Conducting a focused assessment of the female genitourinary system needs to include several different factors. It is important to ask about the onset, location, duration, characteristics, alleviating and aggravating factors as with any other assessment. This can be used to determine the source of pain and the type of issues that the patient is experiencing. The patient should also give a full history. In this history, try to gather as much information as you can about the sexual history of the patient, as this can indicate the likelihood of sexually transmitted diseases, as in this patient.
Clients who do not use barrier method contraception and have multiple sexual partners are more likely to be diagnosed with sexually transmitted diseases (Nelson & Williams, 2013). The assessment should also include a physical assessment of the vulva area to determine the type of discharge present (if present) and any swelling or lesions around the area (Hammerschlag & Kohlhoff, 2012). The discharge can be tested to make an assessment of which microorganism is causing the symptoms.
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"Focused Assessment of the Female Genitourinary System".
There are some other factors that need to be discussed in terms of this chlamydia diagnosis. The first is whether the patient is pregnant, as this can change the type of treatment that is prescribed (Hammerschlag & Kohlhoff, 2012). In this case, the patient tests negative for pregnancy, which means that standard antibiotics can be used, such as arythromycin (Workowski & Bolan, 2015). The patient should also be given patient education, which will be discussed below. The previous sexual partners of the patient also need to be informed, as they may also have chlamydia and need to receive treatment to prevent passing on the disease to other people, or back to the patient herself (Workowski & Bolan, 2015). It is noted that the patient used to be in an abusive relationship.
This also needs to be addressed, and therapy can be recommended to the patient if she wants to work through any issues associated with this history of abuse. The patient notes that she is on birth control, but should be informed that this does not prevent sexually transmitted diseases and that she is putting herself at risk for long-term illnesses such as herpes or HIV infection (Workowski & Bolan, 2015). These findings and recommendations should be documented in the medical record in detail, including sexual history, as this can help in the case of further issues or complications like pelvic inflammatory disease.
The main nursing diagnosis for the client is chlamydia. A test should also be considered for other sexually transmitted infections, as gonorrhea is a common co-infection for chlamydia (Nelson & Williams, 2013). Other nursing interventions include promoting regular testing, getting partners tested on a full STD panel, and education about how STDs are caught and the potential long-term effects of not getting treatment. Education is very important as a nursing intervention in the case of STDs, as it can help prevent their spread through the population. The patient needs to be aware that using condoms is important outside of monogamous relationships, and that regular testing is recommended for those who do not use condoms (Nelson & Williams, 2013). She should also be advised about other contraception methods and their benefits and negatives if she is not looking to get pregnant (Nelson & Williams, 2013).
The teaching strategy should be open-minded about different approaches to sexual health and refrain from judgment. The success of the educational intervention can be monitored through assessing how often the patient comes in for a STD panel and whether she informs the nurse about increased condom usage in her sexual activity (Nelson & Williams, 2013).
