successful pelvic examinations
TRANSCRIPT
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SUCCESSFUL PELVIC
EXAMINATIONS
How SANE’s Succeed in challenging situations.
Minnesota Forensic Nurses Education Conference
September 14, 2018
Fridley MN
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Barbara Kern-Pieh, RN CNM MSN SANE-A SANE-P
Questions from SANE’s ahead of time
• How to keep competence and confidence when long spaces between exams?
• How do you find the “Hiding cervix”?
• What are the normal colors for:• the cervix?
• vagina?
• Discharge?
• When to use the petite vs x-large speculum?
• What to do if surplus tissue seems to cave in vaginal walls?
• Help us problem solve difficult situations:
• Positioning
• Elderly
• Immobile
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First steps to successful exams
• Promote excellence in forensic nursing through education and collaborative partnerships.
• Improve care and long-term health outcomes for victims of violence in Minnesota.
• Practice.
• Find joy in your work
• Share support
• Find joy in learning!
• Vote at end for the most joyful speculum story
Ways to practice on your own
• Practice words that will reassure patient
• State the expected
• You tube teaching videos – also humorous
• My beautiful cervix
• One video recommended masturbate prior to exam – increased lubrication and opened up vagina
• Humor “JoJo Head” “pinch grunt”
• “No Kids for You” Humorous use of duct tape, umbrella…
• Find joy
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SUCCESSFUL PELVIC EXAMINATIONS
• Maximize comfort
• Know what your challenges will be• Position
• Speculum choice
• Patient characteristics
• What are Normal cervix vs. STI
• Recent trauma
• General categories
• Adolescent
• Post menopausal
• Chronic medical conditions
• Developmental disability
• Genital surgery
• Specific cases
• Sent in
• From the audience
SUCCESSFUL PELVIC EXAMINATIONS
• Potential challenges• Patients feel exposed and lack control
• Emotional distress and fear of pain – patient reluctant
• Racial and ethnic groups fear how they will be treated
• Sexual minority groups
• Obese women
• Women with other disabilities
• Victims of sexual assault
• Trauma victims • Challenging Pelvic Exam , Bates, Carroll, Potter J Gen Intern Med 26(6)651-7
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Solutions for Success• Empower the patient
• Explain / demonstrate
• Elicit details about past experiences with pelvic exam and strategize together
• Plan / explain exam while clothed and before recline.
• Void before exam
• Chaperone
• Policy for chaperone per institution/ gender of provider
• Advocate for emotional support
• Educate advocate
Recommendations for exam after trauma
• Acknowledge patients anxiety
• Accommodate requests
• Do what is necessary in time constraints
• Supportive person/ object
• Keep clothed respectfully as much as possible
• Assure patient that examiner will stop if asked – negotiate what next
• Include patient in plans for best positioning
• Keep informed using positive language
• Anxiolytic medication if appropriate.
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Disassociate
• Some patients methods for coping
• Child like voice
• Startle to ambient sounds
• Continue with your evaluation of best practice.
Positions
• Maximize comfort
• Maximize information
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Dorsal lithotomy using stirrups
• Practitioner has good visibility and access for evidence collection
• Patient able to lie on back
• Uses foot supports (stirrups) for lower limb support
• Moves to edge of exam bed
• Speculum handle down
Side Lying Knee-Chest
• Does not require stirrups
• For woman who is comfortable and balanced on side
• Top leg closer to chest,
• Bottom leg straightened
• Speculum handle pointed either direction
• Angle speculum toward small of back – not toward patients head
• Assistant may elevate leg
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V-shaped Position
• May or may not need stirrups
• Patient must be able to lie on back
• Speculum inserted with handle up
• May be more comfortable with support pillow in small of back.
Diamond-shaped position
• Stirrups not needed
• Must be able to lie flat on back
• Speculum with handle up
• Assistant may be needed to hold feet together
• Wedge, Pillow, or bath blanket may be used under small of back to elevate
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Use of Obstetric Stirrups
• Offer more support
• Not likely available in ED setting
• If position is best choice, try using support staff to position legs.
M-shaped position
• Does not require use of stirrups
• Entire body supported by table
• Patient lies on back, knees apart, feet resting close to buttocks
• Speculum inserted with handle up
• If patient needs support, assistant may hold feet in place
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External genital evaluation
• Evaluate structures
• Document injuries
• Photo-documentation
• Evidence collection
laceration
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Laceration
Laceration and erythema
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Lichen Sclerosis
Speculum
• Speculum is just one tool to help you maximize information
• Now lets review how to maximize comfort
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Our tools can be mistaken
Photograph speculums Shoes arrived by mail
Our tools can be mistaken
• Several years ago, my husband thought that my speculum collection was a collection of shoe horns.
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Speculum selection
• Based on history of patient previous experiences
• History of assault
• Size
• Available selection at your institution
Pederson- or - Graves
Vaginal length and width vary by age, race, parity and height, and weight.
Narrow speculum may be more comfortable, Wide speculum may provide better visuilzation
op1
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Slide 28
op1 office pc, 9/6/2018
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Ultra-narrow vs. Medium Pederson
Fiber optic lighted transparent
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Insertion technique – make your own video
• Hand separate labia
• Initial insertion oblique
• Avoid sensitive anterior structures
• Angle speculum depends on anatomy• If anteverted, direct toward spine
• If retroverted direct toward sacrum
• See rugae? – anterior or lateral
• Smooth? Posterior
• Reinsert if needed to find cervix
• Lock open NO distressing clicks
Cant find cervix?
• Use finger to sound vagina
• Estimate length
• Estimate location
• Change speculum size or type/shape
• Use condom to hold back lateral walls of vagina
• Avoid skimming cervix
• Open handle end of speculum
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Our tools can be mistaken
• En Route to Panama to provide Pap smears, my suitcase was packed with plastic speculae.
So I made sun glasses out of speculae!
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Vaginal Gallery
• Look for pink folds of rugae
• Color and texture of discharge
• Erythema
• History
• Document any injuries.
The Cervix
• Evaluate cervix
• Collect
• photograph
• Look at lateral vaginal walls
• Swab vagina for evidence
• Closing speculum• Care not to trap cervix or vaginal tissue
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Cervix Gallery
Cervix Gallery - fertile mucous, mid spot
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Cervix Gallery• Cervix has two cell types
• Squamous cells – flat light pink line vagina and face of cervix
• Columnar cells more red, appear rough, line the inner part of the cervical tube
• Transition zone changes with age
• Transition zone susceptible to HPV –cervical cancer
• This slide has a pap collection brush in the cervical os, transition zone clearly demarcated
Cervix Gallery – ectropian
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Cervix Gallery – healed lacerations
Cervix Gallery – polyp and polypectomy
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Cervix Gallery; Menses – os and rugae
Cervix Gallery normal variations
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Cervix Gallery
Cervix Gallery Herpes
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Cervix Gallery Herpes
Chancre Gallery –Chanre (syphyllis)
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Cervix Gallery petechiae
Cervix Gallery -Trichomonas
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Cervix Gallery Chlamydia
STI Gallery - Gonorrhea
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STI Gallery - HPV
Genital Gallery Yeast and BV
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Genital variations
• Female Genital Cutting
• Illegal in US and European Countries, still widely practiced .
• Piercings/ tatoos / implants
• Increasing in popularity, can alter the genital structures
• Trans with bottom surgery
• Post radiation
• Genital cancer/ vulvectomy
Female Genital Cutting
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Type 1
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Type III
Type III
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Why you should keep your training speculum in the glove box
• Can practice en route to the exam
• Can show it to the officer who pulls you over when you tell them that you are going to a SA case and you need to not make the victim wait.
• Self lighting feature could be used as a flashlight
Specific cases
• Atrophic Vaginitis
• Atrophy and stenosis, shortening and reduced elasticity following radiation
• Liberal use of lubricant
• Topical lidocaine
• Weigh benefit/risk of blind collection
• If internal injuries need to be evaluated, involve ED staff, consider conscious sedation if patient and staff agree to benefit.
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Specific cases – Vulvodynia/ vestibulitis/ vaginismus
• Tactile discomfort with touching Labia or area around the vagina
• Vaginismus – painful spasms
• Generous use of lubricant
• Discontinue exam, weigh risk –benefit to continue
Choosing positions/stirrup use
• Good visibility
• Examiner evaluation of injuries and evidence collection
• Patients perception
• Position can be perceived as disempowering, abusive and humiliating
• Don’t replicate position of assault if possible
• Physical comfort
• Language – “stirrups” vs. “foot supports”
• “Cold and hard” vs. “easy to clean”
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Gender non conforming
• Sensitivity to possibility of previous experiences with the system
• Concern for voyeurism on the part of health care providers
• Advocate present sensitive to circumstances
Patients with disabilities
• High prevalence of abuse with patients with disabilities
• Most victims are able to assent and cooperate with exam
• Plan for time - Let your back up know you will be longer with this exam
• Safe positioning/ transfer/
• Respectful etiquette• Include PCA, service animal, sign interpreter
• Screen for potential abuser to be Relative/ caregiver
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Side walls caving in?
• Use a condom to hold side walls back
• Used widest/ largest speculum available
• Open handle aperture slowly
I don’t have many opportunities
• Use your practice speculum
• Insert into your hand demo
• Cooking jars
• Review teaching tapes on internet
• Hand separate labia
• Initial insertion oblique
• Avoid sensitive anterior structures
• Angle speculum depends on anatomy• If anteverted, direct toward spine
• If retroverted direct toward sacrum
• See rugae? – anterior or lateral
• Smooth? Posterior
• Reinsert if needed to find cervix
• Lock open NO distressing clicks
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Color range –Pale pink to cyanotic blue
Specific Case
• Developmentally delayed Adult
• Unable to sit
• Use any assistance –How does PCA do peri care?
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Unable to Relax
• Use your confident positive words
• Share control with the patient
• Let patient know the benefit to seeing Cx, collection
• Offer time to relax
• Anti anxiety Rx
• Problem solve together – What has worked in past
• Engage advocate if appropriate
• Use smallest tools available
I have a long vagina
• Use longest tool available
• Roll hips up on bath blanket
• Raise hips on fists
• Separate Labia Majora to get more length from speculum blades
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Cant find the cervix
• Check surgical history
• Digital exam – how deep/ which direction
• Angle speculum depends on anatomy
• See rugae? – anterior or lateral
• Smooth? Posterior
• Reinsert large if needed
• Posterior pressure / rock handle
• Patient position – roll hips
Conclusion
• Pelvic exams are a challenge for the practitioner as well as the patient
• Improve the technical skills of the provider
• Acceptance and comfort of the diverse / traumatized patients
• With
• positive information,
• close collaboration,
• Modicum of creativity,
Even the most challenging pelvic examinations can be successful.
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So use your lenses and turn on those lights