Case Study Sexually Transmitted Infections
You are the nurse in a walk-in clinic. A.P. is being seen this morning for a 2-day history of diffuse, severe abdominal pain. She has complaints of nausea without vomiting; she denies vaginal bleeding or dis- charge. A.P. reports having unprotected sex with several partners recently, two of whom had penile dis- charge. Her last menstrual period ended 3 days ago. She has no known drug allergies and denies previous medical or psychiatric problems. Vital signs are 108/60, 110, 20, 100.6 ° F (38.1 ° C). Physical examination reveals that her abdomen is very tender. The slightest touch of her abdomen causes her to wince with pain. Bowel sounds are normal. Pelvic examination reveals purulent material pooled in the vaginal vault, which appears to be coming from the cervix. a sample of the vaginal drainage is obtained and sent for culture. The result of a pregnancy test is negative; a rapid diagnostic test for chlamydial infection has a positive result.
1. Which of these assessment findings are significant and why?
2. What medical interventions can you anticipate?
3. What should you teach A.P. about chlamydial infection?
4. How would you provide emotional support to A.P. at this time?
Case Study Progress
The physician has the option of treating A.P. by one of two different methods. First, the physician could prescribe treatment over a period of 1 week. A.P. would be given the first dose of doxycycline (Monodox) 100 mg PO, and then she would be prescribed the same dose to be taken PO bid for 7 days. Second, the physician could prescribe a one-time dose of azithromycin (Zithromax) 1 g PO, which could be adminis- tered in the clinic.
5. Which choice is best for A.P.? Explain your reasoning.
6. You tell A.P. that chlamydial infection is a sexually transmitted infection (STI) that is mandated to be reported to the public health department. What is the purpose of reporting the infection, and what actions will be taken?
7. A.P. says she does not understand why her partners must be told about the infection. How would you respond?
8. Based on the information A.P. has given you, you determine that she is at risk for other STIs and unplanned pregnancy. What risk assessment questions do you need to ask A.P.?
9. You ask whether someone has talked with A.P. about “safe sex.” She laughs and tells you there is nothing safe about sex. Undaunted, you ask if she would be willing for you to discuss the use of condoms with her sexual partners. She tells you that she is already careful; if she does not “know the guy,” then she uses a condom. How are you going to respond?
10. You ask A.P. whether she has been tested for HIV. She says no, she does not know anyone with acquired immunodeficiency syndrome (AIDS) and she does not have sex with gay men. Now what are you going to say?
11. You ask her whether she would like to be tested for HIV. It will not cost her anything, no one will know the results but she, and it is completely confidential. She agrees to the test. What counseling will you provide A.P.?
12. You make an appointment for A.P. to return to the clinic in 1 week for her HIV test results. Describe the instructions you will give to A.P. before she leaves the clinic.
Case Study Progress
A.P. returns to the clinic in 1 week for her HIV test results, which are negative. Her culture results confirm the diagnosis of chlamydial infection.
13. What are your primary nursing concerns at this time?
14. A.P. has completed the course of antibiotic therapy and is no longer experiencing any symptoms. After counseling her on ways to reduce her risk of acquiring another STI, you determine that A.P. understood your teaching regarding safe sexual practices if she states that she will do which of the following? Select all that apply.
a. Use a new application of spermicidal jelly before each sexual encounter
b. Not worry about contacting an STI if the man states he has few partners
c. Have her partner and her both wear a new condom with each sexual encounter
d. Douche with an over-the-counter solution within 4 hours of having intercourse
e. Inspect the genitalia of her partner before intercourse or other contact with perianal area
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The significant assessment findings in this case are the diffuse, severe abdominal pain, purulent material pooled in the vaginal vault, and a positive rapid diagnostic test for chlamydial infection. These findings suggest that A.P. may have a sexually transmitted infection (STI) causing pelvic inflammatory disease (PID), which can lead to severe abdominal pain and can cause complications such as infertility.
Medical interventions that can be anticipated for A.P. include prescribing antibiotics to treat the chlamydial infection and follow-up care to ensure that the infection is fully treated and to monitor for complications of PID.
A.P. should be taught that chlamydial infection is a common STI that is caused by the bacteria Chlamydia trachomatis and is spread through unprotected sexual contact. Symptoms can include pelvic pain, vaginal discharge, and fever. It is important to be tested and treated for chlamydial infection to prevent complications such as PID.
To provide emotional support to A.P., the nurse can listen actively and empathetically, provide reassurance and validation of A.P.’s feelings, and offer resources such as counseling or support groups.
The best choice for A.P. would be a one-time dose of azithromycin (Zithromax) 1 g PO. This is because azithromycin is a single-dose treatment that has a high cure rate and is easier for patients to comply with than a 7-day course of doxycycline.
Reporting the infection to the public health department is done to track the spread of STIs in the community and to ensure that all sexual partners of the infected person are notified and treated to prevent further spread of the infection.
The nurse can respond by explaining that informing partners is important to prevent further spread of the infection and to protect their own health. It is also a legal requirement in many states.
To assess A.P.’s risk for other STIs and unplanned pregnancy, the nurse can ask about the number and types of sexual partners, frequency of unprotected sexual contact, use of birth control, and history of STI testing.
The nurse can respond by explaining the importance of consistent and correct use of condoms to reduce the risk of STIs and unintended pregnancies, and also suggest to A.P. to get herself tested for other STIs and encourage her to have open communication with her partners about safer sex practices.
The nurse can explain to A.P. that anyone who is sexually active is at risk for HIV, regardless of the sexual orientation or HIV status of their partners. It is important to get tested to know one’s HIV status and to protect one’s own health.
Before A.P. leaves the clinic, the nurse should explain the testing process and what the results mean, including the potential for false-negative results in the early stages of infection. The nurse should also provide information about risk reduction and prevention strategies, such as consistent and correct use of condoms and regular testing.
The nurse should give A.P. clear instructions for when and where to return for her HIV test results, and emphasize the importance of following up and discussing any questions or concerns she may have.
The primary nursing concerns at this time are ensuring that A.P.’s infection is fully treated and that she is monitoring for any complications of PID, such as infertility. The nurse should also ensure that A.P. is aware of the importance of regular follow-up and testing for STIs.
A.P. would demonstrate understanding of safe sexual practices by
