Guidelines 2016 – Well-Woman Annual Gynecologic Exam
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
the initial visit to a gynecologic clinician for the purpose of preventive health care that includes discussion of health topics relevant to a woman’s age and risk factors, a full comprehensive health history, an exam, screening tests, and immunizations
Refer to the american college of obstetricians and Gynecologists (acoG), Your Annual Health Care Visit, for recommended age-related health topics, exams and screening tests, and immunizations.
II. HISTORY
a. medical history
1. General health status
2. Recent changes in health status
3. allergies
4. Surgeries
5. Significant injuries
6. current medications, including herbs and supplements
7. last colonoscopy/mammogram if age appropriate
8. Vaccination status. Is the woman up to date on age-appropriate vaccines? Refer to the centers for Disease control and Prevention (cDc) vaccination guidelines for current recommendations. Federal law requires that each patient receive a Vaccination Information Statement (VIS) prior to being given any immunization. a copy of the VIS can be found on the cDc site (www.cdc.gov/vaccines).
9. Birth control history, past and present
B. Recent changes in immediate family history
c. Gynecologic history
1. menstrual history
a. last menstrual period
b. menarche
c. Interval
d. Duration
e. Flow
f. Dysmenorrhea
g. Recent changes in pattern/flow, others
D. urinary tract history
1. History of past infections: how often, treatment, approximate date of last infection
2. current problems (discomfort, pressure, incontinence)
3. History of genitourinary surgery
e. Pap smear history
1. Date of last Pap smear, human papillomavirus (HPV) vaccine or testing
2. age-appropriate abnormal Pap smear history (approximate dates, clinical intervention)
F. Sexual history
1. Sexual orientation
2. age at first sexual experience/intercourse
3. number of sexual partners
4. length of time with present partner
5. Issues related to sexual function
a. libido
b. Dyspareunia
c. Postcoital bleeding
G. Social history
1. Date of birth
2. Smoking history
a. age at first cigarette
b. number of cigarettes/packs smoked each day
c. Desire for smoking cessation
i. Prior attempts
ii. method(s) used
iii. Was it successful? If no success, would the patient like to try again?
3. alcohol use
a. age at first drink
b. current use. How many drinks per day per week?
c. alcohol type
d. Has the patient, or any family member/friends, felt or expressed concern? Does alcohol use cause issues/problems in the home or workplace? If so, a referral to a therapist might be considered and discussed.
4. Recreational drug use
a. Past use
b. Present use
c. Has the use of substances caused difficulties with relationships or in the workplace? If so, a referral might be considered and discussed.
5. exercise history
a. Does the woman exercise? What kind of exercise, for how long, and how often?
b. Has this pattern changed from a previous pattern? In what way?
6. abuse history
a. Was the woman abused as a child (physical abuse, mental abuse, sexual abuse)?
b. Is there a history of domestic violence? Does the woman feel safe at home? Does she fear harm for herself or her children?
c. If abuse is current and the woman agrees, efforts to reach local social services that deal with abuse should be noted and a plan of action developed. If the woman is not ready to act, it would be appropriate to give her the names and numbers of local
resources and strategize how she can safely keep these numbers where she can find them.
d. Women at risk should be encouraged to develop a plan for a quick departure from their residence. this plan should include, but not be limited to, bringing cash, birth certificates/passports for self and children, a spare set of car keys, copies of prescrip- tions for self and children, and a safe haven thought out in advance (see abuse and violence guidelines in Chapter 6).
7. nutritional/dietary history
a. Is the woman happy with her current weight?
b. Does she consider her diet well balanced?
c. Has she actively attempted to lose weight?
d. If so, what plans or methods has she used? Has she taken any weight-loss medication (prescription or over the counter)? Has this been successful?
e. nutritional counseling may be appropriate.
8. Safe sex practices
a. use of condom (past and present)
b. avoidance of unsafe situations involving use of alcohol, drugs, and casual, unprotected sex
c. annual Women’s Health care
III. PHYSICAL EXAM (AGE APPROPRIATE)
a. Vital signs
B. Weight/height/body mass index (BmI)
c. General exam
1. Skin
2. Head/eyes, ears, nose, throat (eent)
3. thyroid
4. lymph nodes
5. Heart
6. lungs
7. abdomen
8. extremities
9. Breasts
D. Gynecologic exam with accommodations for the woman’s ability to assume the traditional position for the examination due to limita- tions posed by musculoskeletal conditions such as arthritis, paralysis, amputation, joint replacements, and aging joints and muscles that are less flexible. consider side-lying position versus on her back with feet in stirrups.
1. external genitalia
2. Vagina
3. cervix
e. Internal pelvic exam if indicated
1. uterus
2. adnexa
3. Rectum
IV. LABORATORY EXAMINATION
a. urine dipstick/culture as indicated
B. Pap smear as indicated (refer to Pap smear guidelines in Chapter 10)
c. Sexually transmitted infection (StI) testing as indicated by age and history
D. Vaginal cultures if indicated
e. General hematologic screening as indicated by age, health history, and access to other routine health care. example: If the woman has no primary care provider and has not had a baseline lipid level, fasting blood sugar, and any other laboratory tests that seem to be indicated, then it would seem appropriate to do the laboratory tests and refer the patient as indicated.
V. TREATMENT/INTERVENTION
a. order mammogram/bone density testing as indicated by age and history
B. teach and/or reinforce breast self-examination
c. order laboratory tests as indicated
D. administer/refer for vaccines as appropriate to setting
e. teach as appropriate to history and physical findings, including, but not limited to, changes in Pap smear guidelines, diet, exercise, vaccines, smoking cessation, alcohol use, safe sex, StI testing, and general safety
F. Prescribe for birth control method chosen or any other treatment indi- cated by findings
G. allow time for questions and concerns; make future appointment(s) for discussion or evaluation of specific problems or concerns raised during the visit
H. Refer to other care providers as appropriate
Website: www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens- Health-Care/Well Woman-Recommendations
NOTE
this chapter is an ideal and comprehensive guideline created to encourage the most thorough and ideal initial well-woman exam. clearly, this guide- line is meant to be adapted to your setting and time constraints. Follow-up exam should include review and update of initial information. For a compre- hensive treatise on health assessment of women, see the companion book: Helen a. carcio and mimi clarke Secor, Advanced Health Assessment of Women (Springer Publishing, 2015). As this edition was being revised, conflicting opinions existed regarding the benefit of a bimanual exam for the well- woman exam, although the ACOG remains firm with its recommendations.