Well Women Health Visit and Pelvic Exam with Specimen Collection Last Review: November 2016 Intervention(s) and/or Procedure: Practice Setting: Authorized Implementers: Competencies and Educational Requirements: Assessment of the Well Woman, including: 1. Pelvic examination, including speculum and bimanual examination and collection of specimens for cervical cancer screening. 2. Clinical assessment and collection of specimens for infections including sexually transmitted infections (STIs) 3. Clinical breast examination Primary Care practice clinics within the Edmonton Southside Primary Care Network. Registered Nurses (RN) in the role of Primary Care Nurse (Edmonton Southside Primary Care Network). 1. The implementing RN must complete the Registered Nurse Pap Test Learning self-study module (Alberta Health Services, 2012) and associated practical components (including review of pap test adequacy rates) prior to engaging in independent practice in this area. 2. The nurse must assess his/her individual competence in all aspects of the intervention on a yearly basis and decide if it is appropriate for him/her to perform the procedure on an ongoing basis or whether further education or support is required. 3. The nurse must engage in continuing professional development to achieve and maintain competence, including regular review of updates to the RN Pap Test Learning Module. Updates can be obtained from www.screeningforlife.ca/cervical
Indications/Clinical Conditions: Contraindications and Exclusions: 1. The RN has an explicit relationship with the physician regarding Pap test results management and follow up. 2. Patient consents to examination and specimen collection by the implementing RN. 3. Patient has been referred to the RN by an authorizing physician for assessment and exam. 4. Patient meets the criteria for the Alberta Cervical Screening Guidelines - http://www.topalbertadoctors.org/cpgs/919105 5. Breast Cancer screening is being conducted as part of the physical exam or in response to concerns identified by the patient. The patient and physician are aware that it is NOT being used as a dedicated form of breast cancer screening according to the TOP guidelines. 1. No verbal consent from the patient or substitute decision maker for the RN to implement this medical directive. 2. Patient s that have not met the criteria for screening 3. Patient s who have not been referred to the RN by a responsible physician. 4. Pregnancy Guidelines for Implementation (all above indications must be met):
Assessment, Treatment, and Monitoring Parameters: 1. The RN obtains a full health history, including: Menstrual history: age of onset, regularity, date of last menstrual period, age at menopause, history of sexual activity since last menstrual period. Possibility of pregnancy or need for emergency contraception. Abnormal vaginal discharge: onset, colour, consistency, quantity. Contraception: method of birth control, use of condoms, use of lubricant. Sexual history: date of last sexual contact, sex of contacts (male/female/both), number of partners in the past 2 months (specific to infections with a 60 day reportable requirement) number of partners in the past 6 months (specific to infections with a 180 day reportable requirement) types of sexual contact (oral, vaginal, anal intercourse) percentage of time for condom use and for which types of sexual contact (anal, vaginal, oral), feasibility of contacting sexual partners should they require notification, testing and treatment locations (e.g., internet, commercial sex establishments, other) where sexual contacts are met, sexual and drug use practices of sexual contacts (if known), STI and HIV status of sexual contacts (if known), possible occupational exposure to blood borne pathogens (e.g., needle stick) or accidental exposures (i.e., exposure to blood during a fight) History of STI s Dyspareunia Gynecological history: surgeries, recent procedures, GTPAL (gravida, term, preterm, abortions, living), cesarean versus vaginal birth, post-coital bleeding, bleeding between periods, previous cervical screening for cytology and results, pregnancy complications (e.g., ruptured membranes, vaginal bleeding). Health history: recent procedures, diabetes, current medications, mobility concerns, smoking, substance abuse, and self-breast examination. Allergies
Screening for woman abuse 2. Prior to examination the RN addresses client questions or concerns and describes the process of examination to the patient. 3. The RN offers to perform a clinical breast examination including: Inspection and palpation of the breasts for masses or lumps, tenderness, symmetry, or nipple discharge. 4. The RN performs the pelvic exam, including speculum and bimanual, as indicated based on the RN Pap Test Learning Module guidelines for examination. 5. The RN will collect appropriate specimens which may include: specimen for cervical screening for cancer, specimens for STI screening. 6. The RN will ensure that results are appropriately sent to the responsible physician and follow up procedures are in place within the clinic. The RN will discuss with the patient when and how she will receive results. 7. The RN will discuss HPV vaccination with women as recommended by the Canadian Communicable Disease Report. 8. The RN will consult the physician with any abnormal findings as part of the pelvic or breast exam as advised by the RN Pap Test Learning Module; including but not limited to: suspicious moles/lesions on the perineum, genitourinary pain (e.g., PID, suspected ectopic pregnancy, presence of an abscess), systemic symptoms, inability to complete required screening due to anatomy or woman s comfort level, symptoms of STI, cervical abnormalities, and special circumstances (e.g., sexual assault). 9. The RN will provide follow up and health teaching surrounding STIs as per Public Health Agency of Canada guidelines: http://www.phacaspc.gc.ca/std-mts/sti-its/guide-lignesdir-eng.php
Communication and Documentation: 1. Documentation in the patient s medical record needs to include: name of the medical directive, name of the implementer (including credential), and name of the physician/authorizer responsible for the directive and patient. 2. Information regarding implementation of the procedure and the patient s response should be documented in accordance with standard documentation practice. * Implementation of Protocol in Practice Setting: 1. The Primary Care Nurse (RN) and the authorizing physician in each clinic must sign the Edmonton Southside Primary Care Network "Medical Directive and Protocol Approval Form" indicating acceptance of this medical directive for implementation in the primary care practice setting. 2. Upon accepting this medical directive, it is in permanent effect (including in the case of revisions to the protocol) until otherwise retracted. 3. The implementing RN within each clinic is responsible to notify the authorizing physician(s) of any updates to the medical directive/protocol. Endorsed by: Clinical Governance Committee Date: November 21, 2016 References: Alberta Health Services (2012). Registered Nurse Pap Testing Learning Module. Retrieved from www.screeningforlife.ca/cervical. Calgary, AB: Cancer Screening Programs. * Potter, P.A. & Perry, A.G. (2006). Fundamentals of Nursing. St. Louis: Mosby.