Approaches to Patient Scenarios
Question
You are a nurse practitioner and you have 3 different patient scenarios. How would you approach these topics/scenarios?
1. A 12-year-old female has had secondary amenorrhea for 3 months. She started her menses at 9 years old and has had a 28-day cycle for the past 2 years. What do you want to do and why? How would your approach vary if the patient were 10 years old and had her menses for only 6 months?
2. After several discussions with her clinician, Erica decides to start taking birth control pills as her contraceptive method. She is dispensed 4 packs with verbal and written instructions. Erica, however, is also given advice by her girlfriend on how to take the pills. Whenever Erica begins her period, she stops taking the pill and does not start a new pack until the Sunday after her bleeding stops. In 6 months, Erica is pregnant.
3.Judy refuses any form of hormonal contraception. She is afraid of needles and therefore does not want Depo. She does not want to gain weight or “be changed” by the pill. The thought of something in her arm is “freaky”, no Norplant is out. She is consistently given condoms and vaginal contraceptive film by the clinic. Several months later, Judy is pregnant. She hadn’t been using condoms. She just shrugs, “I didn’t think that I would really get pregnant, I had chlamydia; doesn’t that make you infertile?”


Solution
Approaches to Patient Scenarios
Approach to scenarios 1
For this case, what I
would want to do as a nurse practitioner is to determine the underlying cause.
Etiological factors include pregnancy, stress, weight changes, underlying
illness, primary ovarian insufficiency, hypothalamus disorders, pituitary disorders,
ovarian tumors, or other hormonal problems such as excessive production of
prolactin and benign pituitary tumors (Kerns et al., 2022). Determining the
cause will guide the diagnosis process and how to approach the issue in terms
of treatment strategies. However, it is common for girls to skip or experience
irregular periods, especially during the first two years. In the case of a
ten-year-old who had menses for only six months, the approach would be similar.
This is because the factors causing secondary amenorrhea are similar,
especially during the first two years of menstruation. Ruling out the cause
will also provide a practical guide for diagnosing the underlying abnormality
and evaluating the applicable treatment strategy.
Approach to scenarios 2
Birth control pills are
meant to prevent one from getting pregnant effectively. The instructions for a
28-day pack are that one pill should be taken daily for four weeks in a row and
start a new pack on the 29th day (Borsella, 2021). Therefore,
contraceptive pills are meant to be taken continuously during or off- periods.
Taking contraceptive pills as directed can be about 99% effective in pregnancy
prevention. Missing one or more pills during a cycle places one at a higher
risk of unwanted pregnancy. This explains Erica’s situation. She followed the
wrong guidelines in taking the contraceptive pills as she stopped taking the
pill during her period instead of continuing. Also, she ought to complete a
pack before beginning on a new pack. Her wrong ways of taking the contraceptive
pills have made them less effective, which has led to her pregnancy. Therefore,
I will explain to her the mistake that resulted in pregnancy for this scenario.
After that, I will advise her to seek an effective family planning method six
weeks after giving birth and follow the practical instructions and guidelines
to avoid unwanted pregnancies.
Approach to scenarios 3
Chlamydia is a severe
infection that causes Pelvic Inflammatory Disease (PID), which increases the
risk of blockage, scarring, and inflammation of the reproductive organs,
especially the fallopian tubes (Leeper & Lutzkanin, 2018). This can make
fertilization impossible. However, one can still get pregnant with a chlamydia
infection in some cases. Therefore, Judy should not have assumed that she would
not get pregnant since she had the infection. Consequently, her contraceptive
option, vaginal contraceptive film, is a super-thin film usually inserted in
the vagina. It dissolves and eventually releases nonoxynol-9, a chemical
responsible for killing sperms.
However, according to the
Centres for Disease Control and Prevention, the vaginal contraceptive film is
not as effective as other birth control methods. It is 82% effective; hence a
woman may get pregnant within the first year of use ((Mauck & Vincent,
2020). However, another contraceptive method should be used to increase its
effectiveness, such as in Judy’s case, where she was advised to use condoms.
Her pregnancy resulted from the low effectiveness of vaginal contraceptive film
and her failure to use another birth control as a backup. For her case, I will
advise her to seek professional medical treatment to treat the chlamydial
infection since it may lead to complications during pregnancy. During
pregnancy, infected women are more likely to go into preterm labor, deliver
prematurely, have a low birth weight baby, or experience premature membrane
rupture (Leeper & Lutzkanin, 2018). Also, the antibiotics used to treat the
infection are safe for use during pregnancy.
References
Borsella, M. (2021). Women’s Knowledge of, Access to, and
Experiences with Emergency Contraception in New Brunswick (Doctoral
dissertation, Université d’Ottawa/the University of Ottawa).
Kerns, J., Itriyeva, K., & Fisher, M. (2022). Etiology
and management of amenorrhea in adolescent and young adult women. Current
Problems in Pediatric and Adolescent Health Care, 101184.
Leeper, C., & Lutzkanin, A. (2018). Infections during
pregnancy. Primary Care: Clinics in Office Practice, 45(3),
567-586.
Mauck, C. K., & Vincent, K. L. (2020). The postcoital test in the
development of new vaginal contraceptives. Biology of reproduction, 103(2),
437-444.




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