Assessment
of the
Reproductive
System
• The nurse is often the first health
care professional to assess the
client with a reproductive system
disorder. Basic assessment of the
reproductive system should be
part of every complete physical
examination.
Assessment techniques
• History
• The nurse uses data about client’s age,
sex, and culture to assess the risk for
certain diseases. The nurse considers the
client’s age in evaluating the reproductive
system.
• Personal history( the nurse assesses he
client’s health habits, such as diet, sleep,
and exercise patterns.)
• Family history helps to determine the
client’s risk for conditions that affects
reproductive system functioning.
• Diet history is often critical for the correct
interpretation of presenting symptoms of
the reproductive system.
• Social history of the client provides insight
into the whole person, including stressors,
job history, education.
Menstrual History
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Age at menarche
Interval, regularity, duration and amount of flow
Date of most recent menstrual period
Was most recent menstrual period normal?
Dysmenorrhea
Premenstrual symptoms (e.g., swelling, headache, mood
swings, pain)
Abnormal uterine bleeding
Symptoms of menopause
Age at menopause
Postmenopausal bleeding
Obstetric History
• Number of
pregnancies, live
deliveries, stillbirths,
abortions
• Difficulties with
pregnancies,
deliveries
• Birth weight of babies
• Problems with
infertility
Use of Contraception
• Type used (past and
present)
• Difficulties with
method, suitability
• If discontinued,
reasons for doing so
Sexual History
• Sexual orientation
• Regularity of
intercourse
• Number of partners in
the past 12 months
• Associated symptoms
(e.g., pain, postcoital
bleeding)
• Sexual dysfunction
Current health problem
• If a client seeks medical attention
for a problem related to the
reproductive system, the nurse
asks additional questions to
explore the chief complaint.
1. Onset (sudden or gradual)
2. Chronology
3. Current situation (improving or deteriorating)
4. Location
5. Radiation
6. Quality
7. Timing (frequency, duration)
8. Severity
9. Precipitating and aggravating factors
10.Relieving factors
11.Associated symptoms
12.Effects on daily activities
13.Previous diagnosis of similar episodes
14.Previous treatments
15.Efficacy of previous treatments
Most complaints
concern
• pain,
• discharge,
masses,
•and reproductive
functioning
Pain
• Onset, location, radiation, character,
severity
• Relation to menstruation
• Aggravating and relieving factors
• Use of analgesics and their effect
• Associated gastrointestinal, urinary or
vaginal symptoms
• Are symptoms related to an encounter with
a new sexual partner?
• The nurse should not assume that the
initial medical diagnosis is conclusive
Vaginal Discharge
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The nurse asks about:
Onset, color, odor, consistency, quantity
Relation to menstrual period
Associated symptoms (e.g., rectal or urethral
discharge, vaginal itch or burning, urinary
symptoms, malaise, abdominal pain, fever)
• Relation to medication use (e.g., antibiotics,
steroids)
• History of previous vaginal or pelvic infections
and their treatment
Masses
any reported masses in the breast
should be evaluated
• Soreness, tenderness
and their relation to
menstrual cycle
• Redness, swelling,
nipple discharge
• Change in contour,
presence of masses
• Is client breastfeeding?
Bleeding
• Heavy bleeding or lack of bleeding may concern
the woman.
• The possibility of pregnancy is considered in any
sexually active woman with amenorrhea. Any
postmenopausal bleeding needs to be
evaluated.
• The nurse asks when the bleeding occurs in
relation to certain events, such as the menstrual
cycle or menopause, intercourse, trauma. In
additional, the nurse notes the presence of
associated symptoms
Other Associated Symptoms
• Ulcerations
• Persistent lesions
• Sense of pelvic relaxation (pelvic organs
feel as though they are falling down or out)
• Infertility
• Pelvic infection
Examination of the Female
reproductive System
• General
1. Apparent state of health
2. Appearance of comfort or distress
3. Color (e.g., flushed or pale)
4. Nutritional status (obese or
emaciated)
5. Match between appearance and
stated age
Breast Examination
• Inspect breasts with client in sitting and
then in supine position
• Assess symmetry, contour, skin color,
thickening, dimpling or retraction of
overlying skin, veins, redness, streaking
• Examine nipples for symmetry, discharge,
erosion, crusting, color
• Palpate breast and axilla for consistency,
tenderness, masses
Lymph Nodes
• Palpate the following areas and identify
enlargement, tenderness, mobility and
consistency:
• Upper extremity: supraclavicular area,
infraclavicular area, axilla, epitrochlear
nodes
• Lower extremity: inguinal nodes
Lymphatic System
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Enlarged, painful nodes (in
axilla, groin)
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Lymph Node Areas Adjacent to
Breast Area
A Pectoralis major muscle
B Axillary lymph nodes: levels I
C Axillary lymph nodes: levels II
D Axillary lymph nodes: levels III
E Supraclavicular lymph nodes
F Internal mammary lymph nodes
Examination of the Female Pelvis
Equipment Needed
• Exam Table Equiped with Stirrups
• Flexible Light Source
• Vaginal Specula in Various Sizes
• Warm Running Water
• Lubricating Jelly
General Considerations
• The patient must have an empty bladder.
• The patient must be appropriately gowned and draped.
• Use non-sterile gloves on both hands. Double-glove your
dominant hand if you intend to perform a rectal or
rectovaginal exam.
• Properly dispose of soiled equipment and supplies.
• Both male and female examiners should be chaperoned
by a female assistant.
• Always tell the patient what you are about to do
before you do it.
• The breast exam is usually done just before routine
pelvic exams.
Examination of the External Genitalia
Positioning the Patient
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Start with the patient lying
supine on the exam table
with the head elevated 30 to
45 degrees.
Assist the patient to place
her heels in the stirrups.
Adjust the angle and length
to "fit" the patient.
Have the patient slide her
hips down until she contacts
your hand at the edge of the
table.
Have the patient relax her
knees outward just beyond
the angle of the stirrups.
Vulvar Self-Examination
• The examination of the external female genitalia is an
excellent time for teaching about vulvar self-examination.
• Perform a vulvar self-examination monthly between
menstrual periods if you are older than 18 years or if you are
sexually active.
• Sit in well-lighted area on a soft surface (bed ).
• Use a handheld mirror to visualize your external genitalia.
• Examine the area around the vaginal opening from the mons
pubic to the perianal area.
• Feel and visually inspect the area.
• Report to your health care provider new nodes, warts,
growths of any type, ulcers, sores, blisters, change in skin
color, painful areas, areas of itching or inflammation, or any
change in vaginal discharge.
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Pelvic examination
A pelvic examination is recommended every 1 to 3 years for women
older than 18 years or younger, sexually active adolescents. The
woman should not be douche for at least 24 hours before the pelvis
examination, because doing so may prevent an accurate evaluation of
smears, cultures, and cytologic data.
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Speculum Exam
Warm and lubricate the speculum by holding it under
running tap water.
Announce what you are going to do and then touch the
patient on the thigh with the speculum before proceeding.
Expose the introitis by spreading the labia from below using
the index and middle fingers of the non-dominant hand
(peace sign).
Insert the speculum at a 45 degree angle pointing slightly
downward. Avoid contact with the anterior structures.
Once past the introitis, rotate the speculum to a horizontal
position and continue insertion until the handle is almost
flush with the perineum.
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Open the "bills" of the speculum 2 or 3 cm using the
thumb lever. Position the bills so that the cervix "falls" in
between.
Secure the speculum by turning the thumb nut (metal
speculum) or clicking the ratchet mechanism (plastic
speculum). Do not move the speculum while it is locked
open.
Observe the cervix and vaginal walls for lesions or
discharge. Obtain specimens for culture and cytology as
indicated.
Withdraw the speculum slightly to clear the cervix.
Loosen the speculum and allow the "bills" to fall
together. Continue to withdraw while rotating the
speculum to 45 degrees. Again, avoid contact with the
anterior structures.
Replace the drape while you prepare for the rest of the
exam.
Reassure the patient, if the exam is normal so far, say
so.
Vagina
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Inflammation
Atrophy
Discharge
Lesions, ulcerations, excoriation
Masses
Induration or nodularity
Relaxation of perineum (ask client to bear down
and observe for any bulging of vaginal walls)
Cervix
• Position, color, shape, size, consistency
(see below)
• Discharge
• Erosions, ulcerations
• Cervical tenderness
• Bleeding after contact
Consistency of cervical tissue: normal cervix is pink and feels firm, like the tip of the
nose; in pregnancy, the cervix is bluish and feels softer, like the lips of the mouth
Bimanual Exam
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Apply a small amount of lubricant to the index and
middle fingers of your dominant hand.
Uncover the vulva and lower abdomen by moving the
center of the drape away from you.
Announce what you are going to do and then touch the
patient on the thigh with the back of your hand before
proceeding.
Spread the labia and insert your lubricated index and
middle fingers into the vagina. Avoid contact with the
anterior structures.
Place your other hand on the patient's lower abdomen.
Examine the cervix:
– Palpate the cervix with your index finger noting size,
shape, and consistency.
– Gently move the cervix side to side between your
fingers and note mobility and tenderness.
– Gently lift the cervix forward and note mobility and
tenderness.
Examine the anterior uterine fundus:
Continue to lift the cervix with the vaginal hand.
Press downward with the abdominal hand and palpate the
uterus (if possible).
Note consistancy and tenderness. Attempt to estimate uterine
size.
Examine the adnexal structures:
Pull back vaginal hand to clear cervix.
Reposition vaginal hand into the right fornix, palm up.
Sweep the right ovary downward with the abdominal hand 3
or 4 cm medial to the iliac crest.
Gently "trap" the ovary between the fingers of both hands (if
possible). Note its size and shape along with any other
palpable adnexal structures.
Pull back and repeat on the left side.
Replace the drape and assist the patient to remove her feet from
the stirrups and sit up.
Reassure the patient, if the exam is normal, say so.
Leave the room and allow the patient to dress before continuing
with the consultation.
Uterus
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Position
Size
Contour
Consistency of uterine tissue
Mobility
Pain on movement
Adnexa
• Ovaries cannot usually be felt unless the client is very
thin or the ovaries are enlarged.
• Tenderness
• Masses
• Consistency
• Contour
• Mobility
• Adnexal pain on movement of cervix or uterus
(Chandelier's Sign): Extreme pain elicited with
movement of the cervix during bimanual pelvic
examination. Indicates pelvic inflammatory disease.
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Tenderness with cervical motion is an
important sign of pelvic disease. You should
both observe the patient's face and ask her if
the examination is painful in any way.
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Your ability to palpate the uterus and ovaries
will depend on the patient's anatomy, the size
of your hands, and your level of skill.
Diagnostic Assessment
• Laboratory tests
• The Papanicolaou Test (Pap smear) is
cytologic study that is effective in detecting
precancerous and cancerous cells from
the cervix. You will obtain a (Pap) smear
and other specimens as part of most
pelvic exams
Blood studies
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Pituitary gonadotropin
Steroid hormones
Serologic test
Syphilis detection
Microscopic Studies
• Wet preparation (wet smears). The examiner
can obtain secretion from the vaginal pool at
the beginning of a speculum examination.
Specimens also can be obtained from the
vaginal walls, labia, or vulva during the
examination. The specimens are placed on
glass slides and are treated with a wet
preparation such as potassium hydroxide
(KOH). The slides are examined under
microscope to confirm or rule out the
presence of a pathogen.
Radiographic examination
• General X-ray Studies
• Pelvic masses, calcified tumors or fibroids,
dermoid cysts, and metastatic bone
changes may be evident. No specipic
client preparation is nedded.
• Computer tomography (CT) scans can
detect and evaluate masses and lymphatic
enlargement from metastasis. This scan
can differentiate silid tissue masses cystic
or hemorrhagic structures.
Hysterosalpingography
• is an x-ray study of the cervix, uterus, and fallopian
tubes and it is performed after the injection of a
contrast medium. This test is used in infertility
workups to evaluate tubal anatomy and patency
and uterine abnormalities.
The client is placed in the lithotomy position. A
speculum is inserted, and the cervix is visualized.
Radiopaque oil is inserted through the cervix,
uterus, and fallopian tubes. If the fallopian tubes
are patent, the contrast material spills into the
peritoneal cavity
Mammography
• Is the x-ray study of the soft tissue of the
breast. It asses differences in the density
of breast tissue. It usually necessitates
two low-dose x-ray views of each breast:a
view from the side and a view from above.
• Follow-up care. If the result are not
communicated at the time of the
mammogram, the woman should know
when to expect the result. She should be
assessed for her knowledge of breast selfexamination.
Other diagnostic tests
• Ultrasonography is a nonradiographic
diagnostic technique. The client should
have a full bladder to enable visualization
of the uterus with abdominal
ultrasonography; a full bladder is not
necessery for tranvaginal scans. There is
no specific follow-up care for the client
after this procedure.
• Magnetic Resonance Imagine(MRI).this
scan effectively distinguishes between
normal and malignant tissues.
Endoscopic Studies
Colposcopy is suited for inspection of the cervical epithelium,
vagina, and vulvar epithelium. This procedure can locate the
exact site of precancerous and malignant lesions for biopsy.
The woman is placed in the lithotomy position. The clien
should not douche or use vaginal preparations for 24-48
hours before the examination.
The physician locates the cervix, or vaginal site, through a
speculum examination. Cervix has to be cleaned from
secretions. Acetic acid, 30%, applied to the cervix acts as a
mucolytic agent to acceptuate important morphologic
features. The physician uses a colposcope or microscope to
inspect the area in question.a biopsy also may be taken if
abnormal cells are seen. After the procedure, the nurse
assists the woman as for a pelvic examination and provides
suplies to clean perineum.
Laparoscopy
• is highly accurate diagnostic tool for
exploring the pelvic cavity. It is preferable
to a laparotomy for minor surgical
procedures.
• After the procedure the client requires
postoperative care similar to that for other
clients after general anesthesia but is
usually discharged on the day of the
surgery.
Hysteroscopy
• is endoscopic examination that permits
visualization of the interior of the uterus
and the cervical canal. the client receives
the same preparation as for pelvic
examination.
• Care is the same as that after a pelvic
examination.
Biopsy studies
• Cervical biopsy. Cervical tissue is
removed for additional cytologic study. a
• Endometrial biopsy and aspiration.Both
are used to obtain cells directly from the
lining of the uterus in women at risk for
cancer of the endometrium.
Breast biopsy and aspiration
• An incisional biopsy is the surgical
removal of tissue from a breast mass. An
excisional biopsy removes the mass itself
for hystologic(cellular) evaluation.
Aspiration biopsy is the removal of fluid or
tissue from the breast mass through a
largebore needle.
• Postoperative discomfort is usually mild
and is controlled with analgesic
administration or the use of the heating
pad.