MED-SURG I NOTES-1.pdf

MEDICAL SURGERY STUDY GUIDE NOTES
STUDY GUIDE 1
PERIMENOPAUSE
Perimenopause is the period extending from the first signs of menopause to beyond the complete cessation of
menses. It is also be defined as the period around menopause, lasting to 1 year after the last menstrual period.

Treatment
1) Since unintended pregnancy can occur during perimenopause, nurses should encourage clients to use oral
contraceptives at least for 1 year. Oral contraceptives provide perimenopausal women with protection against
uterine cancer, ovarian cancer, anemia, pregnancy and fibrocystic breast changes as well as relief from
perimenopausal symptoms.
2) However women who smoke and are 35 years of age should not take oral contraceptives because of an
increased risk of cardiovascular disease.
3) Since there’s a major issue with breast health in perimenopausal women, they should be encouraged for routine
breast self-examinations. Mammograms are highly essential as well.

MENOPAUSE
It is the permanent physiologic cessation of menses for 1 year due to declining ovarian function; during this
time, reproductive function diminishes and ends. Post menopause is the period beginning from about 1 year after
menses cease. Menopause starts gradually and is related with a multitude of clinical manifestations.
So, menopause can be diagnosed as: No menstruation for a year in the absence of other biological or
physiological causes.
Changes signaling menopause begin to occur as early as the late 30s, when ovulation occurs less frequently,
estrogen levels fluctuate, and FSH levels increase in an attempt to stimulate estrogen production.

A 43-year-old woman reports symptoms of hot flashes, weight gain, and insomnia. She says, “I can’t be going
through menopause, something else must be wrong! My mother didn’t go through menopause until she was 54
years old!” What is an appropriate response by the nurse?
a) “You definitely are going through menopause, even though it is unusual to do so at such a young age.”
b) “These are not menopausal symptoms, and you need tests to determine what is happening.”
c) “This is menopause, and you will have to live with it.”
d) “Menopause usually happens anytime between ages 40 and 55. It sounds like you are upset about this.”
ANSWER: D
Rationale: Menopause usually occurs anytime between ages 40 and 55. The average age is 47. Common
symptoms are hot flashes, chilliness, breast flabbiness, weight gain, insomnia, and more frequent headaches. This can
be an anxiety-producing time for women, and the nurse can offer support.

Clinical Manifestations of Menopause
1) Irregular menses.
2) Atrophy of breast tissue (breast tenderness) and genital organs (thinning of pubic hair and shrinkage of labia).
3) Mood changes long before menopause occurs.
4) Hot or warm flashes and night sweats due to hormonal changes denote vasomotor instability.
5) Barely perceptible warm feeling to extreme warmth followed by profuse sweating, discomfort, sleep
disturbances and fatigue.
6) Loss in bone density, and vascular changes.
7) Vaginal secretions decrease, and women may report dyspareunia ( discomfort during intercourse).
8) The vaginal pH increases, leading to bacterial infections and atrophic vaginitis.
9) Reports of fatigue, forgetfulness, weight gain, irritability, trouble sleeping, feeling “blue”, and feelings of
panic.




1

, Which of the following facts is/are true about the physiology of menopause? (Select all that apply).
a) The menopausal period marks the natural biologic end of reproductive ability.
b) Chemical menopause occurs when the ovaries are removed in premenopausal women.
c) As ovarian function decreases, the production of estradiol decreases and is ultimately replaced by estrone
as the major ovarian estrogen.
d) With decreased ovarian function, the second ovarian hormone, progesterone, which is produced during the
luteal phase of the menstrual cycle, also is markedly reduced.
e) Surgical menopause often occurs during cancer chemotherapy, when cytotoxic drugs arrest ovarian
function.
ANSWER: A, C, & D
Rationale: B is incorrect. Surgical menopause, not chemical menopause, occurs when the ovaries are
removed in premenopausal women. E is incorrect. Chemical menopause, not surgical menopause often occurs during
chemotherapy.

Psychological Considerations
Some women may experience role confusion, whereas others experience a sense of sexual and personal
freedom. Women may be relieved that the childbearing phase of their lives is over.
Because of preexisting impairments and treatments associated with disabling conditions, women with
disabilities may experience menopause in ways that differ from women without disabilities. Women with preexisting
impairments viewed menopause as having negative effects on their health. They indicated a desire to make decisions
about medical management of menopause and its symptoms. Nevertheless, they considered menopause to be a minor
issue compared to the other physical issue they face related to their disability. This indicated that information was their
best defense; in addition, they found that knowledge of their own body could be helpful. They reported that they try to
avoid health care providers.
Nursing Implications: Nurses should further explore the concerns related to menopause, expressed by women
with disabilities. Because women desire a major role in medical decision making related to menopause, they need to be
provided with accurate, up-to-date information about results of studies related to all methods of symptom management.
Furthermore, the women’s view that they know their own bodies better than anyone else needs to be recognized and
taken into consideration when providing care. Nurses should take every opportunity to discuss health-related issues
and concerns of women with disabilities.

Medical Management
1) Hormone Therapy: Contrary to long-held beliefs of HT to prevent hot flashes, osteoporotic fractures and
cardiovascular disease, HT has been found to be less effective than originally believed. Studies have shown that it
increases the risk of breast cancer, heart attack, stroke, and blood clots. The current recommendation for treatment of
hot flashes with HT is to use the lowest dose possible for the shortest time possible.
Nurses need to be knowledgeable about HT-related issues to be able to respond to women’s questions about
HT use.

A woman is seeking advice from her nurse concerning problems associated with menopausal symptoms. The
client reports hot flashes, palpitations, dizziness and headaches. The physician orders hormone replacement
therapy. What should the nurse teach this client about hormone replacement therapy?
a) Hormone replace therapy (HRT) may be prescribed to alleviate severe manifestations of menopause
indefinitely.
b) The addition of estrogen stimulates monthly shedding of the intrauterine lining, decreasing the risk of
uterine cancer.
c) HRT relieves hot flashes and night sweats but increases problems of vaginal dryness and urogenital tissue
atrophy.
d) Long-term HRT increases the risk for breast cancer, ovarian cancer, asthma, urinary incontinence and
venous thrombosis.
ANSWER: D




2

, Method of HT Administration
1) Both estrogen and progestin are prescribed for women who have not had a hysterectomy.
2) Two basis regimens for HT: (i) estrogen alone, and (ii) estrogen + progestin
3) The purpose of estrogen in both regimens is to replace the estrogen that was lost because of menopause.
4) The progestin is present for one reason only: to counterbalance estrogen-mediated stimulation of the
endometrium, which can lead to cancer of the uterus.
5) Women who no longer have a uterus (hysterectomy) do not need the progestin component; they are given
estrogen only.
6) Although progestin can protect against estrogen-induced cancer of the uterus, it increases the risk of estrogen-
induced cancer of the breast.
7) Also, progestin appears to increase the risk of adverse cardiac event.
8) Estrogen suppress bone mineral resorption, and thereby have a positive effect on bone mass.
9) Estrogen raises HDL cholesterol and reduces LDL cholesterol. These actions partially explain the low
incidence of coronary heart disease in pre-menopausal women. As such, we can say that it is beneficial for a
menopausal woman to receive HRT if she has a familial risk of heart disease.
10) The principal benefits of EPT are suppression of vasomotor symptoms, prevention of urogenital atrophy,
prevention of bone loss and osteoporotic fractures, and reduction of colorectal cancer risk.
11) HT does not protect against cardiovascular disease, and clearly should not be used with this objective in mind.
12) To reduce cardiovascular risks, post-menopausal women should avoid smoking, perform regular exercise,
decrease intake of saturated fats, and take drugs as indicated to treat HTN, DM, and high cholesterol.
13) The major risks of EPT are MI, pulmonary embolism, DVT, CVA, breast cancer, gallbladder disease, and
dementia.
14) ET is safer than EPT but still poses risk for CVA, DVT, ovarian cancer, and gallbladder disease.
15) Women who underwent hysterectomy (removal of uterus) can take unopposed estrogen (estrogen without
progestin) because there is no longer a risk of estrogen-induced hyperplasia of the uterine lining. [progestin
prevents proliferation of the uterine lining and hyperplasia].
16) Physicians also order estrogen therapy for patients with prostrate cancer. WHY? Although it doesn’t cure the
prostrate cancer itself, it delays the progression of the cancer and increases survival while maximizing quality
of life.
17) Why are prostrate cancer patients recommended estrogen therapies? The goal is to reduce the production of
androgen (male hormone) in the body to prevent them from reaching prostate cancer cells.

Risks and Benefits
HT is contraindicated in women with a history of breast cancer, vascular thrombosis, impaired liver function,
uterine cancer, and undiagnosed abnormal vaginal bleeding. Because the risk of thromboembolic phenomena
is increased with HT, women who elect to take it should be taught the signs and symptoms of DVT and
pulmonary embolism and instructed to report these signs and symptoms immediately. Women who take HT
should be assessed for leg redness, tenderness, chest pain, and shortness of breath. Furthermore, they need to
be informed about the importance of regular follow-up care, including a yearly physical examination and
mammogram. An endometrial biopsy is indicated for any irregular bleeding. Because the risk of
complications increases the longer HT is used, HT should be used for the shortest time possible. Estrogen
alone or in combination with a progestin does not reduce risk of dementia or cognitive impairment.

The nurse is reviewing the history of a patient who is requesting HRT. Based upon which of the following
conditions is HRT contraindicated?
a) History of vaginal dryness
b) History of vascular thrombosis
c) History of hot flashes and night sweats
d) Family history of osteoporosis
ANSWER: B

2) Alternative Therapy for Hot Flashes: Problematic hot flashes have been treated with venlafaxine (Effexor),
paroxetine (Paxil), gabapentin (Neurontin), and clonidine (Catapres). Similarly vitamin B6 and vitamin E may be
effective. Some women seek herbal treatments. Since only few data exist about their safety or effectiveness,
assessment of menopausal women should address their use of complementary and alternative therapies and
supplements. Glucose levels also affect hot flashes; thus, nurses can encourage patients to maintain stable glucose
levels.
3

, A client just diagnosed as menopausal is not sure if she wants to begin hormone replacement therapy (HRT).
Which of the following alternatives can be considered?
a) Vitamin B
b) Acupressure
c) Vitamin D
d) Biofeedback
ANSWER: D
Rationale: As a result of the controversy surrounding the use of HRT, non-traditional or alternative therapies
have become more popular. The following complementary therapies are examples of those used by menopausal women
to reduce associated discomforts: acupuncture, biofeedback, massage, herbs, vitamin E, soy protein (soy is full of plant
estrogens), massage and yoga.

3) Maintaining Bone Health: Factors that predispose a woman to risk of osteoporosis include a thin body frame, race
(Caucasian or Asian), family history of osteoporosis, nulliparity, early menopause, moderate to heavy alcohol ingestion,
smoking, caffeine use, sedentary lifestyle, and a diet low in calcium. The primary intervention of nurses is to advise
women to remain active and begin a regular exercise regimen of weight-bearing activity (e.g. walking); to take a
calcium supplement; to decrease or stop smoking; and to discuss with their health care provider the use of
pharmacologic agents to reduce bone loss if indicated.
Since pregnancy and breast-feeding can lower bone mass, and women undergo rapid bone loss after
menopause when levels of the bone strengthening hormone estrogen drop dramatically, (the removal of ovaries will
have the same effect on bone mass) nurses should encourage their mid-adult clients to:
a) Increase their exercise (particularly weight-bearing exercises such as, walking, jogging, hiking, heavy
gardening, dancing, weight-training with free weights or machines). However, swimming and bicycling are
not considered weight-bearing exercises even if they are excellent cardiovascular exercise choices.
b) Limit high dietary sodium intake because high sodium is demonstrated to have harmful effects on bone
integrity.
c) Magnesium is involved in bone formation and influences the activities of osteoblasts and osteoclasts; it also
affects the concentrations of both parathyroid hormone and the active form of vitamin D. Research has found
that women with osteoporosis have lower serum magnesium levels than those who do not. Thus maintain
sufficient intake of magnesium.

4) Maintaining Cardiovascular Health:
i) Regular physical exercise increases the heart rate and HDL levels.
ii) Weight-bearing exercise is recommended at least four times a week.
iii) Pharmacologic therapy (e.g., aspirin, beta-blockers, “statins,” ACE inhibitors) may be indicated in women
who have cardiovascular disease or are at high risk for it.

5) Behavioral Strategies: Regular health screening is recommended for women at the time of menopause: gynecologic
examinations, mammograms, colonoscopy, fecal occult blood testing, and bone mineral density testing if at risk for
osteoporosis.

6) Nutritional Therapy: Women should be encouraged to increase their intake of foods high in calcium (e.g., nonfat
yogurt, green leafy vegetable, seafood, and calcium-fortified foods). Calcium and vitamin D supplementation helps in
reducing bone loss and prevents morbidity associated with osteoporotic fractures.

Which of the following is the correct recommended daily allowance of calcium in a post-menopausal women
not taking HRT?
a) 1500 mg/d
b) 1200 mg/d
c) 300 to 500 mg/d
d) 1300 mg/d
ANSWER: A




4