Transcript Slide 1

Part 2
Routine Gynecologic Health Care
Module 1
Facilitating a GYN Examination
Objectives
Facilitating a GYN Examination
At the completion of this module the participant will
be able to:
1. Identify the areas that may require special attention
when taking a reproductive health history in WWD.
2. Discuss the preparation and components required in
safely transferring WWD to the examination table.
3. Describe strategies to minimize spastic activity during
pelvic examinations.
4. Describe 5 alternative positions for accomplishing a
pelvic examination.
Preparation for the Appointment
• Schedule a longer appointment
• Select the most accessible exam room and
have necessary equipment available
• Practice with staff
– Ask for patient’s preferences
– Providing assistance
– Safe transfer techniques
• Flag the chart to indicate patient requires
accommodation
History: what to include
• Reason for the visit
• Menstrual history:
– Menstrual calendars can be very helpful
– Ask about specific symptoms associated with the periods,
e.g. increased seizure activity, mood changes
• Sexual history:
– Women with disabilities are often seen as asexual. Ask
specifically about sexual activity, past and present, abuse
history and need for birth control.
• Gynecological history
• Reproductive history and reproductive plans/desires
• Discuss past pelvic exam history and experience
Preparing for the Pelvic Exam
Before the exam, determine if your exam is for
preventive care only, or adds to the diagnosis
of a presenting problem
Assure that the patient feels safe, well
supported, and confident that she will not fall
Consider extra padding on exam table, use
pillows and blankets liberally
ADA Requirements for Office
Adaptation
If a physician's office does not provide an
examination table that can be accessed, the office
must provide assistance to help patients onto the
high tables, including lifting them if necessary.
Such measures must be undertaken in a safe
manner to avoid injury to the patient and to preserve
the dignity of the patient as much as possible.
Source: ADA 1990 1
Transferring to the Examination
Table
Be prepared to assist patients with transfers to
the exam table
Consider adapting the office with an electric
table for ease of transfers, also helpful for
other patients with mobility issues
Do not perform exams in the wheelchair
(including breast exam) unless it is preferred
by the patient and no other option is available
Adjustable Examination Table
Lowers to
17-20 in.
Side rails
and leg rests
Transfer Assistance
Several options are available to transfer
the patient who uses a mobility
assistance device to the exam table
Some women need assistants, use of a
transfer board or a lift
Adapt transfer strategy for each patient
and situation
Accomplishing Safe Transfers
Make sure
to lock the
wheel
chair
Use
assistive
devices
Teach
personnel
safe lifting
techniques
Assistants
should
stay with
the patient
to prevent
falls.
Transfer to a High-Low Table
Source: Simpson KM. Table Manners and Beyond.20012
Assisted Transfers with a board
• A transfer board can
provide support and
increase safety
• Requires exam table to
be close and at the same
height as the wheelchair
seat height
Source: Sure Safety Transfer Board 3
Easy Pivot Lift
• Safe and effective
transfers
• Useful for skin inspection
and undressing as well
as transfers
• Operated by single
assistant
• Requires no effort from
user
Source: Easy Pivot Lift 4
Sling (Hoyer-type) Lift
• Manual or battery
powered
• May be portable or
permanently
installed
• User is suspended
in sling during
transfer
Source: Ultralift 1000 5
Two-Person Transfer
One assistant
stands behind the
patient and lifts
under the arms
A second assistant
stands in front of
the patient and lifts
under the knees
Patient seated in wheelchair
crosses her arms
Source: National Institute of Dental and Craniofacial Research, NIH 6
Positioning on the exam table
Be aware of:
Impaired
balance,
weakness
Spasticity
Skin
pressure,
especially
over the
sacrum
Contractures
Pelvic Exam –
Managing Spasticity
• Slow, gentle positioning can minimize
spastic activity
• Use of diazepam or Baclofen should be
done with great care 7, 8(see text)
• A local anesthetic gel may be helpful in
minimizing discomfort and unintended
stimulation
Pelvic Exam – Important tips
Empty bladder first
Stirrups may hinder, not help. Consider
alternatives
Alternative positions can be used to
facilitate the exam. Let the patient help you!
Pelvic Exam – Choice of
Speculum
• Try a small narrow Pedersen for women
with narrow introitus
• Some WWD will have pelvic laxity and a
larger Graves speculum is helpful
Pederson Speculum
Graves Speculum
Pelvic Exam – Other
Considerations
If a traditional pap smear
cannot be obtained a
modified pap or HPV DNA
testing can be done
Use of pelvic ultrasound can
be considered if exam is
impossible
• Consider insurance issues with this
Side-Lying Knee Chest Position
• When side-lying
position needed
• Lower leg may be
straightened
• Assistant supports
legs, turning
• Insert speculum with
blades pointing to
back
Source: Simpson, Table Manners and Beyond, 2001 2
Diamond Position
• Offers more support
• Assistant(s) may
support knees and
feet
• Insert speculum
handle up
• Perform bimanual
from side of table
Source: Simpson, Table Manners and Beyond, 2001 2
OB Stirrup Position
• Assist in leg
placement
• Use padding and
straps if necessary
• Insert speculum
handle down
• Perform bimanual
from foot of table
Source: Simpson, Table Manners and Beyond, 2001 2
V Position
• Assistant(s) support
one or both legs at
the knee and ankle
• Insert speculum
handle up
• Perform bimanual
from side of table
Source: Simpson, Table Manners and Beyond, 2001 2
M Position
• Offers support
• Useful for
amputees
• Insert speculum
handle up
• Perform bimanual
from side of table
Source: Simpson, Table Manners and Beyond, 2001 2
Coding Suggestions
• Understanding and
using E/M service
codes is essential for
appropriate billing.
• See ACOG Quick
Reference on CPT
Coding for Women
with Disabilities (12)
Summary –
The GYN Examination
Preparation and communication are key
• Prepare patient, space, staff, equipment
• Communicate with patient, staff
• Review and refine
Facilitating the GYN Examination
Module Quiz
True/False
1. When taking a patient history, discuss previous
experience with a pelvic exam.
2. Ask the patient about her transfer needs and
techniques that work for her.
3. A technique to manage spastic activity during the
examination include using a slow and gentle approach.
4. Use a pediatric speculum for who have a narrow
introitus or limited hip mobility.
5. Positioning for a pelvic examination requires that the
patient be on her back
References – Part 2 Module 1
Slide
Reference
6, 9
1. Americans with Disabilities Act of 1990, Title 42 Public Health and Welfare. Accessed at
http://www.ada.gov/pubs/ada.htm#Anchor-36876 on 12/10/07
11,12,
21-25
2. Table Manners and Beyond: the Gynecological Examination for Women with Developmental Disabilities
and other Functional Limitations. Ed Simpson KM. Women’Wellness Project., 2001. Accessed at
http://www.bhawd.org/sitefiles/TblMrs/contents.html on 12/20/07
12
3. Sure Safety Transfer Board. Accessed at http://store.wrightstuff.biz/transferdisc.html. Accessed on
12/20/07
13
4. Easy Pivot Lift. Accessed at www.easypivot.com Accessed on 1210/07
14
5. Ultralift 1000. Accessed at www.just-patient-lifters.com on 12/10/07
15
6. National Institiute of Dental And CranioFacial Research. Wheel Chair Transfer: A health provider’s guide.
Nationa. NIHl Accessed at: http://ice.iqsolutions.com/nohic/poc/publicatioin/wheelchair.pdf on 12/10/07
17
7. Zafonte R, Lombard L, Elovic E. Antispasticity medications: uses and limitations of enteral therapy.
American Journal of Physical Medicine & Rehabilitation 2004; 83(10 Suppl):S50-8.
17
8. Mooney JF 3rd, Koman LA, Smith BP. Pharmacologic management of spasticity in cerebral palsy. Journal
Of Pediatric Orthopedics 2003; 23(5):679-86.
20
9. Quint EH, Elkins TE. Cervical cytology in women with mental retardation. Obstetrics and Gynecology
1997;89: 123-6.
20
10. Matthews-Greer J, Rivette D, Reyes, R, Vanderloos, CF, Turbat-Herrera EA. Human papillomavirus
detection: verification with cervical cytology. Clin Lab Sci 2004;17:8-11)
References – Part 2 Module 1
Slide
Reference
20
11. Lee KJ, Lee JK, Saw HS. Can human papillomaviurs DNA testing substitute for cytology in the detection
of high-grade cervical lesions? Arch Pathol Lab Med. 2004:128:298-302.
26
12. Refer to CPT Coding in Quick links at http://www.acog.org/
Module 2
GYN Health Care
Objectives
GYN Health Care
At the completion of this module, the participant
will be able to:
1. Identify the barriers to and special considerations
needed for breast and cervical cancer screening for
women with disabilities.
2. Discuss barriers to identification and treatment for
sexually transmitted infections in WWD.
3. Understand the requirement for the examination of the
skin and identification of potential skin breakdown.
GYN Cancer Screening
GYN Cancer Screening
WWD are less likely to have
recommended cancer
screening
• Risk is not acknowledged
• Inadequate access
All women require ageappropriate cancer
screening regardless of
functional limitation
Cervical Cancer Screening
Cervical Cancer Screening
Occurrence
Women with severe functional limitations
are 57% less likely to receive pap smears
than women without disabilities1
Women with severe functional limitations
(FL) are offered fewer pelvic exams and
pap smears 2
Source: Chan 1999 (1) and Diab 2004 (2)
Attitudinal Barriers
Cervical Cancer Screening
WWD are seen as asexual and
not at risk for HPV infection
associated with cervical cancer.
HCP uncomfortable with the
disability and fear autonomic
dysreflexia from the exam.
Environmental Barriers
Cervical Cancer Screening
Difficulty getting on exam table (37%)
Lack of time (31%)
Inability to find a provider (29%)
Insurance
Source: Nosek & Howland 19974
Autonomic Dysreflexia (ADR)
Occurs in women with spinal cord injury (SCI) at
or above T6
Response to noxious pelvic stimulation
Requires immediate attention
– Stop the examination
Avoid ADR by emptying bladder and minimizing
stimulation/discomfort
Overcoming Attitudinal Barriers
Cervical Cancer Screening
• Ask all patients about sexual
activity and other risk factors for
HPV
• Involve the patient in her care
and ask how the exam can be
made easiest for her
• Take time with the patient or
reschedule for the exam at a
better time
Overcoming Practice Barriers
Cervical Cancer Screening
Attempt to adapt office practice to women with disabilities
Practice facilitating pelvic exams
Modify Pap technique if needed and /or consider HPV DNA
testing.
Coordinate care
Learn about autonomic dysreflexia and how to prevent and treat
it.
Cervical Cancer Screening
Frequency Considerations
• Criteria for screening start and intervals are the
same as in the general population
• If too uncomfortable to do exam, assess risk of
HPV infection
–
–
–
–
Sexual activity
Number of partners
Smoking
History of previous HPV
• Discuss with patient a reasonable approach
Using Anesthesia for Pelvic
Exam
When is it
appropriate?
Issues of
consent
Maximize
impact :
Coordinate
with other
providers
Consider
ultrasound
as an
alternative
Breast
Cancer
Screening
Mammography Scenario
Breast Cancer Screening
• Women over age 65 with 3 or more
functional limitations (FLs) were less
likely (28.3%) to receive a mammogram
in the last year than women with no FLs
(37.9%). Chevarley, 200612
• Women over age 50 with self-reported
cognitive limitation were 30% less likely
than women without cognitive limitation
to utilize mammography. Legg, 200413
Breast Cancer Screening
Women’s Identified Barriers
Difficulty
getting into
position
(34%)
Source: Nosek & Howland 19974
Had not
been told by
a provider to
get a
mammogram
(25%)
Belief that
they were at
very low risk
for breast
cancer
(24%)
Attitudinal Barriers
Breast Cancer Screening
Providers
• Too difficult to have a mammogram
• No knowledge of risk factors due to no
availability of family history (more common in
women with developmental disabilities)
Patients
• Perception of risk
• Preoccupation with other health issues
Environmental Barriers
Breast Cancer Screening
• Physical
– Access to mammography sites and machines
• Social
– Adequate help not available
Breast Cancer Screening
Considerations
Mammography
If its impossible
to do a
mammogram?
• Find out in your community where the machines
are that go down low enough for wheelchair
users.
• Assess the patients physical ability to have the
test
• Ultrasound (US) use alone not established,
only as adjunct for palpable mass
• US poses insurance problems for screening
• CBE coupled with US has been used 14
Breast Cancer Screening
Guidelines / Patient Education
• Guidelines for breast cancer screening are the
same as in the general population
• Educate patients about risk factors
• Clinical exam:
– Contractures or movement may require changes in
clinical exam technique
– Train personal attendants to do breast exams
– SBE instruction for patient or trusted assistant
– CBE by Health care providers
– Mirror inspection
Accessible Mammography
• Bucky lowers to 24”
from floor
• Tilting C-Arm
• Table which adjusts for
women who can’t stand.
• Tilt features to assist
positioning.
• Ability to X-ray in
standing seated or
supine position15
Summary – Cancer Screening
• With few exceptions, cancer screening
should occur at same rate as for women
without disabilities
• Simple technique modification, patience
and patient education can facilitate most
screening
• Coordinate cancer screening with other
procedures.
Screening for
Sexually
Transmitted
Infections
•Cerebral palsy
•Cognitive impairment,
•Communication impairment
•Lives in group home
•Prejudged as not sexually
active
•Sexual abuse
•Acute abdomen - Chlamydia
STI Case Study - Jenny
Informational Barriers
Sexually Transmitted Infections
Informational barriers:
•
•
•
•
Failure to ask about sexual practices and sexual abuse
Failure to screen women for sexual activity and STI’s16
Failure to educate women about safe sex practices
Failure to offer information on seeking help for sexual
abuse.
Physical difficulty using barrier method of
contraception 17
Delayed Diagnosis – STIs
STI’s often • Mistaken for UTIs
go
• Woman may not be
undetected
able to see discharge
or
• Woman may have
diagnosis
unperceived or atypical
physical symptoms 18
is delayed
Sexually Transmitted Infections
Overcoming Barriers
• Ask all patients about risk for STI
• Regular screening warranted - Similar
incidence as in general population18
• In women with a difficult pelvic exam,
urinary screening for STI is indicated
• Educate attendant care providers about
atypical symptoms
Sexually Transmitted Infections
Overcoming Barriers
Counseling:
– Educate women about atypical symptoms of STI17
– Counsel about sexual abuse (see Part 1, Mod 2)
– Educate women about safe sex and condom use
• Be alert for latex allergy in regard to condom use
• Be aware of manual dexterity needed for some of the
barrier methods
– Women with developmental disabilities require
simple and specific messages (See Part lV
Module 2)
Summary
Sexually Transmitted Infections
• Screening is same as for general
population
• Adapt prevention strategies to
accommodate disability
Resources for Teaching on STIs
For education of women with developmental disabilities:
Let’s Talk About Health: What every woman should know (workbook
and video tape) Women’s Health Project, The Arc of New Jersey,
985 Livingston Ave. N. Brounswick, NJ 08902. (732)246-2525 x 28
http://www.arcnj.org/html/mainstreaming_medical_care.html
Woman be Healthy: A curriculum for women with mental retardation
and other developmental disabilities. North Carolina Office on
Disability and Health (919)966-0871.
www.fpg.unc.edu/~ncodh/WomensHealth
Skin Examination
Skin Health and Injury
During the GYN exam for women with
mobility impairments or developmental
disabilities, it is essential to check skin for:
– breakdown
– infectious process
– bruising
Skin Inspection
• Should be performed daily, but this does
not often happen
• Positioning for pelvic examination is a
critical opportunity to assess vulnerable
skin overlying pelvic bones (ischial
tuberosities and greater trochanters)
Skin Breakdown:
Pathophysiology
•
•
•
•
Interface pressure
Shear
Friction
Moisture
Risk Factors for
Pressure Ulceration
•
•
•
•
•
•
•
•
Limited mobility
Sensory impairment
Incontinence
Poor nutrition, dehydration
Vascular disease, smoking
Obesity, underweight
Poorly fitted equipment
Inadequate assistant care
Grade 1 Pressure Ulcer
Non-blanchable erythema, usually wellcircumscribed. Even though skin is
intact, tissue damage has already
occurred and intervention is needed.
Source: European Pressure Ulcer Advisory Panel 20
Grade 2 Pressure Ulcer
Partial-thickness skin loss involving
epidermis, dermis, or both. Appears as
an abrasion or blister.
Source: European Pressure Ulcer Advisory Panel 20
Grade 3 Pressure Ulcer
Full-thickness skin loss that involves
damage to subcutaneous tissue and
may extend to, but not through,
underlying fascia
Source: European Pressure Ulcer Advisory Panel 20
Grade 4 Pressure Ulcer
Extensive destruction/necrosis/damage
to muscle, bone, or supporting
structures. Full thickness skin loss
may not be present over entire lesion.
Source European Pressure Ulcer Advisory Panel 20
Management
•
•
•
•
Relieve pressure!
Clean and debride wound
Assess for clinical infection; consider antibiotics
For Grade 1 and early Grade 2 wounds, apply
semipermeable film dressing (e.g., Tegaderm);
use saline wet to dry dressing for deeper
wounds
• Coordinate with wound care specialists21
Summary - Skin Health
• Skin examination is an essential part of
the gynecological examination.
• Discovery of any degree of pressure
wound should prompt immediate action.
GYN Health Care
Module Quiz
True/False
1. WWD do not have the same risks as women without
disabilities for cervical cancer .
2. Autonomic dysreflexia can be averted by hydrating the
patient prior to the examination.
3. Mammography is the best screening procedure in
WWD for the detection of early breast cancer.
4. Urinary tract infections can sometimes mask sexually
transmitted infections for WWD.
5. Pressure ulcers are common and unavoidable for WWD
with mobility disabilities.
References – Part 2 Module 2
Slide
Reference
34
1. Chan et al. Do Medicare patients with disabilities receive preventive services? A population-based study.
Arch Phys Med Rehabil 1999 Jun; 80(6):642-6.
34
2. Diab ME, Johnston MV. Relationships between level of disability and receipt of preventive health services.
Arch Phys Med Rehabil 2004 May;85(5):749-57.
34
3. Centers for Disease Control. Use of Cervical and Breast CancerScreening Among Women With and
Without Functional Limitations – United States, 1994-1995. MMWR Weekly 1998;47:853-6. Accessed
September 21, 2007 at http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00055280.htm
36, 45
4. Nosek MA, Howland CA. Breast and cervical cancer screening among women with physical disabilities.
Arch Phys Med Rehabil 1997; 78(12 Suppl 5) S39-S44.
40
5. Markowitz, LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER. Quadrivalent Human
Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practice (ACIP).
MMWR 2007;56:1-24. Accessed September 21, 2007 at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr56e312a1.htm
40, 57
6. American College of Obstetricians and Gynecologists. HPV Vaccine – ACOG Recommendations. ACOG
Committee on Adolescent Health Care. Accessed September 21, 2007 at
http://www.acog.org/departments/dept_notice.cfm?recno+7&bulletin=3945.
41
7. Quint EH, Elkins TE. Cervical cytology in women with mental retardation. Obstet 75 1997;89:123-6.
41
8. Lee KJ, Lee JK, Saw HS. Can human papillomavirus DNA testing substitute for cytology in the detection of
high-grade cervical lesions? Arch Pathol Lab Med. 2004;128:298-302.
40, 41
9. American College of Obstetricians and Gynecologists. Practice Bulletin #45: Cervical cancer screening.
ACOG 2003
References – Part 2 Module 2
Slide
Reference
41
10. American College of Obstetricians and Gynecologists. Access to reproductive health care for women
with disabilities in Special Issues in Women’s Health Care. ACOG, Washington DC, 2004.
42
11. McCarthy EP, Ngo LH, Roetzhelm RG, Chirlkos TN, Li D, Drews RE, Iezzoni LI. Disparities in breast
cancer treatment and survival for women with disabilities. Annals of Internal Medicine 2006;145:637-45.
44
12. Chevarley FM, Thierry JM, Gill CG, Ryerson AB, Nosek MA. Health, preventive health care and health
care access among women with disabilities in the 1994-5 National Health Interview Survey, Supplement on
Disability. Women’s Health Issues 2006;16:297-312.
44
13. Legg JS, Clement DG, White KR. Are women with self-reported cognitive limitation at risk for
underutilization of mammography?. Journal of Health Care for the Poor and Underserved 2004;15:688-702
48
14. Smith RA, et al. American Cancer Society guidelines for breast cancer screening: update 2003. CA
Cancer J Clin 2003;53:141-69.
48-50
15. Breast Health and Beyond for Women with Disabilities: A provider’s guide to the examination and
screening of women with disabilities. Breast Health Assess for Women with Disabilities, Alta Bates Summit
Medical Center. San Francisco 2003.
54
16. Nosek, MA, et al. National Study of women with disabilities: Final Report. Sex Disabil 2001;19(1):5-39.
Accessed at http://www.bcm.edu/crowd/finding4.html on 12/10/07
54, 57
17. Schopp LH, et al.. Removing service barriers for women with physical disabilities: promoting accessibility
in the gynecologic care setting. J Midwifery Women’s Health 2002 Mar-Apr; 47(2):74-9.
References – Part 2 Module 2
Slide
Reference
55, 56
18. Monroe SA. New tests for bacterial sexually transmitted diseases. Curr Opin Infect Dis 2001;14:45-51.
62
19. Grey JE, Enoch S, Harding KG. ABC of wound healing: Pressure ulcers. BMJ 2006;332:472-5
65-68
20. European Pressure Ulcer Advisory Panel, Accessed at http://www.epuap.org/grading.html on 12/10/07
69
21. Agency for Health Care Policy and Research. Treatment of pressure ulcers. Clinical Guideline Number
AHCPR Publication No. 95-0652. December 1994 Accessed at
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.5124