be removed
at time of diagnosis whether pregnancy is continued or
terminated.
5.
After a T380A has been in place for 10 years, check with
manufacturer regarding possible approval for a longer time.
CONSULTATION/REFERRAL
1.
Difficult IUD insertion or removal.
2.
Suspected ectopic pregnancy.
3.
To NP or MD for IUD removal if pregnant.
4.
Other complications related to IUD use.
5.
Presence of actinomyces on Pap smear report and evidence of
pelvic infection.
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REFERENCES
1.
2.
3.
4.
5.
6.
Robert Hatcher et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co., New York, 2004. (Current)
ParaGard T380A Intrauterine Copper Contraceptive, Physician Prescribing
Information, Duramed Pharmaceuticals, Inc., May 2006.
World Health Organization, Medical Eligibility Criteria for Contraceptive Use, Third
Edition, 2004, <http:www.who.int/reproductive-health/publications/mec/> (March 15,
2005).
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
"Preventive Screenings and Immunizations," U. S. Department of Health and
Human Services, Office of Women's Health,
<http://www.womenshealth.gov/screeningcharts/highrisk/>.
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NURSE PRACTITIONER PROTOCOL FOR
IUD INSERTION: MIRENA® LNG IUS
(levonorgestrel-releasing intra-uterine system)
DEFINITION
The levonorgestrel intrauterine system (LNG IUS, brand name Mirena®)
system consists of a small T-shaped frame with a steroid reservoir that
contains LNG, a potent progestin found in many combination oral
contraceptives, progestin-only pills, and implants.
The IUS releases a low dose of LNG (20 mcg per day) into the uterine
cavity for at least five years, a system similar to that of LNG implants or
LNG-containing mini-pills. As with these methods, thickening the
cervical mucus and inhibition of ovulation, sperm motility and function are
considered the primary means of preventing pregnancy. A weak foreignbody effect is also noted which could decrease implantation.
SUBJECTIVE
OBJECTIVE
ASSESSMENT
1.
Desires an IUD as method and long-term contraception.
2.
Is in a stable, mutually monogamous relationship.
3.
Has at least one child.
4.
History is negative for pelvic inflammatory disease unless there
has been a subsequent intrauterine pregnancy.
5.
Has detailed health history (includes menstrual, sexual,
contraception, personal health and family history) that does not
reveal a condition representing an unacceptable health risk
according to the product prescribing information and to the World
Health Organization (WHO) Medical Eligibility Criteria for
Contraceptive Use.
1.
Normal pelvic exam at the time of insertion.
2.
Negative pregnancy test at the time of insertion.
4.
Negative laboratory tests at the time of insertion:
a.
Pap smear in last 12-15 months which rules out cervical
malignancy.
b.
Negative gonorrhea and chlamydia tests within the last 60
days.
c.
Wet mount if indicated.
d.
Hemoglobin or hematocrit within the last 60 days.
Patient has no condition representing an unacceptable risk if using the
Mirena.
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PLAN
DIAGNOSTIC STUDIES
1.
Lipid profile beginning by age 45. Consider screening
women age 20-44 in the presence of high-risk factors for
CVD. Rescreen every 5 years or more often depending on
test results and high-risk factors. For Recommended Tests
and Immunizations for Women with High-Risk Factors refer to
www.womenshealth.gov.
2.
Blood glucose beginning by age 45. Consider screening
women at an earlier age in the presence of high-risk factors
for diabetes. Rescreen every 3 years or more often
depending on test results and high risk factors. For
Recommended Tests and Immunizations for Women with
High-Risk Factors refer to www.womenshealth.gov.
3.
Screen women for colorectal cancer according to district
policy/procedure for colorectal cancer screening.
THERAPEUTIC
PHARMACOLOGIC
1.
May give an over-the-counter (OTC) nonsteroidal antiinflammatory agent 30-60 minutes before the procedure to
reduce discomfort.
2.
Insert Mirena per manufacturer’s directions. May be
inserted any time in the cycle as long as pregnancy has
been ruled out.
NON-PHARMACOLOGIC MEASURES
1.
Take precautions to avert a vasovagal reaction
(syncope/fainting) caused by uterine manipulation and
sounding. After IUD insertion, allow the patient to lie still
for at least 30 seconds (while explaining how to check for
strings). Ask about pain or cramping. If the patient says
she feels okay, have her sit up slowly while being
supported. If no problems in 30 seconds, allow her to
stand.
2.
Treat signs of vasovagal reaction (pallor/cyanosis, pinchedface look, dilated pupils, weak and rapid pulse, rapid
shallow breathing, hypotension) according to the
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Emergency Protocols and Procedures section of this
manual.
3.
Heat to pelvic area for discomfort.
PATIENT EDUCATION/COUNSELING
1.
Counsel patient according to seven basic elements of informed
consent (BRAIDED – Benefits Risks Alternatives Inquiries
Decision Explanation Documentation).
2.
Teach patient to check for IUD strings.
a.
b.
c.
d.
The IUD can be expelled without being noticed.
Check for the strings frequently during the
first months, then after each menses and any time there is
abnormal cramping while menstruating.
Inspect tampons on removal for IUD removal.
If patient cannot feel the strings, or if the plastic part is felt,
use another method of contraception and return to the
clinic.
3.
Review warning signs and symptoms of possible problem: pain,
discharge, abdominal pain or missing string.
4.
Take over-the-counter ibuprofen or naproxen sodium and/or apply
heat to the pelvic area for discomfort.
5.
Should consider changing to another contraceptive method if
behavior puts client at risk for PID (i.e., multiple partners, partners
with multiple partners).
6.
Use condoms to reduce the risk of STDs/HIV.
7.
Discuss altered menstrual bleeding patterns:
a.
1 to 4 months: may have frequent spotting.
b.
1 to 6 months: reduced duration and amount of bleeding.
c.
Overall 90% reduction in menstrual bleeding.
d.
After 12 months, about 20% of women have no bleeding.
e.
The patient should keep a menstrual record and report a
sudden change in menses or suspected pregnancy
immediately.
f.
Give patient copy of Mirena post-insertion instructions.
8.
The Mirena system reduces dysmenorrhea and leads to a
significant reduction in the amount and length of bleeding.
9.
After the system is removed, menstruation returns within 30 days.
Fertility rapidly returns to normal.
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10.
Outside of clinic hours, seek physician or emergency care if
warning signs develop.
11.
As with other progestin-only methods, persistent ovarian
follicles can occur. They do not require treatment or removal
of the Mirena, and they usually resolve spontaneously.
However, regular follow-up by ultrasound is recommended
until cysts disappear.
12.
The Mirena is effective for five years.
13.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
14.
Emphasize importance of keeping immunizations current; assess
client’s immunization status and administer vaccines indicated
according to the current Advisory Committee on Immunization
Practices (ACIP) childhood or adult immunization schedule. If
client declines vaccination, document refusal. See the Georgia
Immunization Program Manual, Recommended Schedule and
Guidelines, for current ACIP schedules and administration
guidelines for each vaccine. The Georgia Immunization Manual
may be accessed online at
http://www.health.state.ga.us/programs/immunization/publicatio
ns.asp.
FOLLOW-UP
1.
Re-examine and evaluate the patient shortly after the first postinsertion menses, but no later than three months afterwards.
2.
If evidence of pelvic inflammatory disease, see Nurse Protocol for
Pelvic Inflammatory Disease. IUD removal not necessary unless
no improvement after 2-3 days of antibiotic treatment.
3.
If pregnancy occurs, advise patient IUD should be removed at
time of diagnosis whether pregnancy is continued or terminated.
CONSULTATION/REFERRAL
1.
Difficult IUD insertion or removal.
2.
Suspected ectopic pregnancy.
3.
To NP or MD for IUD removal if pregnant.
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4.
Other complications related to IUD use.
5.
Presence of actinomyces on Pap smear report and evidence of
pelvic infection.
REFERENCES
1.
2.
3.
4.
5.
6.
Robert Hatcher et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co. New York, 2004. (Current)
Mirena (levonorgestrel intrauterine system) Physician Prescribing Information, Berlex,
April 2006.
World Health Organization, Medical Eligibility Criteria for Contraceptive Use, Third
Edition, 2004, <http:www.who.int/reproductive-health/publications/mec/> (March 15,
2005).
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
"Preventive Screenings and Immunizations," U. S. Department of Health and
Human Services, Office of Women's Health,
<http://www.womenshealth.gov/screeningcharts/highrisk/>.
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NURSE PROTOCOL FOR IUD-RELATED
DYSMENORRHEA
DEFINITION
Painful menses during intrauterine device (IUD) use.
ETIOLOGY
Presence of the IUD. Differential diagnosis includes mechanical
pressure of IUD against wall of uterus, partial expulsion, pelvic
inflammatory disease (PID), endometriosis, cancer, leiomyomata and
ectopic pregnancy. Since cramping and abdominal pain may be signs of
pregnancy or infection, those two problems must always be ruled out.
SUBJECTIVE
1.
Patient says she has an IUD, and complains of painful menses.
2.
May have history of heavy or late menses.
3.
Patient reports IUD type and date inserted, when last checked
and when the strings were last felt.
4.
May have history of:
a.
PID/STDs; vaginal infection/discharge.
b.
Recent partner change or multiple partners.
c.
Pain with IUD in past.
5.
May have symptoms of vaginal or pelvic infection.
1.
External exam usually within normal limits.
2.
Speculum exam usually within normal limits; may note vaginal
discharge or partially-expelled IUD. Note length of IUD strings.
3.
Bimanual exam usually within normal limits; may note tenderness
on examination; may feel partially-expelled IUD.
OBJECTIVE
ASSESSMENT
IUD-related dysmenorrhea.
PLAN
DIAGNOSTIC STUDIES
1.
Sensitive urine pregnancy test.
2.
Hemoglobin/hematocrit, if indicated.
3.
Gonorrhea and chlamydia tests; vaginal wet mount, if indicated.
4.
Pap smear, if indicated.
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THERAPEUTIC
PHARMACOLOGIC
Prostaglandin inhibitors/nonsteroidal anti-inflammatory drugs
such as:
1.
2.
3.
Ibuprofen 400 mg PO 4 hours as needed for pain.
(Maximum dose 1.2g/day)
OR
Naproxen 500 mg every 12 hours as needed for pain.
(Maximum dose 1gm/day)
OR
Over-the-counter-strength products (e.g., Advil, Nuprin,
Aleve, Motrin IB, coated aspirin, or acetaminophen) per
package directions prn.
NON-PHARMACOLOGIC MEASURES
1.
Heating pad or hot-water bottle to pelvic region; hot baths
or showers; warm liquids taken orally.
2.
For moderate to severe dysmenorrhea not relieved by any
of the above, the IUD may be removed if the patient
desires and replaced with progestin-releasing IUD.
PATIENT EDUCATION/COUNSELING
1.
Discuss findings, treatment rationale.
2.
Discuss correct use and side effects of medications.
FOLLOW-UP
Return to the clinic if symptoms are not relieved or if foul discharge
begins.
CONSULTATION/REFERRAL
Symptoms not relieved by the above measures.
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REFERENCES
1.
2.
3.
American Society of Health-Systems Pharmacists, American Hospital Formulary
Service, Bethesda, MD, 2007, pp. 2061-2067, 2102-2108.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co., New York, 2004. (Current)
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NURSE PROTOCOL FOR
LOST IUD STRINGS
DEFINITION
Disappearance of the IUD (intrauterine device) strings.
ETIOLOGY
Expulsion of the IUD, retraction of the strings into the uterine cavity, or
perforation of the IUD through the cervix or uterine wall. Use of an IUD
(from another country) that never had a string attached. In some rare
instances, clinicians have intentionally cut strings off or cut the strings
short.
SUBJECTIVE
Patient may report that she cannot feel IUD strings on self-exam.
OBJECTIVE
No IUD strings visible upon careful examination of the vagina and
cervical opening, and inability to feel the strings.
ASSESSMENT
IUD strings not visible.
PLAN
DIAGNOSTIC STUDIES
Sensitive urine pregnancy test (HCG)
THERAPEUTIC
If pregnancy is ruled out by HCG and exam:
1.
Prepare cervix as with insertion.
2.
Gently rotate cytobrush inside cervical canal to snag IUD string. If
unsuccessful, attempt to retrieve the IUD string using curved
forceps, alligator forceps, or IUD retriever. Use tenaculum if
necessary to steady the cervix.
a.
b.
c.
3.
If strings located and patient wants removal, remove the
IUD with gentle, steady traction. Provide another method of
contraception if appropriate.
If dislodgement or abnormal placement suspected, remove
IUD. Provide alternative contraceptive methods.
Consider giving doxycycline 100 mg BID for 7-10 days if
aggressive probing for string retrieval or IUD removal
difficult.
If unsuccessful in locating strings:
a.
Refer for pelvic ultrasound or if necessary, abdominal xrays.
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b.
c.
If the IUD is identified as properly positioned in the uterus,
no action is necessary; reassure the patient.
If ultrasound identifies the IUD, but unable to identify in
uterus, refer to MD. Advise alternative method of
contraception.
PATIENT EDUCATION/COUNSELING
1.
If the IUD is removed advise the patient to use another method of
contraception.
2.
Check for IUD strings after each menstrual period.
3.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
FOLLOW-UP
Return to clinic as needed for contraception or yearly exam.
CONSULTATION/REFERRAL
Consult with a physician for any questions regarding management (see
Nurse Practitioner Protocol for IUD Removal).
REFERENCES
1.
2.
3.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co. New York, 2004. (Current)
Leon Speroff and Phillip Darney, A Clinical Guide for Contraception, Lippincott
Williams and Wilkins, Baltimore, 2001. (Current)
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NURSE PROTOCOL FOR
IUD-RELATED MENORRHAGIA
DEFINITION
Abnormal heavy menstrual bleeding with an IUD in place, defined as
heavy, prolonged periods lasting more than seven days with large clots.
The use of eight (8) or more pads/day may also constitute heavy
bleeding.
ETIOLOGY
Presence of IUD in utero. Other causes to consider may be: pelvic
inflammatory disease (PID), partial expulsion of the IUD, dysfunctional
uterine bleeding as a result of an endocrine imbalance, cancer of the
cervix or endometrium, cervical or uterine polyps, abnormal
perimenopausal bleeding, fibroids, and pregnancy.
SUBJECTIVE
OBJECTIVE
1.
Patient describes prolonged (7+ days) bleeding, heavy
menses with or without clotting, cramping pain, and/or needing
frequent pad change.
2.
May have decrease in appetite. May have dizziness, weakness or
tiredness.
1.
Patient's skin may appear pale.
2.
External exam usually within normal limits.
3.
Internal exam may be within normal limits, or may note partiallyexpelled IUD or feel device in the cervical canal, and/or may elicit
pain upon cervical motion.
4.
Bimanual exam may be within normal limits, or may elicit
tenderness or pain in uterus and adnexal areas characteristic of
PID.
ASSESSMENT
IUD-related menorrhagia.
PLAN
DIAGNOSTIC STUDIES
1.
Hematocrit or hemoglobin.
2.
Sensitive urine pregnancy test.
3.
Gonorrhea and chlamydia tests, vaginal wet mounts, if indicated.
4.
Pap smear, if indicated.
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THERAPEUTIC
PHARMACOLOGIC
1.
If hemoglobin below normal, treat according to Nurse
Protocol for Iron Deficiency Anemia.
2.
Ibuprofen 400 mg PO every 4 hours as needed for relief
of pain. Begin at the onset of menses and continue at
least 3 days. (Maximum dose 1.2 g/day.)
NON-PHARMACOLOGIC MEASURES
1.
Remove the IUD for the following:
a.
b.
c.
2.
Partial expulsion.
Patient is using/soaking 1 pad per hour.
Patient desires removal for any reason.
Strongly consider IUD removal if hemoglobin has dropped
>2 g/dL from previous reading or is <9 g/dL or hematocrit
has dropped >6% over 4-6 weeks, or is <27%.
PATIENT EDUCATION/COUNSELING
1.
Iron-rich foods.
2.
Signs of possible pelvic infection and excessive bleeding.
3.
Check for IUD string after each period.
4.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
FOLLOW-UP
Return in 4-6 weeks for evaluation of bleeding and
hematocrit/hemoglobin.
CONSULTATION/REFERRAL
1.
Refer immediately if suspect ectopic pregnancy.
2.
If no relief with therapy after 1-2 menstrual periods.
3.
If no improvement in anemia after 4 weeks of therapy.
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REFERENCES
1.
2.
3.
4.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co. New York, 2004. (Current)
Leon Speroff et al., Clinical Gynecologic Endocrinology and Infertility, Seventh
Edition, Lippincott Williams and Wilkins, Baltimore, 2004. (Current)
American Society of Health-Systems Pharmacists, American Hospital
Formulary Service, Bethesda, MD, 2007, pp. 2061–2067.
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NURSE PROTOCOL FOR
PREGNANCY WITH IUD IN PLACE
DEFINITION
Intrauterine pregnancy while an IUD is in place. There is a 50% chance
that a spontaneous abortion will occur if the IUD is left in place. An
increased risk of septic abortion is noted in the second trimester if an
IUD is left in a pregnant uterus. If the IUD is removed early in
pregnancy, the abortion rate will be approximately 25%. Approximately
5% of the spontaneous pregnancies occurring in women who have an
IUD in place will be ectopic. Rule out ectopic pregnancy in any woman
with a positive pregnancy test while using an IUD.
ETIOLOGY
Failure of the IUD to prevent implantation of a blastocyst.
SUBJECTIVE
1.
Patient reports possible symptoms of pregnancy (e.g., nausea,
breast tenderness, missed menses, spotting and/or change in
appetite).
2.
IUD history: IUD type, when inserted, expulsions, last checked
and last felt strings. Patient may report that strings have become
shorter or cannot be felt at all.
3.
Patient may report repeated late, heavy, painful periods.
4.
May have pelvic pain, vaginal discharge, fever, chills,
myalgias and headaches.
1.
External exam is usually within normal limits, although tenderness
may be noted.
2.
Cervix may have bluish discoloration (Chadwick's/Goodall's sign);
strings of IUD may or may not be seen at os.
3.
Cervical softening, softening of the uterine-cervical junction
(Hegar's sign) detected on bimanual exam; may feel strings at
cervical os; uterus may be enlarged and soft; adnexae usually
within normal limits.
4.
Sensitive urine pregnancy test is positive.
OBJECTIVE
ASSESSMENT
Pregnancy with IUD in place.
PLAN
DIAGNOSTIC STUDIES
Serum pregnancy test and/or ultrasound if indicated.
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PATIENT EDUCATION/COUNSELING
1.
Discuss findings, implications, treatment rationale and possible
complications.
2.
Discuss risk of ectopic pregnancy and infection which are
indications to go to the ER.
3.
Advise patient she is at increased risk for preterm labor and
spontaneous abortion if IUD left in place. However, reassure her
that fetus is not at increased risk for birth defects with IUD in
place. Advise patient that at time of removal she is also at risk for
spontaneous abortion, although spontaneous abortion risk is less
with removal than if IUD were left if place.
4.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
CONSULTATION/REFERRAL
To nurse practitioner or physician, for possible IUD removal and
pregnancy management (See Nurse Practitioner Protocol for IUD
Removal).
REFERENCES
1.
2.
3.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co., New York, 2004. (Current)
Robert Hatcher et al., The Essentials of Contraceptive Technology, Johns
Hopkins School of Public Health, Population Information Program, Baltimore, 2001.
(Current)
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Nurse Protocols for Registered Professional Nurses
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NURSE PRACTIONER PROTOCOL FOR
IUD REMOVAL
DEFINITION
Removal of an IUD by the clinician at the patient's request, due to clinical
findings such as pregnancy, infection or partial expulsion, or per
recommended time frame for the device. It is important to comply with a
woman’s wishes if she wants to have her IUD removed.
SUBJECTIVE
1.
Patient may request IUD removal for any reason.
2.
Patient may report a condition that precludes IUD use, such as
suspected or confirmed pregnancy, or no longer in a stable,
mutually monogamous relationship.
3.
Patient may complain of dysmenorrhea, dyspareunia,
menorrhagia, aching, abdominal pains, tenderness on ambulation,
malaise, chills/fever.
4.
History of use of the Copper T380A for 10 years or Mirena for 5
years.
OBJECTIVE
May have findings on pelvic exam or laboratory tests that require IUD
removal such as: partial expulsion, enlargement of uterus, positive
pregnancy test, other pelvic infection/disease.
ASSESSMENT
Indications for removal of IUD.
PLAN
DIAGNOSTIC STUDIES
If indicated:
1.
Sensitive urine pregnancy test.
2.
Wet mount of vaginal secretions.
3.
Gonorrhea and chlamydia tests.
THERAPEUTIC
(by APRN or MD)
NOTE: Easier removal may be possible at the time of menses or at
midcycle.
1.
If indicated, paracervical block.
2.
If patient not pregnant, remove IUD slowly, applying gentle,
steady traction to string with sponge forceps.
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3.
If patient is not pregnant and the IUD cannot be removed with
gentle traction, use a tenaculum to steady the cervix and
straighten the anteversion or retroversion.
4.
If the patient is not pregnant and the strings are not visible, probe
for them in the cervical canal with a cytobrush or cotton tipped
applicator, narrow (e.g., alligator-type) forceps or IUD retriever.
See Nurse Protocol for Lost IUD Strings.
5.
If patient is pregnant and in first trimester with strings visible, after
counseling and with patient’s consent, attempt to remove IUD
using gentle traction on IUD strings.
PATIENT EDUCATION/COUNSELING
1.
Choose a non-hormonal method of contraception for two
menstrual cycles if the patient desires pregnancy or any method if
the patient does not desire pregnancy.
2.
Delay pregnancy for 2-3 months, to allow uterus to regain normal
endometrium.
3.
There are no known major long-term side effects after removal of
an IUD.
4.
In pregnant patient, advise her that she is at increased risk of
preterm labor and spontaneous abortion if IUD is left in place.
However, reassure her that the fetus is not at increased risk for
birth defects with IUD in place. Advise patient that at time of
removal she is also at risk for spontaneous abortion, although
spontaneous abortion risk is less with removal than if IUD were
left in place.
5.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
6.
Emphasize importance of keeping immunizations current; assess
client’s immunization status and administer vaccines
indicated according to the current Advisory Committee on
Immunization Practices (ACIP) childhood or adult immunization
schedule. If client declines vaccination, document refusal. See
the Georgia Immunization Program Manual, Recommended
Schedule and Guidelines, for current ACIP schedules and
administration guidelines for each vaccine. The Georgia
Immunization Manual may be accessed online at
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http://www.health.state.ga.us/programs/immunization/publicatio
ns.asp.
FOLLOW-UP
Return to clinic as needed, for contraception or yearly exam.
CONSULTATION/REFERRAL
Refer or consult with physician if:
1.
Difficult/failed removal.
2.
Successful removal, patient pregnant.
3.
Unable to visualize and/or probe for strings.
REFERENCES
1.
2.
3.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Leon Speroff and Phillip Darney, A Clinical Guide for Contraception, Lippincott
Williams and Wilkins, Baltimore, 2001. (Current)
Robert Hatcher et al., The Essentials of Contraceptive Technology, Johns Hopkins
School of Public Health, Population Information Program, Baltimore, 2001. (Current)
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TABLE OF IUD COMPLICATIONS AND ACTIONS
CONDITION
ACTION
1. Pain from tenaculum application to
cervix.
May consider application of topical anesthesia
such as Lidocaine gel, Xylocaine gel, etc.
2. Pain with sounding of the uterus
during insertion.
Sound slowly and gently consider smaller
sound. If severe, check alignment of uterine
cavity.
3. Cramping/pain immediately after
insertion, for a day or so thereafter,
or with each menses:
a. if severe
b. if mild
4.
Pain at time of insertion, persistent
and increasing, and signs of
abdominal tenderness:
a. if strings are present
b. if strings are absent
Consider IUD removal.
See Nurse Protocol IUD Related
Dysmenorrhea.
Presume partial perforation has occurred;
remove IUD and treat for pelvic infection.
Consider possibility of perforation. Refer
client to physician.
5. Partial expulsion of an IUD
Remove IUD. Pregnancy test as indicated.
6. Pelvic inflammatory disease
See Nurse Protocol for Pelvic Inflammatory
Disease.
7. Spontaneous abortion
Refer to physician
8. Ectopic pregnancy
Refer to physician
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REFERENCES
1.
2.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co. New York, 2004. (Current)
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NURSE PROTOCOL FOR
MEDROXYPROGESTERONE ACETATE
(Injectable Contraceptive)
DEFINITION
Medroxyprogesterone acetate inhibits ovulation presumably by
suppressing levels of follicular-stimulating hormone (FSH) and luteinizing
hormone (LH) and by eliminating the LH surge. The pituitary gland
remains responsive to gonadatropin-releasing hormone, which suggests
that the site of action of medroxyprogesterone acetate is the
hypothalamus.
SUBJECTIVE
1.
Patient desires medroxyprogesterone acetate as choice of
contraception.
2.
Has detailed health history (includes menstrual, sexual,
contraception, personal health and family history) that does not
reveal a condition representing an unacceptable health risk
according to the product prescribing information and to the World
Health Organization (WHO) Medical Eligibility Criteria for
Contraceptive Use.
3.
May have known risk factor(s), medical condition(s) or medication
use that can increase the risk of developing osteoporosis (see
Nurse Protocol for Osteoporosis in Women: Assessment and
Prevention).
1.
Physical examination and laboratory tests according to
programmatic guidelines.
OBJECTIVE
OR
ASSESSMENT
2.
Physical exam deferred up to 3 months.
Document reason for deferral on chart. Document on Request for
and Consent to Family Planning Services (Form 3700) that client
agreed to have physical exam delayed.
3.
Pregnancy test, if indicated, is negative. If necessary,
(amenorrhea or irregular menses) repeat pregnancy test after a
two-week interval of abstinence or consistent use of a reliable
method of contraception.
Patient has no condition representing an unacceptable risk if using
medroxyprogesterone acetate.
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PLAN
DIAGNOSTIC STUDIES
1.
Lipid profile beginning by age 45. Consider screening
women age 20-44 in the presence of high-risk factors for
CVD. Rescreen every 5 years or more often depending on
test results and high-risk factors. For Recommended Tests
and Immunizations for Women with High-Risk Factors refer to
www.womenshealth.gov.
2.
Blood glucose beginning by age 45. Consider screening
women at an earlier age in the presence of high-risk factors
for diabetes. Rescreen every 3 years or more often
depending on test results and high risk factors. For
Recommended Tests and Immunizations for Women with
High-Risk Factors refer to www.womenshealth.gov.
3.
Screen women for colorectal cancer according to district
policy/procedure for colorectal cancer screening.
THERAPEUTIC
PHARMACOLOGIC
NOTE: Allergic reactions may occur. Encourage client to remain
in the clinic at least 20 minutes after each injection. Refer to the
Allergic Reaction Nurse Protocol as needed.
1.
Give injections to non-pregnant clients: preferred start time
is within the first five days after onset of menstruation,
immediately post-abortion, or within five days postpartum if
not breastfeeding, and at the sixth week postpartum if
breastfeeding. Inject anytime in the cycle if not pregnant;
use back-up method for 7 days.
2.
Medroxyprogesterone acetate 150 mg IM, injected deep
into the deltoid or gluteal muscle. Depending on the size of
the client, may need to use a 1.5 inch needle. Do not
massage the injection site, and also instruct client not to
massage site.
Depo-subQ provera 104 must be given subcutaneously into
the anterior thigh or abdomen. Avoid bony areas and the
umbilicus. Gently grasp and squeeze a large area of skin
in the chosen injection area between the thumb and forefinger, pulling it away from the body. Insert the needle at a
45 degree angle so most of needle is in the fatty tissue.
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The plastic hub should be nearly or almost touching the
skin. Inject slowly – taking about 5-7 seconds.
NOTE: Medroxyprogesterone acetate is to be stored at room
temperature 20o to 25oC (68o to 77o F). Both the vial and the prefilled syringe should be vigorously shaken at least one minute just
before use to ensure the dose is uniformly suspended.
3.
For clients who have received an initial physical
examination showing no contraindications, and have not
developed side effects or danger signs.
Give routine re-injections for medroxyprogesterone acetate
150 mg IM between 11 weeks and 13 weeks from the
previous injections.
Give routine reinjections for depo-subQ provera 104
between 12 and 14 weeks from the previous injection.
If client returns after 13 weeks for medroxyprogesterone
acetate 150 mg IM or 14 weeks for depo-subQ provera 104
and has been sexually active, perform a pregnancy test.
Offer emergency contraception if client has had
unprotected intercourse in the last 120 hours. May give
injection after negative pregnancy tests two weeks apart
and either abstinent or consistent use of a reliable
contraceptive method or give during the next menses.
4.
Assure that patients, who did not receive an initial physical
examination prior to the first injection, have received an
examination showing no contraindications, and have not
developed side effects or danger signs, before giving re-injections.
5.
Assess the patient’s for risk factors for osteoporosis. (See Nurse
Protocol for Osteoporosis in Women: Assessment and
Prevention.) Medroxyprogesterone acetate use plus risk factors
for osteoporosis may pose an increased risk of osteoporosis.
Discuss potential risk for bone loss and consider alternative
contraceptives in patients with significant risk factors for
osteoporosis.
6.
With regard to bone metabolism, there should not be
restriction on the use of medroxyprogesterone acetate,
including no restriction on duration of use, among women
aged 18-45 who are otherwise eligible to use the method.
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7.
Among adolescents (menarche to <18) and women over 45,
the advantages of using medroxyprogesterone acetate
generally outweigh the theoretical safety concerns regarding
fracture risk. Since date are insufficient to determine if this is
the case with long-term use among these age groups, the
overall risks and benefits for continuing use of the method
should be reconsidered over time with the individual user.
8.
It is up to the clinician along with the patient to consider bone
density monitoring if medroxyprogesterone acetate is the
desired method and there are concerns about particular risk
factors for osteoporosis. However, dual x-ray absorptiometry
(DXA) is not routinely indicated at initiation or follow- up of
healthy adolescents who choose medroxyprogesterone
acetate. There is a lack of established criteria in this age
group regarding the degree of loss that would provoke
clinician concern and action.
9.
Recommend calcium/vitamin D supplement(s) daily if patient’s
diet is calcium deficient.
10.
Treatment of side-effects:
a.
b.
Heavy bleeding – Consult/referral.
For bleeding irregularities:
Rule out infection or cervical lesions.
May give:
1)
A combined low-dose oral contraceptive for 1-3
cycles.
2)
Ibuprofen 400mg PO every 4 to 6 hours as
necessary. (Maximum dose 1.2 g/day.)
PATIENT EDUCATION/COUNSELING
1.
Counsel client according to seven basic elements of informed
consent (BRAIDED – Benefits Risks Alternatives Inquiries
Decision Explanation Documentation) with emphasis on schedule
associated with use of this method of contraception. Instruct
client to use back-up contraception during the first week after the
initial injection or if injections are late or missed.
2.
Medroxyprogesterone acetate may decrease the amount of
calcium in the bones. It is not known if use during the
reproductive years affects the risk of fracture in later
postmenopausal years.
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3.
The critical years for building bone mass are from prior to
adolescence to about age 30. A decrease of calcium in the bones
is of most concern for teenagers and those women who have the
following risk factors: low body weight, bone disease, anorexia
nervosa, strong family history of osteoporosis, drugs that can
lower the amount of calcium in the bones (drugs for epilepsy or
steroids), high intake of alcohol, sodas, caffeine and smoking (see
Nurse Protocol for Osteoporosis in Women: Assessment and
Prevention).
4.
Counsel patients on adequate calcium intake from foods like milk,
cheese, yogurt or ice cream or a calcium/vitamin D supplement
daily; regular exercise; and avoiding alcohol, smoking and
excessive intake of sodas and caffeine.
5.
The average delay to ovulation is about 9 months (range of 4-31
months) after the last injection and does not increase with longer
duration of use.
6.
Common side effects may include: bleeding/menstrual
irregularities, weight changes, headache, nervousness, abdominal
pain, dizziness, and weakness or fatigue. Less common side
effects include: decreased libido, backache, leg cramps,
depression, nausea, acne, vaginitis, breast pain, hair loss,
bloating, rash, and hot flashes.
WARNING SIGNALS:
a.
Repeated painful headaches.
b.
Heavy bleeding.
c.
Jaundice.
d.
Severe lower abdominal pain (may be sign of pregnancy).
e.
Pus, prolonged pain, or bleeding at the injection site.
7.
Bleeding irregularities are very common (30% in the first year and
10% thereafter). If necessary, bleeding can be treated with
medication.
8.
Amenorrhea usually occurs in one year or less. Counsel women in
their 40s not to think they are going through menopause when
amenorrhea occurs.
9.
Common side effects may not be relieved until the drug clears the
body 6-8 months after the last injection.
10.
There is minimal to no apparent increased risk for breast
cancer.
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11.
No adverse effects have been noted in infants of mothers using
medroxyprogesterone acetate during lactation. Quality and
quantity of breast milk is not adversely affected.
12.
Decreases in high-density lipoproteins (HDL) and increase in total
and LDL cholesterol levels have been reported in some studies of
women using medroxyprogesterone acetate.
13.
Medroxyprogesterone acetate offers no protection from
STDs/HIV. Counsel on condom use to reduce the risks of
STDs/HIV.
14.
Call or return if there are questions about possible side effects or
development of reasons to avoid use, such as weight gain, heavy
bleeding, headaches or depression.
15.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
16.
Emphasize importance of keeping immunizations current; assess
client’s immunization status and administer vaccines
indicated according to the current Advisory Committee on
Immunization Practices (ACIP) childhood or adult immunization
schedule. If client declines vaccination, document refusal. See
the Georgia Immunization Program Manual, Recommended
Schedule and Guidelines, for current ACIP schedules and
administration guidelines for each vaccine. The Georgia
Immunization Manual may be accessed online at
http://www.health.state.ga.us/programs/immunization/publicatio
ns.asp.
FOLLOW-UP
1.
Return for the next injection in 11-13 weeks for
medroxyprogesterone acetate 150mg IM. Return for next
injection in 12-14 weeks for depo-subQ provera 104. If client
returns after 13 weeks for medroxyprogesterone acetate 150 mg
IM or after 14 weeks for depo-subQ provera 104 and has been
sexually active, perform a pregnancy test. Offer emergency
contraception if client has had unprotected intercourse in last 120
hours. May give injection after negative pregnancy tests two
weeks apart and either abstinent or consistent use of a reliable
method of contraception OR give during next menses.
2.
Outside of clinic hours, seek physician or emergency care if
warning signs develop.
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CONSULTATION/REFERRAL
1.
Development of prolonged side effects (e.g., irregular bleeding).
5.
Development of contraindicating conditions.
6.
Management of chronic coexisting medical problems.
7.
Call Pfizer Medical Information at 1-800-438-1985 for product
information.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
American Society of Health-Systems Pharmacists. American Hospital Formulary
Service, 2007, p. 3103.
“Black Box Warning Added Concerning Long-Term Use of Depo-Provera
Contraceptive Injection,” FDA Talk Paper, T04-50, Food and Drug Administration,
November 17, 2004. (Current)
Depo-Provera Contraceptive Injection Physician Prescribing Information, Pharmacia &
Upjohn Company, November 2004. (Current)
Depo-subQ provera 104TM Physician Prescribing Information, Pharmacia & Upjohn
Company, March 2005.
Robert Hatcher et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Robert Hatcher et al., The Essentials of Contraceptive Technology, Johns Hopkins
School of Public Health, Population Information Program, Baltimore, 2001. (Current)
World Health Organization, Medical Eligibility Criteria for Contraceptive Use, Third
Edition, 2004, <http:www.who.int/reproductive-health/publications/mec/> (March 15,
2005).
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters KluwerHealth,
Inc., 2007 <http://online.factsandcomparisons.com>.
Barbara Cromer, Delia Scholes, Abbey Berenson, “Depot medroxyprogesterone
acetate and Bone Mineral Density in Adolescents-The Black Box Warning: A
Position Paper for the Society of Adolescent Medicine,” Journal of Adolescent
Health, 2006, 39: 296-301.
WHO, Hormonal Contraception and Bone Health, July 2005,
<http://www.who.int/reproductive-health/family_planning/bone_health.html>
(March 12, 2007).
"Preventive Screenings and Immunizations," U. S. Department of Health and
Human Services, Office of Women's Health,
<http://www.womenshealth.gov/screeningcharts/highrisk/>.
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for 2008
NURSE PROTOCOL FOR
ORTHO EVRA™ TRANSDERMAL SYSTEM
(CONTRACEPTIVE PATCH)
DEFINITION
ORTHO EVRA™ is a transdermal patch applied to the skin that releases
synthetic estrogen and progestin hormones to prevent pregnancy.
ORTHO EVRA™ acts by suppressing gonadotropins, similar to
combination oral contraceptives. Although the primary mechanism of this
action is inhibition of ovulation, other alterations include changes in the
cervical mucus which increase the difficulty of sperm entry into the
uterus, and changes in the endometrium which reduce the likelihood of
implantation.
SUBJECTIVE
1.
Patient desires to use contraceptive patches.
2.
Has detailed health history (includes menstrual, sexual,
contraception, personal health and family history) that does not
reveal a condition representing an unacceptable health risk
according to the product prescribing information and the World
Health Organization (WHO) Medical Eligibility Criteria for
Contraceptive Use.
3.
If breastfeeding, has been breastfeeding at least 6 weeks, but
preferably six months or more, after childbirth, to ensure that
breastfeeding has been well established.
4.
If age 35 or older, and does not smoke.
1.
Physical exam and laboratory tests according to programmatic
Guidelines.
OBJECTIVE
OR
2.
Physical exam deferred up to 3 months.
Document reason for deferral on chart. Document on Request for
and Consent to Family Planning Services (form 3700) that client
agreed to have physical exam delayed.
ASSESSMENT
Patient has no condition representing an unacceptable risk if using the
patch.
PLAN
DIAGNOSTIC STUDIES
1.
Lipid profile beginning by age 45. Consider screening
women age 20-44 in the presence of high-risk factors for
CVD. Rescreen every 5 years or more often depending on
test results and high-risk factors. For Recommended Tests
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and Immunizations for Women with High-Risk Factors refer to
www.womenshealth.gov.
2.
Blood glucose beginning by age 45. Consider screening
women at an earlier age in the presence of high-risk factors
for diabetes. Rescreen every 3 years or more often
depending on test results and high risk factors. For
Recommended Tests and Immunizations for Women with
High-Risk Factors refer to www.womenshealth.gov.
3.
Screen women for colorectal cancer according to district
policy/procedure for colorectal cancer screening.
THERAPEUTIC
PHARMACOLOGIC
1.
ORTHO EVRA™ Patch, box of three patches.
a.
b.
c.
d.
e.
2.
Apply the first patch on the first day of menses, on
the Sunday following menses or same day as clinic
visit (quick start). The first day is designated as
“Patch Change Day.”
Remove liner and apply the sticky surface of the
patch on clean, dry skin of the lower abdomen,
buttocks, upper outer arm, or upper torso (not on the
breasts).
Press down firmly on the patch with the palm of the
hand for 10 seconds. Make sure that the edges stick
well.
Remove the patch and apply a new patch on "patch
change day" on weeks 2 and 3. Apply the new patch
to a different area of skin to reduce skin irritation.
No patch is applied on week 4.
For patients not receiving physical exam prior to first 3
months supply, a physical exam must be performed to
dispense additional patches.
PATIENT EDUCATION/COUNSELING
1.
Counsel patient according to the seven basic elements of
informed consent (BRAIDED – Benefits Risks Alternatives
Inquiries Decision Explanation Documentation).
2.
The absorption of medication is identical when applied on any of
the four suggested areas of the body.
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3.
Women who use Ortho Evra are exposed to about 60% more
estrogen than if they were taking a typical birth control pill
containing 35 micrograms of estrogen. In general, increased
estrogen exposure may increase the risk of developing serious
blood clots (for instance, in the legs or lungs) that can block blood
vessels and cause death or serious disability. However, it is not
known whether women using Ortho Evra are at a greater risk of
having these serious problems. One study found a doubling of
this risk and another study found no increased risks. The
manufacturer of Ortho Evra is doing studies on this.
4.
The transdermal contraceptive patch may be less effective in
women with body weight of 198 lbs. or higher. May consider back
up method such as condoms if weight is 198 lbs. or higher.
5.
Check the patch every day to make sure it is sticking. Avoid
touching the sticky surface.
6.
Do not apply creams, oils, or cosmetics near the patch site.
7.
If the patch becomes loose and is still sticky, try to reattach it. If it
is not sticky, replace it with a new patch, and then change the new
patch on the usual change day.
8.
If the patch was off for more than 24 hours, immediately begin a
new cycle of patches and use a back-up method of birth control
during the first week. May want emergency contraception.
9.
If forget to change a patch, change it as soon as it is remembered.
Use a back-up method of birth control for one week. May want
emergency contraception.
10.
Counsel on the use of condoms to reduce the risk of STDs/HIV.
11.
The primary side effects of the patch are headache, nausea,
application site reactions, and breast discomfort. Women using
the patch are more likely to experience breakthrough bleeding
and/or spotting during the first 2 months compared with users of a
triphasic levonorgestrel-containing OC. Discuss danger signs
(ACHES).
12.
Do not attempt to tape down a patch that has become loosened.
13.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
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14.
Emphasize importance of keeping immunizations current; assess
client’s immunization status and administer vaccines indicated
according to the current Advisory Committee on Immunization
Practices (ACIP) childhood or adult immunization schedule. If
client declines vaccination, document refusal. See the Georgia
Immunization Program Manual, Recommended Schedule and
Guidelines, for current ACIP schedules and administration
guidelines for each vaccine. The Georgia Immunization Manual
may be accessed online at
http://www.health.state.ga.us/programs/immunization/publicatio
ns.asp.
FOLLOW-UP
1.
Return as scheduled for evaluation or contact clinic if side effects
or danger signs develop.
2.
If patient did not receive a physical exam, have her return within 3
months for an exam and reassessment.
3.
Established patients should return for evaluation at the end of the
current supply of patches, or sooner if side effects or danger signs
develop. Outside of clinic hours, seek physician or emergency
care if danger signs develop.
CONSULTATION/REFERRAL
1.
Development of any danger signs.
2.
Any other serious health concerns expressed by the patient.
3.
If patient is under the supervision of private doctor(s) for health
problem (e.g. hypertension).
4.
Abnormal initial laboratory values or development of abnormal
values or physical findings that indicate patch should not be
continued.
5.
To nutritionist as indicated.
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REFERENCES
1.
2.
3.
4.
5.
6.
American Society of Health-Systems Pharmacists, American Hospital Formulary
Service, Bethesda, MD, 2007, pp. 3076.
Ortho Evra Transdermal System Physician Prescribing Information, Ortho-McNeil
Pharmaceutical, Inc., revised September 2006.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
World Health Organization, Medical Eligibility Criteria for Contraceptive Use, Third
Edition, 2004,<http:www.who.int/reproductive-health/publications/mec/> (March 15,
2004). (Current)
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
"Preventive Screenings and Immunizations," U. S. Department of Health and
Human Services, Office of Women's Health,
<http://www.womenshealth.gov/screeningcharts/highrisk/>.
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NURSE PROTOCOL FOR
NuvaRing®
DEFINTION
SUBJECTIVE
OBJECTIVE
All combination hormonal contraceptives suppress gonadotropins.
Although the primary effect of this action is inhibition of ovulation, other
alterations include changes in the cervical mucus (which increase the
difficulty of sperm entry into the uterus) and the endometrium (which
reduce the likelihood of implantation). The NuvaRing is a vaginal
contraceptive loop made with a flexible polymer, which contains estrogen
and progestin.
1.
Patient desires to use the NuvaRing® as choice of contraception.
2.
Has detailed health history (includes menstrual, sexual,
contraception, personal health and family history) that does not
reveal a condition representing an unacceptable health risk
according to the product prescribing information and the World
Health Organization (WHO) Medical Eligibility Criteria for
Contraceptive Use.
3.
If breastfeeding, has been breastfeeding at least 6 weeks, but
preferably six months or more, after childbirth.
4.
If age 35 or older and does not smoke.
1.
Physical examination and laboratory tests according to
programmatic guidelines.
OR
2.
Physical exam deferred up to 3 months.
Document reason for deferral on chart. Document on Request for
and Consent to Family Planning Services (form 3700) that client
agreed to have physical exam delayed.
ASSESSMENT
Patient has no conditions representing an unacceptable health risk if
using the NuvaRing.
PLAN
DIAGNOSTIC STUDIES
1.
Lipid profile beginning by age 45. Consider screening
women age 20-44 in the presence of high-risk factors for
CVD. Rescreen every 5 years or more often depending on
test results and high-risk factors. For Recommended Tests
and Immunizations for Women with High-Risk Factors refer to
www.womenshealth.gov.
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2.
Blood glucose beginning by age 45. Consider screening
women at an earlier age in the presence of high-risk factors
for diabetes. Rescreen every 3 years or more often
depending on test results and high risk factors. For
Recommended Tests and Immunizations for Women with
High-Risk Factors refer to www.womenshealth.gov.
3.
Screen women for colorectal cancer according to district
policy/procedure for colorectal cancer screening.
THERAPEUTIC
PHARMACOLOGIC
1.
Box of 3 NuvaRing ® sachets. Store out of direct sunlight.
NOTE: Prior to dispensing to the user, refrigerate at 2-8C
(36-46  F). After dispensing to the user, NuvaRing can be
stored for up to 4 months at room temperature out of direct
sunlight. When dispensed to the user, place an expiration
date on the label not to exceed either 4 months from the
date of dispensing or the expiration date, whichever comes
first.
a.
b.
c.
2.
Place one folded NuvaRing® high in the vagina
within five days of starting a menstrual period, even
if still bleeding. May also be started days 2-5 of
cycle, but in this case use barrier method for
first seven days of NuvaRing use in the first
cycle.
Wear ring for three weeks in a row and remove ring.
After 7 ring-free days, insert a new ring.
Use a back-up non-hormonal method of birth control for
one week when initiating NuvaRing for the first time. Do
not use a diaphragm with the NuvaRing. Women switching
from estrogen-progestin oral contraceptives to the vaginal
ring should insert the ring within 7 days of the last
hormonally-active tablet and no later than the day that a
new oral contraceptive cycle would have been started; a
back-up method of contraception is not needed.
PATIENT EDUCATION/COUNSELING
1.
Counsel the patient according to the seven elements of informed
consent (BRAIDED – Benefits Risks Alternatives Inquiries
Decision Explanation Documentation).
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2.
If starting to use NuvaRing® within the first five days following a
complete first trimester abortion, do not need to use an additional
method of contraception.
3.
If client is switching from progestin-only pills, she should
place the first ring on the same day she takes the last pill.
4.
The NuvaRing® does not require fitting or placement in a specific
position, nor the use of spermicidal jelly. It does not need to
surround the cervix. If discomfort is felt, the device is probably not
placed high enough in the vagina.
5.
Keep the foil pouch. After removal of the system in 3 weeks,
dispose of the NuvaRing® in the pouch. Do not flush it down the
toilet. Keep it out of reach of children and animals.
6.
The primary side effects of the NuvaRing® are similar to those of
combined OC pills. Some women may experience vaginal
irritation or infection. Discuss danger signs (ACHES).
7.
NuvaRing® can be accidentally expelled when it has not been
inserted properly, while removing a tampon, or when straining to
move the bowels. If expelled, rinse ring with cool/lukewarm water
and re-insert promptly (within 3 hours from the time it was
expelled). If lost, insert a new one. Remove new ring on the
original replacement date.
8.
The NuvaRing® does not need to be removed for intercourse. If
removed for longer than 3 hours, use a back-up method for 7
days. If device is out >3 hours and patient has unprotected sex,
use emergency contraception.
9.
Check for possible pregnancy if:
a.
Miss a period and the device was out of the vagina for
longer than 3 hours.
b.
Miss a period and waited longer than a week to insert a
new device.
c.
Miss a period and the NuvaRing® was in place more than 4
weeks.
d.
Followed instructions, but miss 2 periods in a row.
9.
Cigarette smoking increases the risk of serious cardiovascular
side effects from combination oral contraceptive use and
NuvaRing®.
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10.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
11.
NuvaRing® does not protect against HIV infection and other
sexually transmitted diseases. Counsel on use of condoms to
reduce the risk of STDs including HIV.
12.
If scheduled for laboratory tests or major surgery, tell the health
care provider that you are using the NuvaRing®.
13.
Ovulation resumes during the first recovery cycle after
discontinuation, suggesting rapid return of fertility.
14.
Emphasize importance of keeping immunizations current; assess
client’s immunization status and administer vaccines indicated
according to the current Advisory Committee on Immunization
Practices (ACIP) childhood or adult immunization schedule. If
client declines vaccination, document refusal. See the Georgia
Immunization Program Manual, Recommended Schedule and
Guidelines, for current ACIP schedules and administration
guidelines for each vaccine. The Georgia Immunization Manual
may be accessed online at
http://www.health.state.ga.us/programs/immunization/publications.
asp.
FOLLOW- UP
1.
Return to clinic in three months for another box of three (3)
NuvaRing® sachets. After that, return as needed for re-ordering
NuvaRing® or for yearly exams.
2.
If patient did not receive a physical exam, have her return within 3
months for an exam and reassessment.
3.
Return for evaluation or contact clinic if side effects or danger
signs develop. Outside of clinic hours, seek physician or
emergency care if danger signs develop.
CONSULTATION/REFERRAL
1.
2.
3.
4.
Development of danger signs.
Any serious health concerns expressed by the patient.
Abnormal initial laboratory values or development of abnormal
values or physical findings that indicate the ring should not be
continued.
To nutritionist as indicated.
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5.
If patient is under the supervision of medical provider for a health
problem (e.g., hypertension).
REFERENCES
1.
2.
3.
4.
5.
6.
7.
American Society of Health-Systems Pharmacists. American Hospital Formulary
Service, Bethesda, MD, 2007 pp. 3075-3085.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co. New York, 2004. (Current)
NuvaRing Physician Prescribing Information, Organon USA Inc., 2005
World Health Organization, Medical Eligibility Criteria for Contraceptive Use, Third
Edition, 2004, <http:www.who.int/reproductive-health/publications/mec/> (March 15,
2005).
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
"Preventive Screenings and Immunizations," U. S. Department of Health and
Human Services, Office of Women's Health,
<http://www.womenshealth.gov/screeningcharts/highrisk/>.
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NURSE PROTOCOL FOR
VAGINAL CONTRACEPTIVE DIAPHRAGM
DEFINITION
The diaphragm is a dome-shaped rubber cup that is inserted into the
vagina before intercourse. The posterior rim rests in the posterior fornix
and the anterior rim fits snugly behind the pubic bone. The dome of the
diaphragm covers the cervix and prevents sperm from entering.
Spermicidal cream or jelly placed in the dome prior to insertion adds to
its effectiveness.
SUBJECTIVE
1.
Desires vaginal diaphragm for contraception.
2.
No history of:
a.
b.
OBJECTIVE
Known hypersensitivity to latex or natural rubber.
Toxic shock syndrome (TSS).
3.
Has not had a full-term delivery within the past 6-12 weeks.
1.
Pelvic exam shows:
a.
b.
c.
d.
2.
Adequate vaginal tone to hold the diaphragm in
place.
Absence of uterine prolapse, severe cystocele or rectocele.
Uterus is not fixed in retroflexed or retroverted position.
Notch behind the symphysis pubis is adequate to support
the rim of the diaphragm.
Patient is physically able to insert a diaphragm.
ASSESSMENT
Patient has no condition representing an unacceptable risk if using the
diaphragm.
PLAN
DIAGNOSTIC STUDIES
1.
Blood glucose beginning by age 45. Consider screening
women at an earlier age in the presence of high-risk factors
for diabetes. Rescreen every 3 years or more often
depending on test results and high risk factors. For
Recommended Tests and Immunizations for Women with
High-Risk Factors refer to www.womenshealth.gov.
2.
Screen women for colorectal cancer according to district
policy/procedure for colorectal cancer screening.
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THERAPEUTIC
PHARMACOLOGIC
Contraceptive jelly/cream containing spermicide.
NON-PHARMACOLOGIC MEASURES
Fit patient for appropriate size and type diaphragm.
PATIENT EDUCATION/COUNSELING
1.
Counsel patient according to the seven basic elements of
informed consent (BRAIDED – Benefits Risks Alternatives
Inquiries Decision Explanation Documentation).
2.
Insertion, removal and care of diaphragm, with return
demonstration.
3.
Once in position, the diaphragm provides effective contraceptive
protection for 6 hours.
4.
After intercourse, the diaphragm must be left in place for at least 6
hours, but it should be removed as soon as possible
thereafter. Continuous wearing of a contraceptive diaphragm for
more than 24 hours is not recommended.
5.
If more than one act of intercourse in 6 hours, do not remove
diaphragm. Add additional spermicide before each act of
intercourse.
6.
Prevention of toxic shock syndrome
a.
b.
c.
7.
Do not use diaphragm during menses.
Do not leave diaphragm in place for more than 24 hours.
Seek care for danger signs of toxic shock:
1)
Temperature of 101° F or higher.
2)
Diarrhea.
3)
Vomiting.
4)
Muscle aches.
5)
Rash appearing like a sunburn.
Diaphragm will need to be refitted and replaced with new
diaphragm at least every 2 years or:
a.
After vaginal delivery.
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b.
c.
d.
After gynecologic or lower abdominal surgery.
After weight loss or gain of over 10 pounds.
After second trimester abortion.
8.
Counsel on use of condoms to reduce the risk of STDs/HIV.
9.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
10.
Emphasize importance of keeping immunizations current, assess
client’s immunization status and administer vaccines indicated
according to the current Advisory Committee on Immunization
Practices (ACIP) childhood or adult immunization schedule. If
client declines vaccination, document refusal. See the Georgia
Immunization Program Manual, Recommended Schedule and
Guidelines, for current ACIP schedules and administration
guidelines for each vaccine. The Georgia Immunization Manual
may be accessed online at
http://www.health.state.ga.us/programs/immunization/publications.
asp.
FOLLOW-UP
Return to clinic in one month, with diaphragm in place, to assess for
proper fit.
REFERRAL/CONSULTATION
1.
Signs/symptoms of toxic shock syndrome.
2.
Signs/symptoms of urinary tract infection as appropriate.
3.
Signs/symptoms of cystocele or rectocele.
REFERENCES
1.
2.
3.
4.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co. New York, 2004. (Current)
Ortho-McNeil, Ortho Diaphragm, Physician Prescribing Information, Ortho-McNeil
Pharmaceutical Inc., August 2006.
"Preventive Screenings and Immunizations," U. S. Department of Health and
Human Services, Office of Women's Health,
<http://www.womenshealth.gov/screeningcharts/highrisk/>.
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NURSE PRACTITIONER PROTOCOL FOR
NORPLANT® REMOVAL
DEFINITION
Removal of Norplant® at the patient's request, due to clinical findings
such as pregnancy or side effects, or per guidelines that Norplant® must
be removed after 5 years.
SUBJECTIVE
1.
Patient desires Norplant® removal.
2.
May be pregnant.
3.
May complain of severe side effects.
4.
Five years may have elapsed since insertion.
1.
May have a positive pregnancy test.
2.
May have clinical findings of side effects or a contraindication for
continuing with Norplant®.
OBJECTIVE
ASSESSMENT
Removal of Norplant® is desired or recommended.
PLAN
DIAGNOSTIC STUDIES
Pregnancy test, if indicated.
THERAPEUTIC
Remove the Norplant® capsules through a very small incision 1-2 mm
above the insertion site (over the tips of Norplant®) with one of the
following methods, which may take two visits:
1.
2.
Wyeth Instructions/Population Council (standard) at the incision
made to insert implants; use small 3 cubic centimeter syringe of
1% lidocaine; make a 5 mm incision just above the previous
incision and use curved hemostat to disrupt and remove the
implants.
OR
Emory Technique
Use 6-8 cubic centimeter of 1% lidocaine; make an 8 mm to 1 cm
incision at the same location as the incision made to insert
implants, using small hemostat to disrupt adhesions; use Adson
forceps or scalpel to strip the tissue off the implants.
OR
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3.
4.
Pop Out Technique
2-4 cubic centimeter of 1% lidocaine; 2-3 mm incision at the base
of the fan slightly above previous incision, (just large enough to
push implant through opening); push implants to opening; use
scalpel to remove the adhesions; all tips of implants must be fairly
close together to use this technique.
OR
"U" Technique
Make 4-6 mm vertical incision between the lower ends of implants
#3 and # 4; remove implants using a modified vasectomy clamp
(available through Wyeth Laboratories).
PHARMACOLOGIC
Prostaglandin inhibitors/nonsteroidal anti-inflammatory
drugs such as:
1.
2.
3.
Ibuprofen 400 mg PO 4 hours as needed for pain.
(Maximum dose 1.2g/day)
OR
Naproxen 500 mg every 12 hours as needed for pain.
(Maximum dose 1gm/day)
OR
Over-the-counter-strength products (e.g., Advil, Nuprin,
Aleve, Motrin IB, coated aspirin, or acetaminophen) per
package directions prn.
PATIENT EDUCATION/COUNSELING
1.
Dark pigmentation is frequently seen over the implants. It will
eventually go away after removal of implants.
2.
Provide patient with instructions for care and advise to return in
one week for recheck.
3.
Discuss alternative contraceptive method, if desired. Remind
client that she may become pregnant immediately following
Norplant removal if not using alternative contraceptive
method.
4.
Menses may be delayed or irregular for a month or more after
removal.
5.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
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6.
Emphasize importance of keeping immunizations current; assess
client’s immunization status and administer vaccines indicated
according to the current Advisory Committee on Immunization
Practices (ACIP) childhood or adult immunization schedule. If
client declines vaccination, document refusal. See the Georgia
Immunization Program Manual, Recommended Schedule and
Guidelines, for current ACIP schedules and administration
guidelines for each vaccine. The Georgia Immunization Manual
may be accessed online at
http://www.health.state.ga.us/programs/immunization/publications.
asp.
FOLLOW-UP
1.
Return in one week for recheck. Appointment for second removal
visit, if necessary.
2.
Return, as needed, for contraception or yearly exam.
CONSULTATION/REFERRAL
1.
Difficult/failed removal.
2.
Successful removal, patient pregnant.
3.
Persistent side effects.
REFERENCES
1.
2.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Robert Hatcher et al., The Essentials of Contraceptive Technology, Johns Hopkins
School of Public Health, Population Information Program, Baltimore, 2001. (Current)
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NURSE PROTOCOL FOR
AMENORRHEA (PRIMARY AND SECONDARY)
DEFINITION
Primary amenorrhea is defined as no menstrual period by age 14, in the
absence of growth or development of secondary sexual characteristics,
or no menstrual period by age 16, regardless of the presence of normal
growth and development with the appearance of secondary sexual
characteristics.
Secondary amenorrhea is defined as absence of menstrual periods for a
length of time equivalent to a total of at least three of the previous cycle
intervals or six-twelve months of amenorrhea in a woman who
normally experiences irregular menses.
ETIOLOGY
Primary:
1.
2.
3.
Gonadal failure.
Congenital absence of uterus & vagina.
Constitutional delay.
Secondary:
1.
2.
13.
14.
15.
16.
17.
Pregnancy; breastfeeding.
Pituitary disease or tumor; disruption of hypothalamicpituitary axis.
Menopause.
Too little body fat (about 22% required for menses).
Excessive exercise (e.g., long-distance running, ballet
dancing, gymnastics, figure skating, etc.).
Rapid weight loss.
Cessation of menstruation following use of OCs or
medroxyprogesterone acetate.
Recent change in lifestyle (e.g., increased stress).
Thyroid disease.
Polycystic ovary disease.
Anorexia nervosa or other eating disorders.
Premature ovarian failure, ovarian dysgenesis, infection,
hemorrhage, necrosis, neoplasm.
Asherman’s Syndrome.
Cervical stenosis.
Medications including psychotropics.
Chronic illness.
Tuberculosis.
1.
Patient reports absence of menses (as defined above).
2.
History may include:
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
SUBJECTIVE
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a.
b.
c.
d.
e.
f.
g.
h.
i.
OBJECTIVE
Changes in skin/hair, vision/hearing or voice.
Palpitations.
Breast size changes or galactorrhea.
Vasomotor Symptoms.
Changes in weight, dietary habits.
Cold or heat intolerance.
Known medical problems.
Stress.
Exercise patterns (changes or rigorous).
1.
May be obese or underweight for height.
2.
May note on physical examination:
a.
b.
c.
d.
e.
f.
Skin/hair changes -- dry skin or warm, moist skin,
excessive sweating, palmar erythema, acne, hirsutism,
purple abdominal striae, absence of pubic or axillary hair.
Facial plethora, moon facies, exophthalmos, ocular signs,
visual fields defect, impaired auditory acuity, abnormal
thyroid size and consistency, fine silky scalp hair or
alopecia pattern.
Tachycardia.
Breast tissue atrophy, galactorrhea.
"Buffalo" hump of back.
On pelvic exam:
1)
External – Vulvar atrophy, clitoromegaly.
2)
Internal – Atrophic vaginal mucosa, change in
cervical mucous, or imperforate hymen.
3)
Bimanual – Softening of cervix or cervical uterine
junction, cervical stenosis, uterine or ovarian atrophy
or enlargement.
ASSESSMENT
Primary amenorrhea.
OR
Secondary amenorrhea with or without galactorrhea.
PLAN
DIAGNOSTIC STUDIES
1.
Pregnancy test.
2.
For secondary amenorrhea only:
a.
Amenorrhea with galactorrhea, and not breastfeeding:
Draw prolactin level(s) prior to breast exam or 1 week after
exam and no nipple stimulation for 1 week.
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b.
Thyroid-stimulating hormone (TSH) test (for underlying
hypothyroidism).
THERAPEUTIC
PHARMACOLOGIC
Amenorrhea without galactorrhea and negative pregnancy test –
Progestin challenge.
Medroxyprogesterone 5-10 mg 1 tab PO daily for 5-10 days. If
bleeding occurs with progestin challenge test (usually within 2-7
days) and
1.
Patient desires contraception and OCs do not pose an
unacceptable health risk, begin any FDA approved < 35
mcg OC.
OR
2.
Patient does not desire contraception, give
medroxyprogesterone acetate, 10 mg PO daily, for the first
10 days of every month, for three (3) consecutive months.
If no bleeding occurs with progestin challenge test, repeat
pregnancy test.
PATIENT EDUCATION/COUNSELING
1.
Give menstrual calendar and counsel on its use.
2.
Inform that bleeding usually occurs within 2 weeks after treatment
(frequently 2-7 days).
3.
Discuss what can be expected during future evaluation. Explain
that accurate diagnosis may take time.
4.
Review female anatomy and menstrual cycle to help her
understand the testing being done.
5.
Discuss contraception, as indicated.
6.
Explain that post-pill amenorrhea or resumption of normal menses
may take up to 6 months.
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FOLLOW-UP
Return in two weeks if no withdrawal bleeding has occurred after
medroxyprogesterone acetate or no withdrawal bleeding with OCs.
CONSULTATION/REFERRAL
1.
If patient has primary amenorrhea.
2.
Positive pregnancy test.
3.
Amenorrhea with galactorrhea and abnormal test results.
4.
If patient does not have a withdrawal bleed after progestin
challenge.
5.
Patient fails to have spontaneous menses within 3 months after
treatment.
6.
Suspected eating disorders, or polycystic ovarian syndrome.
7.
If patient has abnormal laboratory test(s).
REFERENCES
1.
2.
3.
4.
American Society of Health-System Pharmacists, American Hospital Formulary
Service, Bethesda, MD, p. 3232, 2007.
R. Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co., New York, 2004. (Current)
Leon Speroff and Marc Fritz, Gynecologic Endocrinology and Infertility, Seventh
Edition, Lippincott, Williams & Wilkins, Philadelphia, 2005.
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NURSE PROTOCOL FOR
BACTERIAL CYSTITIS
NOTE: Females under age 18 must be established Women's Health patients.
DEFINITION
Cystitis is a bladder inflammation that may be characterized by
dysuria, frequency and urgency. Bacteria and viruses are often the
cause. Rarely, fungi, chemical agents, and radiation exposure may
cause cystitis.
SUBJECTIVE
1.
Frequency, burning on urination.
2.
Urgency, with or without incontinence.
3.
Suprapubic pain and/or tenderness.
4.
No symptoms of vaginal infection.
If indicated, do work-up for possible vaginal infection, chlamydia
and gonorrhea.
5.
No recent history of fever, shaking chills, unilateral flank pain,
inability to urinate or a sudden decrease in urine volume. No
history of kidney disease.
1.
Lower abdominal tenderness on palpation.
2.
Temperature greater than or equal to 100ºF.
3.
Diagnostic criterion: Dipstick urinalysis positive for either white
blood cells (WBCs) and/or nitrites.
OBJECTIVE
ASSESSMENT
Bacterial cystitis
PLAN
DIAGNOSTIC STUDIES
1.
Urine pregnancy test, if any possibility of pregnancy.
2.
If diagnosis is in question, obtain clean-catch urine for urinalysis
and culture and sensitivity.
3.
If abnormal vaginal discharge or discharge from the urethra,
perform wet prep and perform tests for gonorrhea and chlamydia.
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THERAPEUTIC
PHARMACOLOGIC
1.
Trimethoprim 160 mg / sulfamethoxazole 800 mg
(Bactrim DS, Cotrim DS, Septra DS, Sulfatrim DS).
1 tablet PO, with food, every 12 hours for 3 days.
NOTE: Do not give if patient: has a history of allergy to the
drug components; asthma, kidney or liver disease, folic
acid deficiency states, G6PD-deficiency, or any other blood
dyscrasia; is taking thiazide diuretics, warfarin (Coumadin),
phenytoin (Dilantin), or methotrexate; is pregnant; or, is
breastfeeding an infant <2 months old, or with or an
elevated bilirubin.
OR
2.
Nitrofurantoin (Macrobid®)100 mg, 1 capsule PO with food,
every 12 hours for 7 days or Macrodantin 50 mg. 1 tab PO
four times a day for 7 days.
NOTE: Do not give if patient: has a history of nitrofurantoin
allergy, kidney or liver disease, optic neuritis, G6PDdeficiency or anemia; is taking sulfinpyrazone/Anturane,
probenecid, or magnesium-containing antacids; or is
breastfeeding an infant less than one month old or with
G6PD-deficiency.
OR
3.
If allergic or otherwise intolerant of treatments above, is at
least 18 years old and not pregnant or breast-feeding,
a.
b.
Norfloxacin (Noroxin®) 400 mg, 1 tablet PO
every 12 hours for 3 days if uncomplicated and due to
E. coli, K. pneumoniae, or P. mirabilis.
All other organisms, Norfloxacin 400 mg., 1 tablet PO
2 times a day for 7 – 10 days.
Take at least 2 hours before or 2 hours after food, milk
products, iron or zinc supplements, antacids and/or other
medications.
NOTE: Do not give if: patient has a history of quinolone
antibiotic allergy, tendon rupture, atherosclerotic
cardiovascular disease, kidney or liver disease, neurologic
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disorder or blood dyscrasia; or is taking theophylline,
caffeine (e.g., in pain and fever-relieving medications),
cyclosporine, warfarin (Coumadin®), probenecid,
nitrofurantoin or sucralfate (Carafate®).
4.
For non-curative symptomatic relief, if patient is >12 years
old, is not pregnant or breast-feeding, and has no history of
liver disease:
a.
b.
c.
Phenazopyridine HCL (Pyridium®) 200 mg,
1 tablet PO 3 times a day after meals as needed for
3-15 days.
OR
Nonprescription phenazopyridine HCl 95 mg
(AzoStandard, Azo-Gesic, Prodium) for <2 days.
Follow package directions.
Discontinue medication immediately if any yellowish
or orange discoloration of skin or eyes is noted. This
medication may stain contact lenses.
NON-PHARMACOLOGIC MEASURES
1.
Increase fluid intake (cranberry juice might be suggested)
and empty bladder frequently.
2.
Warm sitz baths.
PATIENT EDUCATION/COUNSELING
1.
The importance of taking the full course of treatment, unless
serious side-effects occur.
2.
Drug-specific instructions and cautions:
a.
b.
c.
For trimethoprim/sulfamethoxazole: avoid sun exposure,
discontinue drug immediately if develop a rash or signs of
liver problems. Drink a full glass of water with each dose.
For nitrofurantoin: discontinue drug if develop peripheral
neuropathy, visual problems, diarrhea, or symptoms of liver
or lung problems.
For norfloxacin: avoid sun exposure, discontinue drug
if develop diarrhea, tendon symptoms, rash or other
allergic symptoms. Drink a full glass of water. May cause
dizziness/drowsiness.
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d.
Phenazopyridine may cause discoloration of urine and may
stain panties. Recommend pantyliners.
3.
Potential risk factors for cystitis and prevention strategies.
4.
Eating or consuming cultured milk products (yogurt, buttermilk)
may help prevent vaginal yeast infection while antibiotics are
being taken.
5.
Seek medical care immediately if medication side-effects or
systemic symptoms develop.
6.
Post-menopausal women may have increased susceptibility for
cystitis because of a decrease in vaginal lactobacilli and an
increased pH. Cultured milk products (yogurt, buttermilk) which
contain live active cultures are good dietary sources of lactobacilli.
Look for product containers labeled "LAC”.
FOLLOW-UP
1.
Patient should call the clinic if cystitis symptoms are not improved
within 48 hours of starting therapy.
2.
If no improvement in 48 hours after starting therapy or if
symptoms persist after therapy is complete, either perform
complete UA, culture and sensitivity and treat or refer for
testing.
REFERRAL/CONSULTATION
1.
If patient is pregnant.
2.
Gross hematuria in a specimen uncontaminated by menses.
3.
Systemic complaints such as temperature >100°F, fast pulse,
shaking chills or unilateral flank pain.
4.
Recurrent cystitis within one month, or more than 3 episodes in
one year.
5.
If follow-up urinalysis reveals unexplained (non-menstrual)
microhematuria without WBCs or nitrite.
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REFERENCES
1.
2.
3.
4.
American Society of Health-Systems Pharmacist, American Hospital Formulary
Service, Bethesda, MD, 2007, pp. 387-393, 410-418, 890-892, 3538-3539.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Constance Uphold and Virginia Graham, Clinical Guidelines in Family Practice, Fourth
Edition, Barmarrae Books, Inc., Gainesville, FL, 2003. (Current)
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
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NURSE PROTOCOL FOR
DYSMENORRHEA (PRIMARY)
DEFINITION
Primary dysmenorrhea is painful menstruation without identifiable
causes; it is also known as spasmodic dysmenorrhea. Elevated
levels of prostagladins E2 and F in the endometrium cause uterine
contractions. This increases intrauterine pressure, creating uterine
ischemia and spasmodic pain. Differential diagnosis includes:
pelvic inflammatory disease, endometriosis, adenomyosis, endometrial
hyperplasia, endometrial cancer, leiomyomata, ectopic pregnancy, IUD
with partial expulsion.
SUBJECTIVE
1.
Note history of: parity, menarche, method of contraception, pelvic
inflammatory disease/sexually transmitted diseases, onset of
symptoms/changes over time, family history of dysmenorrhea,
nutritional status.
2.
May report symptoms of congestive (secondary) dysmenorrhea:
irritability, depression, nervousness, exhaustion, backache,
constipation, bloating, weight gain, breast tenderness, dull ache,
and/or onset of symptoms prior to menses.
3.
May report symptoms of spasmodic dysmenorrhea:
nausea, vomiting, diarrhea, weakness, dizziness, pelvic cramping,
abdominal/back/thigh cramping, sweating, pallor, and/or
headache.
OBJECTIVE
Physical examination usually within normal limits, unless secondary
factors are present.
ASSESSMENT
Primary dysmenorrhea
PLAN
DIAGNOSTIC STUDIES
As indicated:
Pap smear, gonorrhea/chlamydia tests, vaginal wet mount, pregnancy
test.
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THERAPEUTIC
PHARMACOLOGIC
1.
Over the counter analgesics – Coated aspirin, Aleve®,
Motrin IB®, Nuprin®, acetaminophen (e.g., Tylenol®), per
package directions prn.
OR
2.
Ibuprofen 400 mg PO every 4 hours as needed for pain.
(Maximum dose 1.2g/day) or Naproxen 500 mg 2 times a
day prn for pain. (Maximum dose 1g/day)
NOTE: Do not order if patient has a history of allergic
reaction to aspirin.
3.
If patient wants contraception and method poses no
unacceptable health risk: OCs, medroxyprogesterone
acetate, Ortho Evra Patch, NuvaRing may decrease
symptoms.
NON-PHARMACOLOGIC
1.
Topical heat.
2.
Regular exercise may be helpful.
PATIENT EDUCATION/COUNSELING
1.
Primary dysmenorrhea probably does not affect fertility.
2.
Assess patient’s knowledge of activities that may provide relief.
3.
Caution patient if taking prostaglandin inhibitors (Aleve®, Motrin
IB®, Nuprin®, aspirin)
a.
b.
Prolonged chronic use may cause kidney problems and GI
upset.
Stop medication and report severe persistent headaches,
fever and muscle aches, which may be signs of aseptic
meningitis.
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FOLLOW-UP
Return to clinic if no relief from therapy.
CONSULTATION/REFERRAL
1.
For differential diagnosis, as indicated.
2.
Refer to physician if no relief from therapy, or severe side
effects of medication.
REFERENCES
1.
2.
3.
4.
5.
6.
American Society of Health-Systems Pharmacists, American Hospital Formulary
Service, Bethesda, MD, 2007, pp. 2061-2067, 2102-2108.
Linda French, “Dysmenorrhea,” American Family Physician, Vol. 71, No. 2, January
2005.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co., New York, 2004.
(Current)
Constance Uphold and Mary Graham, Clinical Guidelines in Family Practice, Fourth
Edition, Barmarrae Books, Inc., Gainesville, FL, 2003. (Current)
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
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NURSE PROTOCOL FOR
ECTOPIC PREGNANCY
DEFINITION
Implantation of a blastocyst in a location other than the corpus of the
uterus. This may be intrauterine (cervix, interstitial portion of the tube) or
extrauterine (ovary, tube, abdomen, or ligaments). Rupture of the
fallopian tube occurs at 6-12 weeks or up to 3-4 months, after the
menstrual cycle, depending on location of the pregnancy.
Predisposing factors are: previous ectopic pregnancy, history of
salpingitis or pelvic inflammatory disease, adhesions from previous
surgery (e.g., appendicitis), previous tubal ligation and/or tubal
re-anastamosis, or situations where tubal structure is distorted
(developmental, uterine, or adnexal tumors). While an IUD (e.g., Copper
T-380A) may decrease a woman's risk for an ectopic pregnancy, when a
woman using an IUD becomes pregnant, the percentage of pregnancies
which are ectopic is increased.
SUBJECTIVE
1.
History of last normal menstrual period and contraception.
2.
May report:
a.
b.
c.
d.
OBJECTIVE
1.
Associated signs/symptoms of pregnancy such as nausea,
vomiting, dizziness, breast tenderness and/or discharge.
Spotting, cramping prior to expected menses, or missed
menses followed by spotting to profuse bleeding,
amenorrhea (75%).
Mild to severe pain in the pelvic region, often unilateral,
increasing in intensity, particularly on one side, with
radiation to left shoulder.
History of predisposing factors, such as previous ectopic
pregnancy, pelvic infections, use of the IUD and previous
pelvic surgery.
May find on physical examination:
a.
b.
c.
d.
Decreased bowel sounds and/or rebound tenderness.
Soft, bluish cervix; blood at os or in vaginal vault.
Cervical motion tenderness with softening of the cervicaluterine junction; uterus normal to slightly increased in size
(may not correspond to dates), tender, and soft; adnexal
mass or thickness with tenderness.
Signs of hypovolemia or shock (BP lowered, pulse
increased) if tube is ruptured and bleeding profusely.
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2.
Laboratory tests:
a.
b.
Sensitive urine pregnancy test will usually be positive.
Hematocrit/Hemoglobin - within normal limits or below
normal.
ASSESSMENT
Possible ectopic pregnancy.
PLAN
Immediate referral to hospital emergency room.
PATIENT EDUCATION/COUNSELING
1.
Stress urgency of life-threatening situation.
2.
Provide emotional support.
3.
Discuss need to know Rh status and be given RhoGAM, if
indicated.
FOLLOW-UP
At first follow-up visit, discuss:
1.
Possibility of further fertility problems and/or repeat ectopic
pregnancy.
2.
How to decrease the chance of future infection and preserve
remaining fertility.
3.
Options for contraception.
REFERENCES
1.
2.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
Joellen Hawkins, et al., Protocols for Nurse Practitioners in Gynecological Settings,
Eighth Edition, Springer Publishing Co., New York, 2004. (Current)
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NURSE PROTOCOL FOR
PROPHYLACTIC THERAPY WITH FOLIC ACID
FOR REPRODUCTIVE-AGE WOMEN
DEFINITION
Folic acid is a B-vitamin that is necessary for proper cell growth. All
women of reproductive age should consume 400 mcg (0.4 mg) of
folic acid daily to meet 100% of the Recommended Daily Allowance
(RDA).
If folic acid is consumed before and during early pregnancy from a
multi-vitamin or fortified food, it can prevent from 50% up to 70% of
some forms of birth defects called neural tube defects (NTD), such
as spina bifida and anencephaly.
Foods naturally rich in folate include dark green leafy vegetables, orange
juice, dried peas, beans, and lentils. Since 1998, some enriched flour,
cereal, grain products, bread, rice and pasta have been fortified with
folic acid. It is possible, that women that consume fortified products
still may not consume enough folic acid. Taking a daily multivitamin or pill containing folic acid is another easy and effective
way to assure meeting the recommended.
All women of reproductive-age who have had a pregnancy affected
by a NTD have an increased need for folic acid. The CDC guideline
published in August 1991 and the PHS guideline published in
September 1992 recommends that, women who have had a
previous NTD-affected pregnancy:
 Consume 400 micrograms (0.4 milligram) of folic acid daily if
they are not planning a pregnancy.
 Consume 4,000 micrograms (4 milligrams) of folic acid daily
under the direction of their health care provider if they are
planning a pregnancy.
More studies of the prevention of NTDs among other higher risk
women need to be done. Nevertheless, these women should follow
the PHS recommendation of 400 micrograms (0.4 milligram) of folic
acid daily throughout their childbearing years. If they are planning a
pregnancy, it is advisable for them to discuss their potential risk for
having an affected child with their physician. They should talk
about the advantages and disadvantages of using 4,000
micrograms (4 milligrams) periconceptionally (that is, one month
before conceiving a baby through the first three months of
pregnancy). Other high-risk women include:
 Women with a close relative (e.g., sibling, niece, nephew)
who has an NTD.
 Women or their partners who themselves have an NTD.
 Women with insulin-dependent diabetes mellitus.
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

Women with seizure disorders being treated with valproic
acid or carbamazepine.
Women with medically diagnosed obesity.
ETIOLOGY
Neural tube defects occur in the first few weeks after conception.
This is near the time a woman misses her menses. Therefore,
neural tube defects may occur in an unborn baby before a woman
realizes she is pregnant. The spinal cord forms and closes within
the first 28 days of a pregnancy. The chance of having a child with
a neural tube defect for those without a family history are
approximately 1/500 - 1/1000.
SUBJECTIVE
Patient is not currently taking multivitamins with folic acid
or 400 mcg folic acid daily.
1.
2.
Patient has no history of neural tube defect either in
pregnancy or personal history.
Patient has a history of a NTD with a previous pregnancy.
OBJECTIVE
There are usually no obvious signs of folic acid deficiency.
ASSESSMENT
Reproductive age woman with inadequate folic acid intake.
1.
2.
PLAN
No history of previous neural tube defect-affected pregnancy.
Has a history of previous neural tube defect-affected
pregnancy.
THERAPEUTIC
PHARMACOLOGIC
1.
Patient has no history of neural tube defect either in
pregnancy or personal history.
a.
b.
2.
Folic acid 400 mcg (0.4mg), one tablet PO daily.
OR
Multivitamin with folic acid 400 mcg (0.4mg), one
tablet PO daily.
Patient has history of a neural tube defect with a
previous pregnancy.
a.
If the patient plans to become pregnant:
Refer to a physician for planning how to obtain 4
mg of folic acid (one month before conceiving a
baby through the first three months of
pregnancy).
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b.
If the patient is not planning a pregnancy:
Multivitamin with folic acid 400 mcg (0.4 mg),
one tablet PO daily or folic acid 400 mcg, one
tablet PO daily.
PATIENT EDUCATION/COUNSELING
1.
All women of reproductive age
a.
Assess patient’s knowledge about health benefits of
folic acid and neural tube defects
b.
Provide examples of good sources of folate which
include:
1)
Green leafy vegetables (broccoli, romaine
lettuce, spinach, turnip greens, asparagus)
2)
Lentils, black-eyed peas, split peas
3)
Liver
4)
Orange juice
5)
Many fortified breakfast cereals. Some cereals
with 400 mcg (0.4 mg) of folic acid per serving
include: Total®, Product 19®, Grape Nuts®,
Wheat Total®, Multigrain Cheerios Plus®, Smart
Start®.
6)
Since 1998, folic acid has been added to cereals,
breads, pastas, and other foods labeled
"enriched.”
c.
The human body absorbs folic acid more efficiently
from vitamin supplements than from food.
d.
Cooking and storage destroy some of the folate in
foods.
e.
Explain proper use of folic acid supplements. Taking
large doses of multivitamins can be harmful to a
pregnancy; too much of certain other vitamins can
actually cause birth defects.
f.
Review present form of birth control in detail and
assure adherence if not planning a pregnancy.
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g.
2.
Extra amounts of folic acid may make it more difficult
to detect a rare condition called vitamin B12 deficiency,
or pernicious anemia.
Women of reproductive age with a previous history of
pregnancy affected by an NTD
a.
Give handouts about folic acid that are specifically
designed for these women. Emphasize that folic acid
will not prevent all reoccurrence of neural tube defects.
b.
Stress the benefit of planning pregnancies to lessen
the chances of having a baby with a neural tube defect.
These women should return to the clinic if they are
even “thinking” about becoming pregnant.
FOLLOW-UP
1.
Discuss folic acid at each gynecologic visit. Stress the
importance of birth control and planned pregnancies.
2.
Schedule return appointment as appropriate for patient’s family
planning needs.
CONSULTATION/REFERRAL
Refer to physician if history of previous neural tube defect-affected
pregnancy.
REFERENCES
1.
2.
3.
4.
5.
American Academy of Pediatrics, “Folic Acid for the Prevention of Neural Tube
Defects,” Pediatrics, Vol. 104, No. 2, August 1999, pp.325-327. (Current)
American Society of Health-System Pharmacists, American Hospital Formulary
Service, Bethesda, MD, 2007, pp. 3620-3622.
CDC, “Spina Bifida and Anencephaly Before and After Folic Acid Mandate---United
States, 1995-1996 and 1999-2000”, MMWR, Vol. 53, No. 17, 2004. (Current)
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
CDC, Folic Acid Educational Materials For Health Care Professionals,
“Appendices to Preventing Neural Tube Birth Defects: A Prevention Model and
Resource Guide,” http://www.cdc.gov/ncbddd/folicacid/health_materials.htm.
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NURSE PROTOCOL FOR
IRON-DEFICIENCY ANEMIA
IN NON-PREGNANT AND NON-LACTATING
WOMEN 18 AND OVER
DEFINITION
Anemia is a decrease in the number of red blood cells or quantity of
hemoglobin or hematocrit. This reduced blood cell count reduces the
amount of oxygen the blood can carry in the body. Iron-deficiency
anemia, the most common type of anemia, is present in 20% of all premenopausal women in the United States.
ETIOLOGY
The primary cause of iron-deficiency anemia in premenopausal women
is loss of blood through menstruation. In men and postmenopausal
women, bleeding is usually from the GI tract (chronically bleeding
lesions, reflux esophagitis, peptic ulcers, gastric or colorectal
adenocarcinomas).
Iron-deficiency anemia also commonly occurs during pregnancy.
SUBJECTIVE
1.
Usually no symptoms.
2.
Patient may have:
a.
b.
c.
d.
e.
f.
g.
3.
Pallor, malaise, and/or anorexia.
History of GI bleeding.
Changes in stool color or bleeding from hemorrhoids.
Excessive blood loss during menses or history of fibroid
tumors.
Poor dietary intake of iron rich foods, and pica.
History of drug/medication use, especially aspirin and other
NSAIDs.
Nonspecific complaints of headache, poor concentration,
and/or palpitations.
With severe anemia, the patient may also present with:
Weakness and faintness
Shortness of breath
Increased heart rate
Headaches
Sore tongue
4.
Nausea and loss of appetite
Dizziness
Bleeding gums
Confusion and dementia
Symptoms of heart failure
No history of major hemoglobinopathies (e.g., sickle cell anemia,
sickle C disease, sickle beta thalassemia, Hemoglobin CC
disease).
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OBJECTIVE
1.
Patient may have
a.
b.
c.
d.
e.
2.
Pallor, best seen in conjunctivae.
Atrophy of the surface or edges of the tongue.
Inflammation/cracking of the lips.
Spoon nails (thin and concave from side to side).
Tachycardia, flow murmur.
Hemoglobin below 12 g/dL for a non-smoker and below 12.3 g/dL
for smoker or hematocrit below 35.9% for non-smoker and below
36.9% for smoker.
ASSESSMENT
Iron-deficiency anemia.
PLAN
DIAGNOSTIC STUDIES
1.
Order hemoglobin electrophoresis, sickle cell test, if not previously
done or if client’s status unknown.
2.
Stool occult blood x 3, if clinically indicated or patient is age 35
years or older.
THERAPEUTIC
PHARMACOLOGIC
Give 60-120 mg elemental iron PO daily. If patient is taking a
multi-vitamin and mineral supplement with iron, the multi-vitamin
and mineral supplement plus the iron should equal a total of 60120 mg of elemental iron/day. Do not give if client has sickle cell
or hemoglobin variants.
PATIENT EDUCATION/COUNSELING
1.
If the iron upsets the stomach, take iron with a small amount of
food, but not with dairy products.
2.
Introduce iron gradually to minimize stomach upset. Take one
tablet once a day x 1 week, then increase to twice daily if needed.
3.
Beverages consumed with meals have a dramatic effect on iron
absorption from blood.
a.
Orange juice doubles the absorption of iron.
b.
Tea or milk can reduce absorption to less than one half and
should be consumed in moderation between meals.
4.
Antacids, tetracycline, cimetidine and pancrelipase interfere with
iron absorption. Do not take iron within 3 hours of taking these
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medications. Iron affects other medications and a pharmacist or
health care provider should be consulted before starting another
medication.
5.
Iron supplements may cause black or dark green bowel
movements, diarrhea, or constipation.
6.
Counsel patient on other common side effects of iron therapy.
7.
Too much iron is dangerous. Iron tablets may look like candy and
a package of iron tablets can poison a child. Keep iron
supplements out of the reach of children.
FOLLOW-UP
Recheck hemoglobin/hematocrit at the end of 4 weeks of initial
treatment.
1.
If the hemoglobin has increased 1 g/dL or hematocrit by 3%,
continue treatment for 2-3 months to replenish iron stores.
2.
If the hemoglobin is not increased 1 g/dL or hematocrit by 3%:
a.
b.
Assess for compliance with therapy, diet, enteric parasites
and other possible anemia-causing conditions.
Refer to a physician for further evaluation.
CONSULTATION/REFERRAL
1.
Hemoglobin <9 g/dL or hematocrit <27%.
2.
If after 4 weeks the hemoglobin does not increase by 1 g/dL or
hematocrit by 3%, despite compliance with iron supplementation
regimen and the absence of acute illness.
3.
A patient with sickle cell anemia or hemoglobin variants.
4.
If there is evidence of other medical problems.
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REFERENCES
1.
2.
3.
4.
American Society of Health-System Pharmacists, American Hospital Formulary
Service, Bethesda, MD, 2007, pp. 1410-1417.
Constance Uphold and Virginia Graham, Clinical Guidelines in Family Practice, Fourth
Edition, Barmarre Books, Inc., Gainesville, FL, 2003. (Current)
Phyllis Leppert and Jeffery Peipert, Primary Care of Women, Second Edition,
Lippincott, Williams & Wilkins, Philadelphia, 2004. (Current)
Centers for Disease Control and Prevention, "Recommendations to Prevent and
Control Iron Deficiency in the United States," MMWR, Vol. 47, No. RR-3, April 3,
1998.
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NURSE PROTOCOL FOR
OSTEOPOROSIS IN WOMEN:
ASSESSMENT AND PREVENTION
DEFINITION
Osteoporosis means "porous bone.” This condition decreases the
amount of bone in the skeleton, causing the bones to become so weak
that the slightest injury can cause a fracture. Often there are no visible
symptoms or warning signs.
Osteoporosis can affect any bone in the body, but most commonly
involves the spine, wrist and hip. In the spine, individual vertebrae
fracture and collapse, causing the client to become shorter and stooped.
Chronic pain and the appearance of a "dowager's hump" are signals that
the spine is fracturing. Fractures of the wrist or arm can lead to
permanent loss of the use of the arm due to slow healing. Osteoporosis
is the most common cause of hip fracture, which can result in permanent
disability, loss of independence or death. One out of two women and one
in four men over age 50 will have osteoporosis-related fractures.
ETIOLOGY
1.
2.
3.
4.
SUBJECTIVE
1.
Peak bone mass may not be attained because of poor
calcium intake from childhood through the early 30s.
After the early 30s, a gradual loss of bone occurs naturally
with aging, though calcium in the diet will help minimize this. At
about age 35, people begin to lose bone at a rate of 1% to 2% per
year.
Bone loss increases significantly at menopause when the ovaries
stop producing estrogen, or at any time if the ovaries are
removed. In the first 3-5 years after the reduction of estrogen in a
woman's body, bone loss can increase as much as 3% to 10% per
year.
Osteoporosis is eight times more common in women than in men,
partly due to menopause, but also because women usually have
smaller bones and generally live longer. Women also typically
consume less calcium.
May have a known risk factor:
a.
b.
c.
d.
e.
f.
Sex—Women are twice as likely as men to fracture a
bone as a result of osteoporosis.
Age—Older women, especially age 65 and over.
Family history of fractures or osteoporosis.
Personal history of fractures as an adult.
Race—Caucasian and Asian women are at higher risk.
However, African American and Hispanic women are also
at significant risk.
Bone structure and body weight—Small-boned and thin
women have higher risk for osteoporosis.
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g.
h.
i.
j.
k.
OBJECTIVE
Menopause History—Early menopause brought about
naturally or surgically. Women who stop menstruating
because of conditions such as anorexia, bulimia or
excessive exercise are at increased risk.
Menstrual History—Women who stop menstruating
because of conditions such as anorexia, bulimia or
excessive exercise.
Lifestyle—Cigarette smoking, drinking excessive alcohol,
inadequate calcium, little or no weight-bearing exercise.
Medications—Some medications used to treat disorders
such as rheumatoid arthritis, endocrine disorders (e.g.,
hypothyroidism), seizure disorders and gastrointestinal
diseases are risks for osteoporosis. For example, long
term use of parenteral progesterone (medroxyprogesterone
acetate), GnRH (used to treat endometriosis), long term
heparin use, lithium, cholestyramine (used to treat high
cholesterol).
Chronic Diseases/Medical Conditions—AIDS, Cushing’s
syndrome, gastrectomy, hyperthyroidism, inflammatory
bowel disease, rheumatoid arthritis, eating disorders,
severe liver disease, insulin-dependent diabetes mellitus,
chronic obstructive pulmonary disease and cancer are risk
factors.
2.
May have history of chronic back pain.
3.
May have history of fracture of vertebrae, wrist, hip or other
bones.
1.
Note findings on evaluation of skin, thyroid, breast, lungs, weight,
height, abdomen, pelvis and extremities.
2.
May have small bones or thin and petite frame.
3.
Decrease in height.
ASSESSMENT
History, physical exam or age (>65 years old) indicates patient at risk for
osteoporosis AND/OR patient needs education and counseling to
prevent osteoporosis.
PLAN
Refer if indicated for further evaluation.
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THERAPEUTIC
NON-PHARMACOLOGIC
1.
Vitamin D, 400 international units daily (women over age
60, 800 international units daily as a supplement). Vitamin
D can also be obtained from fortified dairy products, egg
yolks, saltwater fish, liver and fortified cereals.
2.
If client does not consume milk and dairy products, or has a
milk allergy or is lactose intolerant:
Calcium supplement, 500 mg or less, 2-3 times a day,
between meals and at bedtime. (See the following Calcium
Recommendations.)
Tums can be taken (two twice a day) for calcium
supplementation, but should not be taken within two hours
prior to taking other medication(s).
Calcium Recommendations
AGE
DIETARY
REFERENCE
INTAKE
9-18 years
1300 mg
19-50 years
1000 mg
51 and older
1200 mg
Pregnant/Lactation
< 18 years
1300 mg
Pregnant/Lactation
> 18 years
1000 mg
NOTE: Certain drugs, such as tetracycline, corticosteroid
or aluminum-containing antacids interfere with calcium
absorption.
NON-PHARMACOLOGIC MEASURES
1.
Adequate dietary intake of calcium (e.g., broccoli, turnip
greens, milk, cheese, yogurt, fortified foods and juices).
See Calcium Recommendations.
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2.
Exercise for 30-60 minutes 3-5 days per week. Maximize
weight-bearing exercise during daily routines (walking,
carrying, moving, playing).
PATIENT EDUCATION/COUNSELING
1.
If in bone-building years (up to age 35), develop good habits:
a.
b.
c.
d.
e.
f.
g.
h.
2.
Get adequate calcium each day. See Calcium
Recommendations.
Get enough Vitamin D through sunshine (15 minutes a day)
and fortified foods, such as milk.
If worried about the fat and cholesterol content of dairy
products, low-fat milks, cheeses and yogurts are available
and are rich in calcium.
If lactose intolerant, or have problems digesting dairy
products, consider other foods that are high in calcium and
additives that provide the lactase enzyme so that dairy
foods can be digested. Some lactose-intolerant individuals
can tolerate up to one cup of milk a day. Consume smaller
servings and consume with meals. Choose naturally-aged
cheeses such as Swiss and cheddar; try yogurt with active
cultures.
Include weight-bearing exercises, such as walking,
aerobics, jogging.
Do not smoke.
Limit consumption of alcohol (i.e. no more than 2
drinks/day), limit caffeine (i.e. no more than 2-3 cups of
coffee/day or the equivalent), avoid excessive sodium,
phosphate and protein.
Emphasize importance of keeping immunizations current;
assess client’s immunization status and administer
vaccines indicated according to the current Advisory
Committee on Immunization Practices (ACIP) childhood or
adult immunization schedule. If client declines vaccination,
document refusal. See the Georgia Immunization Program
Manual “Recommended Schedule and Guidelines” for
current ACIP schedules and administration guidelines for
each vaccine. The Georgia Immunization Manual may be
accessed online at
http://www.health.state.ga.us/programs/immunization/publi
cations.asp.
If near or in menopause, take steps to slow the progress of
osteoporosis and prevent injury:
a.
Get at least 1000 mg of calcium a day.
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b.
c.
Get regular weight-bearing exercise 30-60 minutes 3-5
days per week, such as walking, dancing, hiking.
To reduce the chance of falling:
1)
Wear low-heeled shoes.
2)
Keep stairs free from loose rugs or objects.
3)
Place non-skid tape in the shower/bathtub.
4)
Keep floors uncluttered, free from wires and throwrugs.
5)
Install a night light in the bathroom.
6)
Turn on a light if you get up during the night.
7)
Limit alcohol consumption.
8)
Be aware of medication or medical conditions that
might impair coordination.
3.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
4.
If alcohol abuser, refer to local addiction program.
FOLLOW-UP
As indicated.
CONSULTATION/REFERRAL
1.
For nutrition counseling.
2.
For assessment and possible pharmacologic treatment of
osteoporosis.
The decision to test for bone mineral density should be based on
an individual’s risk profile, and testing is not indicated unless the
results could influence a treatment decision.
Recommendations by the National Osteoporosis Foundation for
bone mineral density screening in women include the following:
a.
b.
c.
All postmenopausal women under age 65 who have one or
more additional risk factors for osteoporosis (in addition to
being postmenopausal and female).
All women age 65 and over regardless of additional risk
factors.
Postmenopausal women who present with fractures (to
confirm diagnosis and determine disease severity).
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REFERENCES
1.
2.
3.
4.
5.
American Society of Health-Systems Pharmacists, American Hospital Formulary
Service, Bethesda, MD, 2007, pp. 2655-2663.
Robert Hatcher et al., Contraceptive Technology, Eighteenth Revised Edition, Arden
Media, Inc., New York, 2004. (Current)
Constance Uphold and Virginia Graham, Clinical Guidelines in Family Practice, Fourth
Edition, Barmare Books, inc., Gainesville, Fl., 2003. (Current)
National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of
Osteoporosis, Washington, DC, 2003. (Current)
Mayo Clinic, <http://www.mayoclinic.com/health/osteoporosis/DS00128,
February 28, 2007.
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NURSE PROTOCOL FOR
SEXUAL ABSTINENCE COUNSELING
DEFINITION
Sexual abstinence is defined as refraining from sexual activity. People of
all ages choose to abstain from sex, for a variety of reasons. Abstinence
is the most effective way to avoid both pregnancy and the spread of
sexually transmitted diseases (STDs). It is important for everyone,
including healthcare professionals, to accept abstinence as a normal and
common choice.
Sexual abstinence can be either primary or secondary. Primary
abstainers have never engaged in sexual activity with another person.
Secondary abstainers are sexually-experienced persons who have
currently chosen to avoid some or all sexual activity.
SUBJECTIVE
Client desires to be sexually abstinent. This may be for personal, family,
religious or medical reasons.
1.
Client may express feelings of not being physically, emotionally or
spiritually ready for sexual activity.
2.
Client may verbalize feelings of pressure from peers, community
and media to begin, or resume, sexual activity.
OBJECTIVE
Physical exam not required.
ASSESSMENT
Sexual abstinence is client’s current lifestyle choice.
PLAN
EDUCATION/COUNSELING
1.
Abstinence education guided by the 1997 General Assembly
House Resolution 457 gave guidelines for expenditure of funds
appropriated for teen pregnancy prevention.
2.
Discuss the following ways to achieve the goal of sexual
abstinence:
a.
b.
c.
Decide what to do about sex when feeling clear-headed,
sober and good about one's self.
Decide, in advance, what sexual activities to say “yes” to;
discuss this with partner and a supportive family member.
Tell a potential sex partner, very clearly in advance, not at
the last minute, what activities you will not do. If possible,
talk at a time when feeling close to each other, but not
sexual (e.g., taking a walk and holding hands).
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d.
Avoid high-pressure sexual situations. Stay sober and
drug-free and avoid being in an empty house or the back
seat of a car with someone who may try to pressure you.
e.
Say “no” clearly, and mean it! Practice the following:
Techniques
Simple “no”
Emphatic “no”
Repetitive “no”
Turn the tables
Examples
“No, thanks,” or “ No.”
“No. I don' t want to do that.”
“No. No. No.”
"You say that if I love you I would. But if
you really loved me, you wouldn’t insist.”
Give a reason
"I’m not ready.” “We can’t be too careful
in this age of AIDS.” “I have decided to
wait until marriage.”
Leave the scene Walk out of there.
Steer clear
If you suspect you will be pressured, do
not go with that person.
Safety in numbers Double date; keep trusted friends
nearby.
f.
g.
h.
i.
3.
Learn more about your body and how to keep it healthy.
Learn more about birth control and safe sex for when a
conscious decision is made about being ready to accept
the responsibility that sexual activity brings. Talk with a
parent or guardian, religious leader or other adult about this
important life decision.
Discuss sexual coercion.
Emphasize importance of keeping immunization’s current;
assess client’s immunization status and administer
vaccines indicated according to the current Advisory
Committee on Immunization Practices (ACIP) childhood or
adult immunization schedule. If client declines vaccination,
document refusal. See the Georgia Immunization Program
Manual, Recommended Schedule and Guidelines, for
current ACIP schedules and administration guidelines for
each vaccine. The Georgia Immunization Manual may be
accessed on line at
http://www.health.state.ga.us/programs/immunization/p
ublications.asp.
When appropriate, inform client of the current Georgia laws about
statutory rape:
a.
b.
Having sexual intercourse with any person under the age of
16 is considered statutory rape;
It does not matter if the person is a male or female;
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c.
4.
It does not matter if the sex is consensual.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
FOLLOW-UP
Invite client to come back for another discussion, as needed.
CONSULTATION/REFERRAL
1.
Talk with teenage clients about adolescent health, youth
development and/or other community programs that can support
sexual abstinence as a choice, provide a safe environment, and
can assist in building skills for remaining abstinent.
2.
For adults who have difficulty with abstinence issues, suggest that
they talk with a religious or other counseling professional who
deals with relationship issues.
REFERENCES
1.
2.
Robert Hatcher et al., Contraceptive Technology, Eighteenth Revised Edition, Ardent
Media, Inc., New York, 2004. (Current)
State of Georgia, Statutory Rape Law, O.C.G.A. § 16-6-3.
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NURSE PROTOCOL FOR LOCAL ESTROGEN
THERAPY FOR TREATMENT OF
VULVAR/VAGINAL ATROPHY
DEFINITION
Symptoms of urogenital atrophy are seen in almost half of untreated
menopausal women as well as in 10-25% of women receiving
conventional doses of systemic hormone therapy (HT). The vagina as
well as the urethra and trigone of the bladder are estrogen-dependent
tissues. When circulating estrogen levels drop because of transient or
permanent ovarian failure (including menopause) or because of antiestrogenic medications, these tissues atrophy.
SUBJECTIVE
Patient may complain of vaginal irritation, pruritis, vaginal dryness,
dyspareunia, dysuria, urge incontinence as well as hot flushes/flashes,
insomnia, and night sweats.
OBJECTIVE
Physical exam findings of urogenital atrophy including the following:
Pale, thin friable vaginal epithelium.
Loss of vaginal rugae and elasticity.
Sparse pubic hair.
Dryness of labial skin and loss of turgor.
Introital petechiae or fissure.
Erythematous urethral meatus.
Eversion of urethral mucosa, urethral caruncle.
ASSESSMENT
Vulvovaginal atrophy associated with menopause.
According to product package insert, no contraindications to using
vaginal estrogen.
NOTE: contraindications for vaginal estrogen products are the same as
for systemically administered estrogen.
PLAN
DIAGNOSTIC STUDIES
1.
Consider FSH and/or thyroid studies if menopause is in question.
2.
Wet prep, urine dip stick, STD tests as indicated to rule out
vaginitis and cystitis.
3.
Pap smear and mammogram according to Georgia Breast and
Cervical Cancer Screening Program guidelines.
4.
Fasting lipid profile and glucose.
5.
Additional screening tests for age as indicated.
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THERAPEUTIC
PHARMACOLOGIC
1.
For relief of atrophic vaginitis:
Premarin vaginal cream (or equivalent), 0.5 - 2 g daily
intravaginally for 3 weeks and one week off. Lower
doses may be effective. Medication should be
discontinued as promptly as possible.
a.
b.
c.
2.
Patient should use lowest dose possible to relieve
symptoms.
Treatment with vaginal cream longer than 6-12
months requires ultrasonic monitoring of endometrial
thickness with biopsy when indicated as estrogen
cream is absorbed systemically.
Latex condom, diaphragm and cervical cap may be
weakened by vaginal cream.
For ASCUS Pap smear with evidence of atrophy:
Premarin vaginal cream (or equivalent), 0.5 - 2 g daily
intravaginally for 3 weeks. Lower doses may be
effective. Medication should be discontinued as
promptly as possible.
PATIENT EDUCATION/COUNSELING
1.
Counsel patient according to seven basic elements of informed
consent (BRAIDED – Benefits Risks Alternatives Inquiries
Decision Explanation Documentation).
2.
Vaginal estrogen cream provides the quickest response and
subsequent relief of symptoms of atrophic vaginitis.
3.
Vaginal moisturizers such as Replens, applied on a regular basis,
have been shown to be beneficial for local vaginal symptoms.
4.
Vaginal estrogen cream may weaken latex condoms, diaphragms
and cervical caps, therefore reducing their effectiveness.
5.
Regular sexual activity has been shown to help maintain vaginal
health.
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6.
Counsel on good health practices, including: diet, intake of
calcium and vitamin D, weight-bearing exercises and increase in
physical activity, breast and cervical cancer screening, safer sex
and STD/HIV risk reduction and testing.
7.
If smoker or tobacco user, refer to local cessation program and/or
Georgia Tobacco Quit Line, 1-877-270-STOP (7867).
FOLLOW UP
1.
As needed for specific problems.
2.
Evaluate response to therapy in 3 months or sooner.
3.
Annual physical exam, Pap smears and mammograms according
to Breast and Cervical Cancer Program guidelines.
REFERRAL/CONSULTATION
1.
For any questions regarding management.
2.
For ultrasound of endometrium and biopsy and if indicated if
treatment with vaginal cream is longer than 6-12 months.
3.
Emphasize importance of keeping immunizations current; assess
client’s immunization status and administer vaccines indicated
according to the current Advisory Committee on Immunization
Practices (ACIP) childhood or adult immunization schedule. If
client declines vaccination, document refusal. See the Georgia
Immunization Program Manual, Recommended Schedule and
Guidelines, for current ACIP schedules and administration
guidelines for each vaccine. The Georgia Immunization Manual
may be accessed online at
http://www.health.state.ga.us/programs/immunization/publications.
asp.
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REFERENCES
1.
2.
3.
4.
5.
6.
American Society of a Health System Pharmacists, American Hospital Formulary
Service, Bethesda, MD, 2007, pp. 3103-3107.
Robert Hatcher, et al., Contraceptive Technology, Eighteenth Edition, Ardent Media,
Inc., New York, 2004. (Current)
Joellen Hawkins et al., Protocols for Nurse Practitioners in Gynecologic Settings.
Eighth Edition, Springer Publishing Co., New York, 2004. (Current)
Leon Speroff and Marc Fritz, Clinical Gynecologic Endocrinology and Infertility,
Seventh Edition, Lippincott, Williams & Wilkins, Philadelphia, 2005.
Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health,
Inc., 2007 <http://online.factsandcomparisons.com>.
Premarin Vaginal Cream, Physician Prescribing Information, Wyeth
Pharmaceuticals, Inc., July 2006.
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