N215 Review Notes

1. G (gravidity) and P (parity)

a. G = # of pregnancies
b. P = outcome of pregnancies
i. TPAL
1. T = term
2. P = preterm
3. A = abortions
4. L = # of live children
2. Hormones
a. Estrogen
i. Menstrual cycle
1. Secondary sex characteristics
2. First half of the cycle before progesterone
ii. Contraception
1. Alters the balance between estrogen and progesterone; part of a
negative feedback system
2. Is not used as a monotherapy in contraception due to increased
coagulability, headaches, and hyperplasia of the uterine
endometrium
iii. Pregnancy
1. Causes breast enlargement, increased vascularity of the uterus,
and causes heavy periods
2. Causes cardiovascular changes, increased LDL and lowered HDL,
and hypercoagulative state
b. Progesterone
i. Menstrual cycle
1. Second half of the cycle
2. Causes PMS symptoms
ii. Contraception
1. Alters the balance between estrogen and progesterone; part of a
negative feedback system
2. Can be used as a monotherapy (Depo-Provera)
3. Can cause weight gain and depression
4. Mirena and Implanon are both progesterone-only
iii. Pregnancy
1. “Hormone of pregnancy”
2. Causes smooth muscle relaxation  gastrointestinal side effect is
constipation
iv. Menopause
1. First hormone to alter/decrease and signal menopause  heavy
periods due to unimpeded estrogen
c. HCG: human chorionic gonadotropin
 i. Pregnancy
1. Rises during pregnancy (doubles in amount every day and peaks
at day #70, or 10 weeks)
2. Nursing intervention in regard to HCG-induced nausea/vomiting:
separate fluids and liquids, eat potato chips (salty) and lemonade
(to increase consumption of fluids), try to avoid an empty
stomach
d. Others: melanin, prolactin
3. The most effective form of contraception is a vasectomy, because you can assess for
effectiveness
4. Combined estrogen-progesterone contraceptives are contraindicated in those that
smoke due to already-heightened risk of CV events d/t hypercoagulative state
a. Or offer mechanical forms of contraception, such as condoms
5. 59-year-old woman would receive the following tests in a follow-up visit
a. Mammogram every year (every 2 years after 40, every year after 50 until age 75)
b. Pap smear
c. Colonoscopy (begins at age 50 and then every 10 years if normal/no risk)
d. Lipid panel (LDLs increase and HDLs decrease in menopause)
e. Screening for STDs
f. Condoms for protection
6. DEXA scanning begins at age 65 unless hx of fractures
7. The goal of PNC (pre-natal care) is to improve maternal/newborn outcomes
a. An initial visit includes a history and physical of the client, including an extensive
array of blood tests and cultures, teaching of the warning signs in pregnancy,
education in nutrition
b. Genetic counseling can be offered before pregnancy or in early pregnancy
c. 10-11 weeks
i. Sequential genetic screening
ii. Ultrasound for nuchal translucency (Down syndrome)
iii. Lab work
d. 15-18 weeks
i. Offer genetic screening again: screening for Down syndrome, trisomy,
neural tube defects (blood work)
e. 18-20 weeks
i. Anatomy scan since the fetus is large enough to display (abnormal)
anatomical markers
f. 26-28 weeks
i. 1-hr glucose tolerance test (GTT) to screen for gestational diabetes; if
screen is positive (glucose >135), then a 3-hr GTT is performed (this is a
diagnostic test)
g. 36 weeks’ gestation
i. Vaginal culture for Group Beta Strep (GBS); if positive, then the patient
will receive antibiotics (penicillin, or if allergy to penicillins, clindamycin,
vancomycin) during labor to prevent transmission to baby
8. Labor
a. First stage
i. Cervix completely closed  cervix dilated to 10cm and starting to push
1. Early: 0-3cm
2. Active: contractions are closer together, last longer, stronger 
patients usually come to hospital
3. Transition: 7-8cm  ready to push; most intense (“yo no puedo”);
short period
b. Second stage
i. Delivery of baby
1. In a first-time mother, labor will last 14-16 hours
2. In a second-time mother +, labor will last half-as-long
c. Third stage
i. Delivery of placenta
1. Signal is lengthening of umbilical cord and gush of blood
9. Treatment for hot flashes in menopause
a. Drink large amounts of cold liquids
b. Dress in layers
c. Avoid triggers (food/alcohol)
10. Weight gain during childbearing can be up to 20 pounds
11. During menopause, weight gain can accumulate around abdomen, and central/visceral
fat accumulation can cause increased risk of stroke/CV event
12. Electronic fetal monitoring (EFM)
a. VEAL CHOP acronym
i. V: variable decelerations  C: cord compression
ii. E: early decelerations  H: head compression
iii. A: accelerations  O: oxygenation
iv. L: late decelerations  P: placental insufficiency
b. Variability in fetal heart tone
i. Normal finding
1. Absent
2. Minimal (0-5 beat variability from baseline)
3. Moderate (6-25 beat variability from baseline)
4. Marked (>25 beat variability from baseline)
c. Category I: variability, no decelerations
d. Category III: late decelerations or bradycardia
e. Early decels signify head compression d/t uterine contraction
f. Late decelerations resolve after resolution of UC and may signify uteroplacental
insufficiency
13. Risk for intimate partner violence and homicide during pregnancy
a. Poverty
b. Adolescence
c. Transgendered
14. Most effective form of pain control during labor is hydrotherapy or epidural
 15. Epidural can cause hypotension and fever
16. Supplements that should be offered include vitamin D (1200 units) and calcium (800
units)
17. GP TPAL
a. Gravidity (# of pregnancies), Parity (outcomes of pregnancy)
b. T (term), P (pre-term), A (abortions), L (living children)
18. The patch and the pill are combined estrogen-progesterone forms of contraception
a. Contraindicated in patients that smoke d/t increased coagulability
19. The Mirena, Nuva-ring, and Depo-Provera are all progesterone-only
20. A form of contraception that leads to family spacing would be the LAM (lactation
amenorrhea method)
a. If you breastfeed exclusively and stimulate lactation every 2 hours, you will not
ovulate (and thus prevent pregnancy) during the 5-6 months postpartum and
this can serve as a form of contraception
b. Though, this will only last 6 months, so 9 months of pregnancy + 6 months of
LAM = 15 months of contraception only
21. Estrogen in puberty (initiates development of secondary sexual characteristics, including
growth of breast tissue, fat over pubis, body hair) is the same thing that causes the
reduction of secondary sexual characteristics in menopause
22. Variability is the single best indicator of fetal well-being
23. Category I strip shows good variability and no decelerations
24. Category III strip shows repeated decelerations, and decreased variability in fetal heart
tones  C-section implicated
25. Category II is some decelerations but not repeated
26. Sinusoidal waves indicate something is neurologically abnormal
27. A flat line = no variability, or prolonged bradycardia (under 110 bpm)
a. Interventions: turn off Pitocin to prevent stress aggravation, IV fluid bolus so that
oxygen-carrying HGB in RBCs can reach fetus faster, change mother’s position,
provide oxygen
28. If a client is mildly anemic at 9.4 HGB, then you can advise the patient to incorporate red
meat, green leafy vegetables, and molasses into their diet

Menopause and health promotion

1. Menopause is a retrospective diagnosiswhen there are no menses for at least one year
2. Average range for menopause is 46-52 +/- 5 years (the 5 years bordering 46-52
constitutes peri-menopause)
3. Ages 48+ is when women contribute most to society
4. Menopause: cessation of menses
a. Perimenopause: “transition from normal ovulation to anovulation to loss of
ovarian function
b. Lasts 5-7 years (46-52)
c. Pre-menopause and post-menopause are the 5 years pre/post
5. By 2020 there will be 60 million women who will be post-menopausal
6. Life expectancy for women is 84.5 years
7. Average age of menopause is 52.3 years
8. Anovulation leads to decreased progesterone production
a. Bleeding problems due to uninhibited estrogenic effects
9. FSH levels >30-40 mIU/mL = menopause (FSH increases in response to body becoming
unresponsive and not maturing follicle)
10. Physiology of menopause
a. Atresia of ovarian follicles
b. FSH increases – 30 mIU/mL is diagnostic
c. Androstendione converts to estrone
d. Progresterone levels decline
e. Testosterone levels decline
11. Aromatase inhibitors inhibit the process of converting testosterone to estrogen
12. Ovarian unresponsiveness to gonadotropins leads to
a. Decreased estrogen
b. Reversion of secondary sex characteristics to pre-pubescent state (breasts, vulva,
bladder)
c. Adverse alteration of serum lipids (LDL increases and HDL decreases)
13. Effects of decreasing estrogen
a. Hot flashes, night sweats, “crawly skin”
b. Sleep disturbances
c. Mood swings, irritability, anxiety
d. Cognitive difficulties
e. Joint aches
f. Perimenstrual headaches
g. Palpitations
h. Loss of libido
14. Menstrual cycle changes
a. Irregular menses
i. Too close or skipped periods
ii. Heavier flow
iii. Prolonged menses
iv. Intermenstrual spotting
v. Pelvic pain is NOT a perimenstrual symptom!!!
b. Decrease in testosterone
i. Decreased libido
ii. Decreased sexual fantasies
iii. Decreased masturbation
iv. Decreased muscle mass
c. Hot flashes
i. Vasomotor instability  dilation of vessels is what happens when you
feel hot
d. Pharmacological treatment for menopause
 i. HRT: progesterone and estrogen lead to increased risk of breast cancer
and heart disease
ii. ERT: estrogen alone but increases risk of uterine hyperplasia
iii. The benefits do not outweigh the risks for MHT
e. Laboratory and screening tests
i. Pap smear
ii. Mammogram (every 2 years after age 40 and 1 year after age 50 until age
75; if 1st degree relative had breast cancer then 35+)
iii. TSH: thyroid function panel done if patient feeling fatigued)
iv. DEXA scans are performed at ages 65+
v. Menopause can be diagnosed with symptoms alone
f. Indications for HRT
i. Osteoporosis prevention and treatment
ii. Urogenital atrophy
iii. Vasomotor symptoms
iv. Menopausal with amenorrhea of 3-6 months
v. Post-oophorectomy
vi. Menorrhagia (abnormally heavy menses)
vii. Menopausal symptoms, even if FSH < 30
g. Contraindications for HRT
i. Endometrial cancer
ii. Estrogen-dependent tumor
iii. Unexplained vaginal bleeding
iv. Recent MI
v. Recent thromboembolic event
vi. Stroke
vii. Pancreatic disease
viii. Active gall bladder disease
h. Relative contraindications for HRT
i. Hypertension
ii. Atypical breast lesions
iii. Diabetes mellitus
iv. History of gall bladder disease
v. Migraine headache
vi. Endometriosis
vii. Smoking
viii. Fibrocystic breast diagnosis
ix. Obesity
x. Seizure disorder
xi. History of DVT or PE
i. Combination estrogen+progesterone HRT
i. Patch with estradiol/norethindrone transdermal system
ii. Progesterone IUD and estrogen
iii. Premphase
 iv. Prempro
v. Estratest (estrogen + testosterone for strength/muscle and libido)
vi. Conjugated estrogen and progesterone cream
j. HRT improves collagen content and thickness
k. Urogenital: improves incontinence
l. Improve sleep and reduce hot flashes
m. Prevents osteoporosis
n. There are options for women with menopausal symptoms
o. Women’s health initiative study
i. 27,000 women studied
ii. mean age of 63.2 years
iii. Found that HRT increased incidence of breast cancer and non-fatal MI
and CHD and concluded that the benefits of HRT did not outweigh the
risk
15. Complementary and alternative medicine for menopause
a. Black cohosh (Remifemin) treats hot flashes and other menopausal symptoms
b. Soy (phytoestrogen), evening primrose oil (stimulates prostaglandins), weight-
bearing exercise, yoga, nutrition, counseling, group therapy, SSRIs
16. Anticipatory guidance/managing vasomotor symptoms
a. Enhance relaxation with meditation, yoga, massage, or leisurely lukewarm bath
b. Get regular exercise to promote better, more restorative sleep
c. Keep cool by dressing in layers, using a fan and sleeping in a cool room
d. Maintain a healthy body weight
e. Don’t smoke
f. When a hot flash starts, try using paced respiration (deep, slow, abdominal
breathing)
g. Avoid perceived personal hot flash triggers (e.g., hot drinks, caffeine, spicy foods,
alcohol) although studies have shown large numbers of women do not support
an association
h. Consider HT or non-estrogen prescription drugs for moderate-to-severe hot
flashes
17. Treatment: lifestyle/sexual
a. Zestra cream (vasodilation to areas of body to increase libido; vulva)
b. Estratest
c. Estriol vaginal cream
d. KY lubricants
e. New partner
f. Increase water intake, cool showers, decrease alcohol intake
18. 40s is highest rate of unwanted pregnancy; only 10% of women fertile after 40
19. Male/female libidos both decline with increasing age; more precipitous in men
20. Gender non-conformity with menopause and age
a. Both MTF and FTM may involve large doses of hormone for transition
b. May lead to increased incidence of reproductive cancers in a population with
decreased access
 c. Very little research exists
d. Smoking cessation
e. Mental health/depression screening and support
21. Research (Cochrane data): sexual problems are frequent among older adults but these
problems are infrequently discussed with providers. Many have not discussed sex with
an NP, nurse, or physician since age 50
22. Barriers to research on sex and aging
a. Most published research on sexual activity is biased by a focus on partnered
activity, yet there are an increasing number of women who live alone
b. Although partner loss is associated with cessation of sexual behavior for many, it
leads to masturbation for others (masturbation and sexual dreams may be more
accurate measure of sexual activity/libido)
23. Leading cause of death in women in the world is heart disease/stroke (not cancer)
24. In U.S. it is heart disease, then cancer
25. Physical changes related to aging
a. Decreased thirst mechanism
b. Teeth loosen and gums recede
c. Decreased sense of taste with decreased salivary secretions
d. Less able to regulate temperature – increased risk for hypothermia
e. Hearing loss (high pitched sounds first) starting in 50s
f. Decrease in lung mass, increased stiffness of chest wall
g. Barrel chest
h. Less effective cough
i. Kyphosis due to vertebral collapse related to osteoporosis
j. Loss of brain volume and cortical cells
k. Memory loss (sleep, exercise, and meditation can allay the severity of this)
l. Slower data processing and retrieval
m. Slower motor response
n. Increased incidence of depression/dementia
o. Increased susceptibility to delirium
i. More commonly seen with infection in older individual
p. Increased incidence of benign tumor
q. Diminished position sense
r. Loss of ankle reflexes
26. Recommended health screening intervals for women over age 65
a. Annual physical exam
b. Annual blood pressure screening
i. HTN in elderly is >140/90
ii. Need 2 consecutive readings to dx HTN
c. Colonoscopy every 10 years from age 50 until age 75
i. African Americans should begin at 45
ii. Hemetest in place of colonoscopy is less invasive
iii. Recommended to avoid colonoscopy ages 76-85
d. Eye exam every 2 years
e. Mammogram every 2 years after age 40 and every year after age 50 until age 75
(little benefit after age 70 according to research)
f. Clinical breast exam: every 2 years until age 74
g. Cervical cancer screening (PAP smear) not recommended after 65 if previous
screens have been negative
h. Bone density DEXA for osteoporosis 65+ and FU based on initial test results
i. Dental exam every year
j. Hearing test yearly
k. Cholesterol check every 3 years (TC <180 and LDL-C <160)
i. Patients with DM or atherosclerotic CVD will have different parameters
for tx
ii. If elevated, then check at least annually
l. Driving safety: no current clear recommendations
i. At age 70, higher risk of being in a collision for every mile driven
ii. Significant increase in collision related to fatality after age 85
iii. Assess related to vision, strength, medications, and cognitive functioning
iv. Recommended screening with no specific interval
1. Falls risk
2. Frailty
3. Dementia
4. Depression
m. Case study: screening and health promotion
i. A 72 y.o. female presents to clinic for evaluation of tx for hx of hormone
therapy s/p 12 years. Been a pack-a-day smoker for 45 years and doesn’t
drink alcohol. 20 years postmenopausal and was last screened for STI in
1989
1. Needs DEXA bone scan, lipid profile, STI screening, mammogram
q1yr until 75, Sx evaluation d/t estrogenic effects s/p 12 years,
colonoscopy, smoking cessation, 1200/800 vitamin D/calcium
supplements, depression/cog screening, eye exam