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Valerie Ballard, DNPWomen’s Health Nurse Practitioner
S.Storm - Dementia
A WELL VISIT IS PART OF A JOURNEY TO WELLNESS AND HEALTH FOR OUR PATIENTS.
As a provider, take the opportunity to listen, teach and make a difference in someone’s life.
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Understand current clinical trends Use evidence based research and national
guidelines in counseling patients Understand emerging issues in the healthcare
of women across the life span Novice, as well as experienced providers
ascertain knowledge
Start of screeningsHow often screenings take placeImportance of interpretation of screenings
Pediatric Family PracticeGynecology
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Is a fundamental part of medical care and is valuable in promoting prevention practices, recognizing risk factors for disease, identifying medical problems and establishing the clinician-patient relationship. (ACOG, 2015)
Remember to treat the whole woman.Take the opportunity to teach, connect with your patient and allow time for questions.
Medical Assist/Nurse – escorts patient to exam room, affirms reason for visit
Weight, height, B/P, pulse, pain score, reason for visit
KNOW YOUR PATIENT BEFORE YOU ENTER ROOM. READ CHART!!!!
MAKE SURE YOU LOOK AT B/P (statistics show providers don’t look at B/P readings)
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Age Appropriate QuestionsWHAT I WANT TO KNOW ABOUT THE PATIENT
DIET (describe your diet) Any history of eating disorder? DRINK MILK? (if not, how do
you receive your calcium) EXERCISE (what do you do,
how often?) WHAT TYPE WORK? Any Trouble Sleeping? HEADACHES (When?, How
often, how relieved?) Ever treated for Depression? ANY HISTORY OF ABUSE Have all Previous paps been
normal? IMMUNIZATIONS
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Are you sexually active? (type of partner), how many partners.
Satisfied with sex life How’s your libido? Is vaginal dryness a concern for you?
Referrals –(Know where to refer in your area or have written information specifics for handouts)
MEDICATION
FOOD
LATEX
CURRENT MEDICATIONS (DOSAGE) WHO PRESCRIBES THEM FOR YOU? Herbal or other OTC medications? What Birth Control are you Using? (perfect
time to do preconception counseling, possible start on Prenatal vitamin as well)
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Married, single, in a relationship with a male or female partner?
Do you Smoke? (Did you ever? How much ? Any desire to quit?)
How would you describe your Alcohol use?
Any recreational drugs?
Chronic Problems (Diabetes, hypertension) Surgeries Age of menarche LMP Age of menopause Number of Pregnancies
Constitution EYES ENT CARDIOVASCULAR RESPIRATORY GASTRO-
INTESTINAL GENITOURINARY MUSCULO-
SKELETAL
SKIN BREAST NEUROLOGIC PSYCHIATRIC ENDOCRINE HEMATOLOGIC/ LYMPHATIC ALLERGIC IMMUNOLOGIC
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Scalp Ears Eyes Thyroid Carotids Lungs Heart (sitting Up) Breast Exam
Inspection (While patient in sitting position, arms positioned on waist)
Ask Patient to lean forward Arms above head Ask Patient to lie back (one arm above head) Switch arms USE THIS OPPORTUNITY TO TEACH
PATIENT SELF-EXAM Circular motion as well as vertical
ABDOMEN LIVER (DEEP BREATH, EXHALE) BOWEL SOUNDS ALL EXTREMITIES MOLE CHECK
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INSPECTION
SPECULUM EXAM
PAP COLLECTION (SPATULA + BRUSH or broom)(age 21)
STD SCREENING ( UP TO AGE 26 OR AS HISTORY DICTATES)
INTERNAL- (Controversial issue –Is pelvic exam actually necessary?)
RECTAL EXAM (all women over 50)
American College of Physicians (ACP) American College of Obstetricians and
Gynecologists (ACOG) American Society of Colposcopy an Cervical
Pathology (SCCP) Centers for Disease Control and Prevention
(CDC) U.S. Preventive Services Task Force (USPSTF)
First Pap age 21 Co-Testing age 30 Subsequent testing Q 3 or 5 years Medicare –Welcome to Medicare Visit Stop paps between ages 65-70
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Start screening for cervical cancer at age 21 years once, using pap tests without HPV.
Test every 3 years but not more frequently Do not perform HPV testing in women
younger than 30 years.
Use a combination of Pap and HPV testing (Co-testing) once every 5 years in women aged 30 years or older who prefer screening less often than every 3 years(ACP, 2015 and CDC, 2013)
Stop screening women older than 65years who have had three consecutive negative cytology results or two consecutive negative cytology plus HPV test results within 10 years, with the most recent test done within 5 years. (ACP,2015)
Women with a history of CIN2 -3 or adenocarcinoma can’t stop screening at age 65. They must continue screening (ACOG, 2013)
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Do not screen women of any age who have had a hysterectomy with removal of the cervix for cervical cancer. (ACP, 2015)
A woman who has had her uterus removed (and also her cervix) for reasons not related to cervical cancer and who has no history of cervical cancer or serious pre-cancer should not be tested. (ACS, 2015)
If the cervix is removed and there is no history of CIN2 or higher, no more screening is needed. For those with high-grade lesions before hysterectomy, keep screening with cytology every 3 years for the next 20 years. That is because recurrent cancer can develop at the vaginal cuff even years later. The role of HPV testing in this setting is unclear. (ACOG, 2013)
Collection Methods:
Liquid Based / Thin Prep
Image Guided
Sure Path
Slide
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No HPV HPV (High Risk) Always HPV (High Risk) reflex on any Pathology HPV (High Risk) reflex Ascus –(under 30 age
group) HPV Always, reflex 16 &18 (Over 30 age
Group)
American Society for Colposcopy and Cervical Pathology (ASCCP)
2012 Updated Consensus
Two-tier terminology system that incorporates ancillary tests and other criteria to distinguish indeterminate lesions as high grade or low grade.
Low grade squamous intracervical intraepithelial lesions (LSIL) – Cervical intraepithelial neoplasia (CIN) 1
High Grade squamous intraepithelial lesions (HSIL) should be managed as CIN2,3,(ASCCP, 2013)
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Cytology reported as negative but lacking endocervical cells can be managed without early repeat.
Cytology reported as unsatisfactory requires repeat even if HPV negative.
HPV-negative and ASC-US results are insufficient to allow exit from screening at age 65 years.
(ACOG, 2012)
MAMMOGRAPHY
DEXA SCAN – MENOPAUSE, EARLIER IF RISK FACTORS DICTATE
COLONOSCOPY –AGE 50, EARLIER IF SYMPTOMS OR FAMILY HISTORY DICTATES
Discuss the benefits and harms of screening mammography with average-risk women aged 40-49years. Order biennial mammography screening if a patient requests it after the discussion. (ACP, 2015)
The U.S. Preventive Services Task Force (USPSTF) recommends routine screening of average risk women should begin at age 50, instead of age 40
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American Cancer Society continues to recommend annual mammography screening for all healthy women beginning at age 40 (ACS)
Clinical breast exam about every 3 years for women in their 20’s and 30’s and every year for women 40 and over (ACS)
Encourage biennial mammography screening for women aged 50 to 74 years.(ACP, 2015)
Routine screening should end at age 74 (USPSTF)
Women should get screening mammograms every two years instead of every year (USPSTF)
Breast self-exams have little value, based on findings from several large studies (USPSTF)
Do not screen women younger than 40 years or older than 75 years, or women of any age who have a life expectancy of less than 10 years. (ACP, 2015)
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Dense Breasts – 19 states now enacted legislation that mandates providers to inform patients of findings of Dense breasts and discuss supplemental screening tests, usually ultrasound. (Study findings are controversial –high rate of False-Positives)
3D mammography “holds the promise of both increasing the cancer detection rate and reducing the false-positive rate”, Sprague, 2015
American Cancer Society’s position on women with family history, a genetic tendency should be screened with MRIs along with Mammograms. About 2% of women fall in this category. (ACS, 2015)
Encourage patients aged 50 to 75 years to undergo colorectal cancer screening :
High-sensitivity FOBT (fecal occult blood test) or FIT (Fecal immunochemical test) every year
Sigmoidoscopy every 5 years Combined high-sensitivity FOBT or FIT every 3
years plus sigmoidoscopy every 5 years Optical colonoscopy every 10 years (ACP, 2015), (USPSTF,2014) (ACS, 2015)
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High Risk due to cigarette smoking: 55 to 74 years of age In fairly good health Have at least a 30 pack-year smoking history
and either still smoke or have quit smoking within the last 15 years.
Screening is done with a low-dose CT scan (LDCT) of the chest.
(ACS, 2015)
LIPID PROFILE
TSH
GLUCOSE
VIT D LEVEL
INFORM PATIENT OF HOW AND WHEN EXAM RESULTS WILL BE DELIVERED.
RESOLVE ANY QUESTIONS OR CONCERNS
Inform patient when you want to see her back in office (one year, 3 months, 6 months)
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Know your Patient. Guidelines are just that …GUIDELINES… Use Clinical Judgement Help Patients take control of their own health Partner with your patients.
American Society for Colposcopy and Cervical Pathology (http://www.asccp.org/)
CDC.gov
http://wwwmedscape.com
American Cancer Society (ACS) American College of Physicians (ACP) ACP offers advice for “Wiser” Cancer
Screening. Medscape. May 18, 2015 American Society for Colposcopy and Cervical
Pathology ( ASCCP) Center for Disease Control (CDC) Sprague. Brian , Annals of Internal Medicine.
February 2015
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United States Preventive Services Task Force (USPSTF)
