troubleshooting smear taking - cervicalcheck · troubleshooting in smeartaking vaginal discharge...
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Troubleshooting Troubleshooting in in
smear takingsmear taking
Dr Aislinn DonovanDr Aislinn Donovan
ICSP Irish Cervical Screening ProgrammeICSP Irish Cervical Screening Programme-- National Study Day National Study Day --
22nd March, 200722nd March, 2007
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Troubleshooting in smeartaking
Presentation Aim
You will be better prepared
to manage difficulties that
may arise when taking smears
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Share a difficult smeartakingexperience with your neighbour
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Difficulties
• Anxious tense woman
• Cannot find the cervix
• Vaginal discharge
• Sexual issues
• Disability
• Communication barriers
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Take Stock
• Take full control
• Explain difficulties to the patient
• Be decisive
• Allay fears
• Relax and take your time
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Helping the woman to relax
• Advise woman that the smear test can be done in a few minutes
• Would she like a friend with her?
• Deep breathing may help
• Give her control - tell her you will stop if she asks you at anytime
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Patient Anxiety
Find out woman's particular fears
• procedure uncomfortable pain e.g. arthritis, find alternate position
• previous experience
• ask if she would like you to talk her through the steps of the procedure as you are doing them
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Upset during procedure
• Smeartaker’s duty to stop procedure
• Calm patient
• Give more time
• Avoid deferring test if possible
• Anxiolytic prior to procedure if no contra indications
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When you cannot find the cervix!
• Patient become more anxious
• Pelvic floor muscles contract
• The more difficulty to locate cervix the longer the procedure takes
• The smear taker becomes flustered!
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What can I do?
• Get the patient to lie flatRemove pillowFlatten couch
• Elevate the pelvisFolded towel under gluteal regionPatient hands (fisted) under gluteal region
• Does this woman still have her cervix?
• PV internal examination locate cervixAntevertedRetroverted
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It’s there but I can’t see it !
• Flaccid walls of vagina– Use larger speculum, wider, without causing discomfort
– Cut glove, at top of thumb finger and place over closed speculum, keeps walls of vagina back and not falling into speculum
– Let rest of glove hang out....so that you can pull it out!
• Left lateral position on couch– With full explanation to patient
– With full informed consent of patient
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It’s there but far away!
Speculum too short
• Gently try next size until appropriate size has been sourced
• Highlights importance of well prepared trolley with different size specula arranged on trolley
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I can see it but I can’t inspect it!
Excess mucousRequest patient to attend mid cycle to avoid menses/blood interfering with specimen
Use back of broom, rotate at outer edge cervix and remove mucous
Rotate broom & carry out procedure
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Vaginal discharge
• Mucous is common - proceed with smear test
• Discharge is less common (it may be profuse, smelly, discoloured yellow or green, bloodstained, frothy) - if you proceed to smear, remember to take any swabs after the smear test has been taken
• Contact bleeding – consider Chlamydia
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What you might find along the way!
Medical clinical signs
• Rash, may be sore or itch
• Infection, may be discharge, warts, pubic lice, ulcerated area
• Incidental finding, psoriasis, alopecia etc.
- arrange full consultation as appropriate
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Know what to expect
Variations• Hymen intact
• Bartholans cysts
• Post operative scars- episiotomy
• Vaginal scarring for other reasons
• Female genital cutting
• Narrow introitus
• Long labia
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Sensitive Issues
• VirginDiscussPatient to be fully informedIf hymen intact, do not proceed
• VaginismusDiscussCounsellingFertility issuesManagement
• Female Genital CuttingAwarenessSensitivity
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Communication difficulties
• Foreign language – interpreter formal/informal
• Medical jargon
• Complicated explanations
• Unclear messages
Keep it simple (check understanding)(check understanding)
Keep it consistent
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Disability
All eligible women should be offered a smear test
• Physical• Intellectual• Psychiatric
Information and Consent
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Social Inclusion
• This programme is for all women between 25 and 60 years
• The challenge for us is to include all women who require cervical screening
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How can ICSP support you?
• Patient literature
• Pictorial leaflet
• DesktopTerminology-Made-Simple aid
• Smeartaker Training and Mentoring
• Clinical Updates
• Website www.icsp.ie• Information Line
• Resource Manual
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End
Thank you