Identifying risk factors for cancer questions
Information collected during the health history is especially
helpful in identifying risk factors for cancer and health-related
behaviors that may lead to sexually transmitted infections.
During the physical assessment, the external genitalia may be
examined. However, the internal pelvic examination is a skill
most often performed by a physician or an advanced practice
nurse. The female genitalia are assessed for lesions, discharge,
masses, and enlargement of internal organs. The rectum and
anus may be assessed during part of this examination if a total
health assessment is being performed. Information about rec-
tal examination is provided later in this chapter.
Identify risk factors for altered female health during the
health history by asking about the following:
• Menstrual history (age of first and last period, length of
flow, type of flow, pain)
• Sexual history (age at which sexual activity began,
number and gender of partners)
• Pain with intercourse, difficulty achieving orgasm
• Number of pregnancies and live births
• History of sexually transmitted infection
• Use of contraceptives
• Frequency of pelvic examinations and Pap smears
• History of vaginal discharge, itching, or pain on urination
• History of smoking (how long, how many packs/day)
• Family history of reproductive or genital cancer
The genitalia are assessed by inspection and palpation. A
description of an internal pelvic assessment of women is
included in this chapter. This is an advanced assessment tech-
nique, but nurses often assist in performing vaginal examina-
tions and need to be familiar with the procedure. In many
instances, male healthcare providers will ask that a female be
present in the room during the examination. Women from
some cultures (e.g., Islam) may agree to a physical examina-
tion of the genitalia only by a female nurse or female physi-
cian. Equipment required includes a vaginal speculum (for
the female examination), a good light source, and disposable
INSPECTING AND PALPATING
THE EXTERNAL GENITALIA
Ask the patient to empty her bladder before the examina-
tion. Place (actually, the woman places herself) the woman
in the lithotomy position on the examination table, with
the legs in stirrups, and draped so that only the genitalia
are exposed. Explain the procedure to her and help her to
relax as it is performed. Be sure to wear gloves during this
Inspect the external genitalia for color, size of the labia
majora and vaginal opening, lesions, and discharge. The
vulva normally has more pigmentation than other skin areas,
and the mucous membranes are dark pink and moist. The skin
and mucosa should be smooth, without lesions or swelling.
The labia should be symmetric without lesions or swelling.
Lesions may be the result of infections (such as herpes or
syphilis). There may normally be a small amount of clear or
whitish vaginal discharge. The vaginal orifice varies in size,
depending on the woman’s age, sexual history, and having
vaginal delivery. In children, loss of hymenal tissue between
the 3 o’clock and 9 o’clock position indicates trauma (from
digits, penis, or foreign objects). Palpate the labia for masses
and the Bartholin’s glands (located slightly below and to the
left and right of the opening of the vagina) for swelling, pain,
INSPECTING INTERNAL GENITALIA
A speculum is used to examine the internal genitalia.
Guidelines for Nursing Care 25-9 lists the sequence of an
internal vaginal examination.
598 UNIT VI Actions Basic to Nursing Care
Guidelines for Nursing Care • 25-9
EXAMINING THE VAGINA
• Explain the procedure to the patient.
• Warm the speculum under warm running water; if cytologic
specimens are to be taken, the water serves as the lubricant; if no
specimens are needed, a water-soluble lubricant may be used.
• Don gloves.
• Using two fingers placed just inside the vagina, press down
gently on the posterior vaginal wall.
• Insert the speculum blades vertically into the vagina, the
posterior portion pointed at a 45-degree angle. Ensure that
no pubic hair is caught in the speculum.
• Turn the speculum so that the handle is down and the blades
are in a horizontal positi
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