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