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Nursing Care Plan

ASSOCIATE NURSING PROGRAM

Student Name: Instructor:

Date: Clinical Site:

Patient Information
Initial: Sex: M / F Age: 52 Ethnic Group: White / AA / Hispanic / Asian
Date of Admission: 12/20/2013 Allergy: NA Weigh: Diet: Regular
Admitting Diagnoses:
Axis I: Sexual Dysfunction (Dyspareunia)/Depression
Axis II
Axis III
Axis IV Marital Distress
Axis V: GAF 70
Patient Past Medical History: Frequent episode of tonsillitis in childhood 6 x per year. Chicken pox (1972). Immunization is up date (chicken
pox, PPD, TB, hepatitis B, flu). No hereditary disease. GTPAL: 2-2-0-0-2, PAP smears and mammography is update. No menstrual period since 12
month ago.
Past Surgical History: Tonsillectomy (1957),

Social History: Hispanic, catholic, bilingual speaker, marriage, Preferred insurance, work as customer service, has two kids but dont live with her,
no tobacco, drug, and ETHO use, active life.
History of present illness: White, female, Hispanic patient comes to medical office, she refers to be depressed for some weeks ago, she is in
postmenopausal stage, she says she feels hot flashes in her face, insomnia, dryness and itching in her genitals that produce discomfort, she also refers
that she does not feel desire to do sexual intercourse because it produces genital pain 3 in the scale of 0-10, no relieve. She refers discomfort during
and after intercourse which makes sex unpleasant due to decreased vaginal lubrication, she does not find an adequate position for it and refers having
a phobia of vaginal penetration. Because she is not able to go through sexual intercourse, marital problems have increased.

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Subjective Findings
(If additional Space is needed please continue on the back of this page)
-Hot flashes
-Insomnia
-Dryness and itching in her genitals
-Does not feel desire to do sexual intercourse
-Genital pain 3 in scale of 0-10
-Sex unpleasant
-Decrease vaginal lubrication
Objective Finding
Vital Sign: BP: 120/90 HR: 78 RR: 18 Temp:98.0

Physical Assessment Findings: Psychological assessment: Patient oriented 3x times. H: Good hair distribution no alopecia, no scalp, normal
facial bone. E: normal movement, pupil equal, round, reactive to light and normal accommodation, no discharge. N: wet mucous, normal nostril, no
deviation. Mouth: wet and pink mucous, tonsil absent, present gag reflex. E: symmetric, no discharged. Neck: carotid pulse symmetric and normal
rhythm, no jugular vein distention, no thyroid palpable mass, no regional nodes. Spine normal curvature, kidney no tenderness, normal thoracic
expansion and breath sound to inspiration and expiration, anterior chest wall good coloration and temperature, Normal heart sound, both breast
normal in size and shape no changes in the skin of the breast and nipples, no tenderness to palpation, no lumps, Abdomen: no bruit over aorta, ileac,
mesenteric or femoral, bowel sound active 4-Q, on the abdominal examination any masses were detected or suprapubic tenderness. Upper extremities
radial and brachial pulse symmetric normal flexion and extension. Lower extremities good hair distribution no edema, temperature bilateral and
normal in both extremities, pulse (dorsalis pedis, posterior tibialis and popliteal) normal, ambulation is normal. Skin good coloration and moist,
genital examination dryness is observed and slightly inflammation, the insertion with speculum was painful in the vagina, infection or yeast are not
evidenced.

Laboratory Studies:
CBC Metabolic Panel Other: (U/A, ABGs, Protombin, etc)
Hb: 14 g/dL LDL: 120 mg/dL FSH: 290Units/mL
RBC: 4.2 x 10/microL HDL: 80 mg/dL Estradiol: 25 pg/mL
WBC: 5000/mm3 Total Cholesterol: 170 mg/dL T 4 & TSH: 2.0ng/dL & 3 micro units/L

U/A: Normal

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Imaging Result: (X-Ray, CT scan, MRI, MRCP, ultrasound.)

X-ray (DEXA) Bone Density
T-score: -2.1- Indicate osteopenia, this means there has been some bone density loss but not enough to be called osteoporosis, even though the bones
are thinner and risk of fracture with minimal trauma is very low.

References: Foundation of Psychiatric Mental Health Nursing: clinical approach.6th ed. / (edited by) Elizabeth M. Varcariolis, Margaret J. Halter
Endoscopic Result: (colonoscopy, EGD..)
Laparoscopic: Do not reveled endometriosis or adherences.

What is the relation between these diagnostic tests with the Patients Disease and or present illness?
Patient comes to the medical office with complaint in painful intercourse (Dyspareunia) in postmenopausal stage, depression, insomnia, dryness in
her genitals, decreased libido, the doctor prescribed several tests where the FSH increased its level and the HDL decreased, these are signs of
postmenopausal stage that support the symptoms of this patient, X- Ray (DEXA) also was prescribed and it showed signs of osteopenia linking with
these signs and symptoms. The laparoscopy do not evidenced endometriosis. U/A do not evidenced infection.

References: Foundation of Psychiatric Mental Health Nursing: clinical approach.6th ed. / (edited by) Elizabeth M. Varcariolis, Margaret J. Halter

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Analysis:
What are the potential Complications / Problems for this patient?
Several potential complications women could experiment in the postmenopausal stage such as painful intercourse due to decreased lubrication
because the estrogen level will decline, and emotional factors could develop in the patient if she suffers divorce from her partner due to her sexual
dysfunction, the risk of cardiovascular disease increases, the bones become brittle and weak leading to an increase risk of fractures, the vagina and
urethra lose their elasticity, the patient could experience a frequent sudden, strong urge to urinate, followed by an involuntary loss of urine, or the loss
of urine with coughing, laughing or lifting. Also decreased sensation that may reduce the desire of sexual activity (libido) and some women gain
weight during this stage.

References: Foundation of Psychiatric Mental Health Nursing: clinical approach.6th ed. / (edited by) Elizabeth M. Varcariolis, Margaret J. Halter

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Medication List

Medication/Order Usage Usual Dose Side effects Nursing Intervention

Premarin 0.45 mg/PO
Osphena 60 mg/PO
Conjugated Estrogen 0.5
mg/Vaginal cream
Estrogen-vaginal 1.25 mg q.d
dryness/burning/itching
Estrogen- agonist-
antagonist/Dyspareunia
Estrogen/Dryness around
vagina
Nausea, vomiting, bloating,
breast tenderness,
headache, or weight
changes may occur
q.d Hot flashes, vaginal
discharge, muscle spasm,
increased sweating
q.d Nausea, vomiting, bloating,
breast tenderness,
headache, or weight
changes may occur
Asses for allergic reaction,
chest pain or heavy feeling,
sudden numbness or
weakness.
Asses risk for stroke and DVT
Asses for mental/mood
changes such as: depression
and memory loss, breast
lump or unusual vaginal
bleeding

References: Foundation of
Psychiatric Mental Health
Nursing: clinical approach.
6th ed. / (edited by)
Elizabeth M. Varcariolis,
Margaret J. Halter
www.webmd.com/.../drug.

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Nursing Care Plan

Once evaluated patients past and present history, select at least three nursing diagnoses from highest to lowest priority. Give nursing interventions
(dependent/independent/collaborative) for each nursing diagnoses with rational for each intervention. Determine a short and long term goal for each nursing diagnoses.

Nursing Diagnoses Desired Outcome Nursing Interventions / Rationales

(..related to..secondary to .evidenced
by..)
Anxiety related to sexual dysfunction
evidenced by painful intercourse.
Short Term: In 2 weeks after Intervention: Teach the patient the importance of using the medication
the treatment the patient will prescribed orally and topically.
begin to experiment relief in Rational: The Estrogen therapy is used in postmenopausal women to relieve
her genitals. the dryness in their vagina and facilitate intercourse.

Long Term: After 4 weeks of Intervention: Inform the patient of the side effects of estrogen therapy.
receiving the treatment the Rational: Breast enlargement, breast tenderness and hot flashes can occur.
patient will experience
moisture in her genitals

References: Foundation of Psychiatric Mental Health Nursing: clinical

approach.6th ed. / (edited by) Elizabeth M. Varcariolis, Margaret J. Halter
Nursing Diagnoses Desired Outcome Nursing Interventions / Rationales
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(..related to..secondary to .evidenced
by..)
Ineffective sexuality pattern related to
sexual performance evidenced by
decreased sexual desire.
Nursing Diagnoses
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Short Term: In the first days
after treatment, the patient
will understand the necessity
of attending sexual
counseling.
Long Term: After 2 weeks
the patient will have gone to
the first appointment of
counseling.
Desired Outcome
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Intervention: Include the spouse/sexual partner in the counseling as much as
possible.
Rational: Sexual partner counseling with ineffective sexuality is required,
because it helps maintain a strong and intimate relationship.
Intervention: Promote Kegel exercises to the patient for tenseness and
relaxation of the vagina.
Rational: This technique helps enhance sexual performance.
References: Foundation of Psychiatric Mental Health Nursing: clinical
approach.6th ed. / (edited by) Elizabeth M. Varcariolis, Margaret J. Halter
Nursing Interventions / Rationales

(..related to..secondary to .evidenced
by..)
Fear related to osteopenia evidenced Short Term: In 24 hours after
by loss of estrogen. the instruction of osteopenia,
the patient will understand
the importance of calcium
intake.
Long Term: In 1 week the
patient will know to choose
products rich in calcium.
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Intervention: Teach the patient to include products in her diet rich in
calcium (milk, green vegetables) and vitamin D (egg, salmon).
Rational: Calcium supplement is the most critical mineral for bone mass,
combining it with vitamin D helps the body absorbs calcium and other
minerals.
Intervention: Promote exercise regimen.
Rational: Exercise treatment for osteopenia can prevent fractures and it can
stop and reserve her bone loss.
References: Foundation of Psychiatric Mental Health Nursing: clinical
approach.6th ed. / (edited by) Elizabeth M. Varcariolis, Margaret J. Halter
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Patients Care Plan Evaluation of Outcomes:

There are some emotional factors that could be contributing to the experience of painful intercourse. Depression, stress, anxiety, body image
problems, intimacy problems and past sexual abuse can all potentially play a role in the cause of dyspareunia, but in this case the patients cause of
dyspareunia is evidenced by loss of estrogen in postmenopausal stage, fortunately the patient and her partner will go see a professional counselor to
improve their intimacy without stress or phobias, also estrogen maintenance or replacement will help the patient enhance the desire, lubrication and
the reminder of the sexual response cycle and diminishes or prevents dyspareunia as well.

References: Foundation of Psychiatric Mental Health Nursing: clinical approach.6th ed. / (edited by) Elizabeth M. Varcariolis, Margaret J. Halter
www.mayoclinic.com/health/painful-intercourse

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Student Evaluation
(To be completed by faculty only)

Comments:

Student Needs to Improve on:

FINAL GRADE: _____________________ Instructors Signature: _____________________________

Date of evaluation: _________________ Students Signature: _______________________________

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