Chester Clinic

 

Case study 06.qxd

Case Study 06.qxd 3/30/06 3:44 PM Page 6-1 A d o l e s c e n t
Adapted from Thomson Delmar Learning's Case Study Series: Pediatrics, by Bonita E. Broyles, RN, BSN,MA, PhD. Copyright 2006 Thomson Delmar Learning, Clifton Park, NY. All rights reserved.
■ White American ■ Doxycycline (Vibramycin) ■ Sexually active teenager ■ Confidentiality of minor client ■ Client teaching Overview: This case requires knowledge of sexually transmitted diseases (STDs), growth
and development, as well as an understanding of the client's background, personal situation, and mother-child attachment relationship.

Case Study 06.qxd 3/30/06 3:44 PM Page 6-2 Lynn is a sexually active 15-year-old who lives in a suburban neighborhood
with her parents and two younger sisters. She does not confide in her par-
ents about her activities, but rather discusses them with her two best friends
in high school, who also are sexually active. Last week a guest speaker at
school discussed the topic of sexually transmitted diseases (STDs) which
Lynn thought quite a bit about since the discussion. She has an appoint-
ment tomorrow for her annual gynecologic examination.
Case Study
In the privacy of the examination room, Lynn tells the nurse about her sexualactivity and comments that her boyfriend has been experiencing a penile dis-charge and is concerned that "he may have infected me with some disease."When questioned by the nurse, Lynn states that she has not experienced anyvaginal discharge, odor, itching, or painful intercourse. The nurse collabo-rates with the gynecologist, who prescribes a C. trachomatis point-of-care test.
1. Discuss the significance of Lynn's
7. What are the common complications
associated with Lynn's condition if it is not 2. Discuss the incidence of chlamydia.
effectively treated? 3. What other assessment data would be
8. Lynn is prescribed doxycycline 100 mg
helpful for the nurse to have to prepare by mouth twice a day for 7 days. Discuss Lynn's care plan? your impression of this prescription.
4. What are the priorities of care for
9. Discuss the adverse effects associated
Lynn during this visit? with Lynn's medication prescription and 5. Discuss the relationship between
the appropriate nursing actions when Lynn's level of growth and development giving Lynn this prescription to fill.
and her risk for STD.
10. Discuss Lynn's priority teaching
6. Lynn's C. trachomatis point-of-care test
needs prior to her discharge from the is positive. What does this finding mean? Questions and Suggested Answers
1. Discuss the significance of Lynn's clinical manifestations. Although
Lynn is asymptomatic, her boyfriend has a penile discharge. According to
the Center for Disease Control and Prevention (CDC), with most STDs, the
woman experiences vaginal discharge, odor, painful urination, and/or
painful intercourse.
Copyright 2007 by Thomson Delmar Learning, a division of Thomson Learning, Inc. Permission to reproduce for classroom use granted.

Case Study 06.qxd 3/30/06 3:44 PM Page 6-3 2. Discuss the incidence of chlamydia. According to the CDC, chlamydia
is the most frequently reported bacterial sexually transmitted disease in the
United States. In 2002, 834,555 chlamydial infections were reported to
CDC from 50 states and the District of Columbia. Under-reporting is sub-
stantial because most people with chlamydia are not aware of their infec-
tions and do not seek testing. An estimated 2.8 million Americans are
infected with chlamydia each year. Women are frequently reinfected if their
sexual partners are not treated.
3. What other assessment data would be helpful for the nurse to have to
prepare Lynn's care plan?
b. How sexually active Lynn is and with how many partners c. Usual menstrual cycle d. Presence of painful urination e. Lynn's use of birth control f. Partner(s)'s use of latex condoms g. Results of C. trachomatis testing 4. What are the priorities of care for Lynn during this visit?
a. Risk for infection, transmission related to contagious nature of STDs b. Risk for injury related to complications of STDs c. Impaired tissue integrity related to presence of pathogenic d. Situational low self-esteem related to having a socially unacceptable e. Deficient knowledge related to condition, treatment, prevention of 5. Discuss the relationship between Lynn's level of growth and develop-
ment and her risk for STD. Adolescence is the second and final growth
spurt during the life cycle. Boys gain more lean muscle mass and girls
develop an increased percentage of body fat in preparation for childbirth.
In addition, this is a time of hormonal changes during which girls develop
breast tissue, menarche begins, and sexual maturation occurs. This is the
stage of identity versus role confusion, and peers are the primary source of
a sense of belonging. Opposite-sex relationships become common, and the
pressures of peers can lead to risk-taking behaviors, among them sexual
intimacy. According to the CDC, "Because the cervix . . of teenage girls
and young women is not fully matured, they are at particularly high risk for
(chlamydia) infection if sexually active."
6. Lynn's C. trachomatis point-of-care test is positive. What does this find-
ing mean? According to the CDC, the C. trachomatis point-of-care test is used
to diagnosis chlamydia. These tests were developed so that they "can be
Copyright 2007 by Thomson Delmar Learning, a division of Thomson Learning, Inc. Permission to reproduce for classroom use granted.

Case Study 06.qxd 3/30/06 3:44 PM Page 6-4 performed within 30 minutes, do not require expensive or sophisticatedequipment, and are packaged as single units. The results are read qualita-tively. These so-called rapid or stat tests can offer advantages in physicians'offices, small clinics and hospitals, detention centers, and other settingswhere results are needed immediately" so treatment can begin. Lynn's testis positive, meaning she has a chlamydial infection.
7. What are the common complications associated with Lynn's condition
if it is not effectively treated? According to the CDC, "If untreated, chlamy-
dial infections can progress to serious reproductive and other health prob-
lems with both short-term and long-term consequences. Like the disease
itself, the damage that chlamydia causes is often ‘silent.' In women,
untreated infection can spread into the uterus or fallopian tubes and cause
pelvic inflammatory disease (PID). This happens in up to 40 percent of
women with untreated chlamydia. PID can cause permanent damage to the
fallopian tubes, uterus, and surrounding tissues. The damage can lead to
chronic pelvic pain, infertility, and potentially fatal ectopic pregnancy. .
Women infected with chlamydia are up to five times more likely to become
infected with HIV, if exposed."
8. Lynn is prescribed doxycycline 100 mg by mouth twice a day for 7 days.
Discuss your impression of this prescription. Doxycycline is among the
common agents used to treat chlamydia infections. Other agents used
include azithromycin 1 g by mouth in a single dose; erythromycin 500 mg
by mouth q.i.d. for 7 days; erythromycin ethylsuccinate 800 mg by mouth
four times a day for 10 days; ofloxacin 300 mg by mouth b.i.d. for 7 days,
or levofloxacin 500 mg by mouth for 7 days. Lynn's dose, frequency, and
duration of treatment is appropriate according to the CDC. The student
should question whether Lynn's boyfriend also is being treated to prevent
reinfection.
9. Discuss the adverse effects associated with Lynn's medication prescrip-
tion and the appropriate nursing actions when giving Lynn this prescription
to fill. Doxycycline is a tetracycline and the dose can be taken with meals
and with a full glass of water to help prevent esophageal ulcerations. The
most common adverse effect is photosensitivity so Lynn should be told to
avoid such activities as sun bathing and swimming in outdoor pools until
she has completed her prescription because she can easily experience a
sunburn even with limited time in direct sunlight. When outdoors she
should wear sunscreen. Lynn's sexual partner(s) also must be identified,
tested, and treated to avoid reinfection and sexual activity should not
resume until treatment is completed. However, if sexual activity does con-
Copyright 2007 by Thomson Delmar Learning, a division of Thomson Learning, Inc. Permission to reproduce for classroom use granted.

Case Study 06.qxd 3/30/06 3:44 PM Page 6-5 tinue, latex condoms should always be used to avoid reinfection. The nursemust stress to Lynn that she take the entire prescription to avoid the devel-opment of antibiotic-resistant microorganisms.
10. Discuss Lynn's priority teaching needs prior to her discharge from the
clinic.
a. Assess Lynn's level of understanding about chlamydia b. Following collaboration with the health care provider, provide Lynn verbal and written instructions regarding: (1) CDC recommendations, "To help prevent the serious consequences of chlamydia, screening at least annually for chlamydia is recom-mended for all sexually active women age 25 years and younger." (2) Transmission of chlamydia infections (during vaginal, anal, or oral sex) and that any sexually active person is at risk for chlamy-dia infection as well as other STDs (assuming other STDs wereruled out).
(3) Medication administration including importance of compli- ance with her prescription of doxycycline (4) Signs and symptoms of adverse effects of doxycycline(5) Signs and symptoms of worsening of condition(6) Contact phone numbers to report signs and symptoms(7) Importance of regular handwashing and appropriate technique(8) Importance of follow-up with health care provider c. Encourage Lynn to discuss her sexual activity and pregnancy pre- vention with her mother.
d. Provide for sufficient time for Lynn and her mother to ask ques- tions, answering them honestly.
e. Document teaching and client and family response.
Daniels, R. (2002). Delmar's manual of laboratory and diagnostic tests. Delmar North American Nursing Diagnosis Association. (2005). Nursing diagnoses: Definitions & classification, 2005–2006. Philadelphia: NANDA.
Spratto, G. R. & Woods, A. L. (2007). PDR nurse's drug handbook, 2007 edition.
Clifton Park, NY: Thomson Delmar Learning.
U.S. Centers for Disease Control and Prevention. http://www.cdc.gov Copyright 2007 by Thomson Delmar Learning, a division of Thomson Learning, Inc. Permission to reproduce for classroom use granted.

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