Pharmacology for Nurses: A Pathophysiologic

Approach
Fifth Edition

Chapter 46
Drugs for Disorders and
Conditions of the Female
Reproductive System

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Hypothalamus and Pituitary Regulation of
Female Reproductive System (1 of 2)
• Hypothalamus secretes gonadotropin-releasing hormone
(GNRH)
– GNRH stimulates pituitary to secrete
▪ Follicle-stimulating hormone (FSH)
▪ Luteinizing hormone (LH)
▪ These act on ovary and cause immature ovarian
follicles to begin developing

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Hypothalamus and Pituitary Regulation of
Female Reproductive System (2 of 2)
• Pituitary hormones
• Rising and falling levels create two interrelated cycles
– Ovarian cycle
– Uterine (menstrual) cycle

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Figure 46.1 Hormonal Changes During the
Ovarian and Uterine Cycles

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Estrogens
• Secreted by ovarian follicles
• Responsible for maturation of sex organs and secondary
sex characteristics of female

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Progestins
• Secreted by corpus luteum (progesterone most
abundant)
• Prepare endometrium for implantation
• High progesterone and estrogen levels in final third of
uterine cycle
– Provide negative feedback to shut off GNRH, FSH,
and LH secretion

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Figure 46.2 Negative Feedback Control of
the Female Reproductive Hormones

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Oral Contraceptives
• Hormones used to prevent pregnancy
– Most common use for female sex hormones
• Most are combination of estrogens and progestins
• Small doses prevent conception by blocking ovulation

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Table 46.1 Selected Oral Contraceptives (1 of 3)
Monophasic
Trade Name Estrogen Progestin
Desogen ethinyl estradiol: 30 mcg desogestrel: 0.15 mg
Loestrin 1.5 / 30 Fe
1.5 slash 30 F E ethinyl estradiol: 30 mcg norethindrone: 1.5 mg
Ortho-Cyclen-28 ethinyl estradiol: 35 mcg norgestimate: 0.25 mg
Yasmin ethinyl estradiol: 30 mcg drospirenone: 3 mg
Zovia - 21 and 28 ethinyl estradiol: 50 mcg ethynodiol diacetate: 1 mg
1/ 50E
1 slash 50 E, dash 21

Biphasic

Trade Name Estrogen Progestin

Mircette ethinyl estradiol: 20 mcg desogestrel: 0.15 mg for 21 days
for 21 days; 10 mcg for 5 days

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Table 46.1 Selected Oral Contraceptives (2 of 3)
Triphasic

Trade Name Estrogen Progestin

Ortho-Novum ethinyl estradiol: 35 mcg norethindrone: 0.50, 0.75, 0.1 mg
7/7/7-28
Ortho Tri-Cyclen-28 ethinyl estradiol: 35 mcg norgestimate: 0.18, 0.215, 0.25 mg
Tri-norinyl-28 ethinyl estradiol: 35 mcg norethindrone: 0.50, 1, 0.5 mg
Trivora-28 ethinyl estradiol: 30,40,30 levonorgestrel: 0.05, 0.075, 0.125 mg
mcg

Four-phasic

Trade Name Estrogen Progestin

Natazia ethinyl valerate: 3, 2, 2, 1 mg dienogest: 0, 2, 2, 0 mg

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Table 46.1 Selected Oral Contraceptives (3 of 3)
Progestin Only

Trade Name Estrogen Progestin

Micronor None None norethindrone: 0.35 mg

Nor-Q.D. None norethindrone: 0.35 mg

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Figure 46.3 an Oral Contraceptive Showing the
Daily Doses and the Different Formulation Taken in
the Last 7 Days of the 28-Day Cycle

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Estrogen–Progestin Contraceptives (1 of 2)
• Act by providing negative feedback to pituitary
– Shuts down secretion of LH and FSH
– Prevent ovulation
• Four types: monophasic, biphasic, triphasic, and
quadriphasic
– Only quadriphasic (Natazia) is approved to treat
heavy menstrual bleeding
– All types equally effective

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Estrogen–Progestin Contraceptives (2 of 2)
• Progestin-only oral contraceptives
– Produce thick, viscous mucus at entrance to uterus
▪ Mucus discourages penetration by sperm
– Inhibit implantation of fertilized egg
– Less effective than estrogen – progestin
▪ 1% – 4% failure rate
▪ Higher rate of menstrual irregularities
▪ Don’t create thromboembolic or breast cancer risk

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Long-Term Hormonal Formulations
• Extended-duration formulations equally effective
contraception
– Depot injections (Depo-Provera) – 3 months
– Subdermal implants – 3 years
– Transdermal patches – 1 patch/week for 3 weeks,
followed by patch-free week
– Vaginal device (NuvaRing) – 3 weeks (removed in
week 4)
– Intrauterine device (Mirena) – 5 years

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Oral Contraceptives, Estrogen–Progestin
Combinations (1 of 2)
• Prototype drug: estradiol and norethindrone (Ortho-
Novum, others)
• Mechanism of action: to inhibit release of FSH and LH,
thus preventing ovulation
• Primary use: as contraceptive, for improvement in
menstrual cycle regularity, to decrease incidence of
dysmenorrhea

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Oral Contraceptives, Estrogen–Progestin
Combinations (2 of 2)
• Adverse effects: edema, nausea, abdominal cramps
– Dysmenorrhea, breast tenderness, fatigue
– Skin rash, acne, headache, weight gain
– Midcycle breakthrough bleeding, vaginal candidiasis
– Photosensitivity, changes in urinary patterns
– Serious cardiovascular side effects more common in
smokers

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 Prototype Drug: Estradiol and
Norethindrone (Ortho-Novum, others) (1 of 6)
Therapeutic Class: Combination oral contraceptive
Pharmacologic Class: Estrogen/progestin
Actions and Uses
The primary use of Ortho-Novum is to prevent pregnancy, an indication
for which it is nearly 100% effective. Ortho-Novum is available in
monophasic, biphasic, and triphasic preparations. When an appropriate
combination of estrogen and progestin is present in the bloodstream,
the release of FSH and LH is inhibited, thus preventing ovulation. Off-
label indications for the drug include acne vulgaris (in females who
have achieved menarche), endometriosis, hypermenorrhea, and
dysfunctional uterine bleeding. Noncontraceptive benefits of Ortho-
Novum include improvement in menstrual cycle regularity and
decreased incidence of dysmenorrhea.
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 Prototype Drug: Estradiol and
Norethindrone (Ortho-Novum, others) (2 of 6)
Administration Alerts
• Tablets must be taken exactly as directed.
• If a dose is missed, take as soon as remembered, or take two
tablets the next day.
• Pregnancy category X.
Pharmacokinetics

Onset Peak Duration

30–60 min 1 month Up to 27 h
(1 month for
contraception)

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 Prototype Drug: Estradiol and
Norethindrone (Ortho-Novum, others) (3 of 6)
Adverse Effects
The most frequent adverse effects of Ortho-Novum are
nausea, breast tenderness, weight gain, and breakthrough
bleeding. Less common effects include edema, changes in
vision, gallbladder disease, nausea, abdominal cramps,
changes in urinary function, dysmenorrhea, breast fullness,
fatigue, skin rash, acne, headache, vaginal candidiasis,
photosensitivity, and changes in urinary patterns.
Cardiovascular adverse effects, the most serious of all,
include HTN and thromboembolic disorders.

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 Prototype Drug: Estradiol and
Norethindrone (Ortho-Novum, others) (4 of 6)
Black Box Warning: Cigarette smoking increases the risk of
serious cardiovascular adverse effects in women who are taking
hormonal contraceptives containing estrogen. This risk increases
markedly with age (over age 35) and with heavy smoking (more
than 15 cigarettes per day).
Contraindications: Hormonal contraceptives are
contraindicated in women with the following conditions: current
or past history of thromboembolic disorders, stroke, or coronary
artery disease; hepatic tumors; known or suspected carcinoma
of the breast, endometrium, or other estrogen-dependent tumor;
abnormal uterine bleeding; cholestatic jaundice of pregnancy or
jaundice with prior oral contraceptive use; known or suspected
pregnancy.
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 Prototype Drug: Estradiol and
Norethindrone (Ortho-Novum, others) (5 of 6)
Interactions
Drug–Drug: Estrogen-containing contraceptives should not
be used concurrently with tranexamic acid due to an
increased risk for thromboembolic events. Rifampin, some
antibiotics, barbiturates, anticonvulsants, protease
inhibitors, and antifungals decrease the efficacy of HCs,
increasing the risk of breakthrough bleeding and the
possibility of pregnancy. Ortho-Novum may decrease the
effects of warfarin, heparin, and certain other
anticoagulants leading to possible thromboembolic events.

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 Prototype Drug: Estradiol and
Norethindrone (Ortho-Novum, others) (6 of 6)
Lab Tests: Values of the following may be increased:
prothrombin time, certain coagulation factors,
thyroidbinding globulin, PBI, T4, platelet aggregation, and
triglycerides. Values of the following may be decreased:
antithrombin III, T3, folate, and vitamin B12.

Herbal/Food: Breakthrough bleeding has been reported

with concurrent use of St. John’s wort.
Treatment of Overdose: There is no specific treatment for
overdose.

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Table 46.2 Adverse Effects of Hormonal
Contraceptives (1 of 2)
Adverse Effect Prevention
Breast milk reduction Some studies suggest that H Cs may reduce the quantity of breast milk. They
should not be taken until 6 weeks postpartum.
Cancer Women who test positive for the human papilloma virus have an increased
risk of cervical cancer. These patients should have regular check-ups.
Because estrogens promote the growth of certain types of breast cancer,
patients with a history of this cancer should not take H Cs.
Glucose elevation HCs may cause slight increases in blood glucose. Patients with diabetes
should monitor their serum glucose carefully during H C therapy.
Hypertension Risk is increased with age, dose, and length of therapy. Blood pressure
should be monitored periodically and antihypertensives prescribed as needed,
or contraceptives re-evaluated.
Increased appetite, These are common effects often caused by high amounts of progestin. The
weight gain, fatigue, dose of progestin may need to be lowered.
depression, acne,
hirsutism
Lupus exacerbation Lupus symptoms may become worse in some patients. A progestin-only H C
may be an option for these patients.

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Table 46.2 Adverse Effects of Hormonal
Contraceptives (2 of 2)
Adverse Effect Prevention
Menstrual Amenorrhea or hypermenorrhea are often caused by low amounts of
irregularities progestin. The dose of progestin may need to be increased. Breakthrough
bleeding and spotting are common with the low-dose oral contraceptives. The
patient may need a higher dose product.
Migraines Estrogen may decrease or increase the incidence of migraines. Because
migraines are a risk factor for stroke, patients with migraines should seek
advice from their health care practitioner.
Nausea, edema, These are common effects often caused by high amounts of estrogen. The
breast tenderness dose of estrogen may need to be lowered.
Teratogenicity Estrogens are pregnancy category X. Patients should be advised to
discontinue HCs if pregnancy is confirmed.
Thromboembolic Estrogens promote blood clotting. H Cs should not be prescribed for patients
disorders with a history of thromboembolic disorders, strokes, or coronary artery
disease or who are heavy smokers.

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Role of the Nurse: Oral Contraceptive
Therapy (1 of 3)
• Monitor blood pressure
• Assess vital signs frequently
• Monitor for symptoms of thrombophlebitis

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Role of the Nurse: Oral Contraceptive
Therapy (2 of 3)
• Oral contraceptives can mimic certain symptoms of
pregnancy
– Breast tenderness, nausea, bloating, appetite
changes
– Reassure patient that side effects do not indicate
pregnancy

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Role of the Nurse: Oral Contraceptive
Therapy (3 of 3)
• May increase risk of breast cancer
– Teach patients to perform breast self-exams
– Provide information on routine mammogram
schedules

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Nursing Practice Application (1 of 15)
Pharmacotherapy With Hormonal Contraceptives
Assessment Potential Nursing Diagnoses*
Baseline assessment prior to administration: • Decisional Conflict
• Obtain a complete health history including cardiovascular, • Disturbed Body Image
peripheral vascular, thyroid, hepatic, or renal disease; • Deficient Knowledge (drug therapy)
migraines; diabetes; pregnancy; or breast-feeding. Note • Risk for Excess Fluid Volume, related to
personal or family history of thromboembolic disorders (e.g., adverse drug effects
MI, stroke, peripheral vascular disease) and of reproductive • Risk for Ineffective Peripheral Tissue
cancers (e.g., breast, uterine, or ovarian cancer). Perfusion, related to adverse drug effects
• Obtain a drug history including allergies, current prescription • Risk for Ineffective Cerebral Tissue
and over-the-counter (O TC) drugs, herbal preparations, Perfusion, related to adverse drug effects
alcohol use, and smoking. Be alert to possible drug • Risk for Ineffective Cardiac Tissue Perfusion,
interactions. related to adverse drug effects
• Evaluate appropriate laboratory findings (e.g., complete blood
count [CBC], platelets, electrolytes, glucose, lipid, and thyroid
function levels, Pap test).
• Obtain baseline height, weight, and vital signs.

*NANDA I © 2014

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Nursing Practice Application (2 of 15)

Assessment Potential Nursing Diagnoses*

Assessment throughout administration: blank
• Assess for desired therapeutic effects depending on
the reason the drug is given (e.g., pregnancy
prevention or hormone replacement).
• Continue periodic monitoring of C BC, platelets, and
glucose.
• Monitor vital signs and weight at each health care
visit.
• Assess for adverse effects: nausea, vomiting,
headache, weight gain, breast tenderness, skin rash,
acne, fluid retention, changes in mood, and
breakthrough bleeding. Immediately report
tachycardia, palpitations, and H TN, especially
associated with angina; severe headache; cramping
in calves; chest pain; or dyspnea.

*NANDA I © 2014

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Nursing Practice Application (3 of 15)
Implementation
Interventions and (Rationales) Patient-Centered Care
Ensuring therapeutic effects: • Instruct the patient to take the drug at
• Monitor appropriate medication administration for the same time daily to help remember
optimal results. (Oral contraceptives are nearly 100% to take the pill. Instruct the patient to
effective when taken as required. Skipping doses not omit doses or increase or
increases the risk of pregnancy. Other types of decrease the dose without consulting
hormonal contraception such as transdermal patches the health care provider.
or depot injections may be desirable for women who • Encourage women to discuss other
experience difficulty in adhering to oral available options (e.g., transdermal
contraceptives or for those who choose not to take patches, depot injections, subdermal
daily medication.) implants) with the health care provider
as appropriate.

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Nursing Practice Application (4 of 15)
Interventions and (Rationales) Patient-Centered Care
Minimizing adverse effects: • Instruct the patient to immediately report:
• Monitor for symptoms of thromboembolism. • Dyspnea, chest pain, or blood in sputum
Monitor blood pressure at each clinical (possible pulmonary embolism)
visit. (Thromboembolic events are an • Heaviness, chest pain, or overwhelming
adverse effect of estrogen/progestin drugs. feeling of fatigue and weakness
The risk increases with age over 35, in accompanied by nausea and diaphoresis
women with a previous history of (possible MI)
cardiovascular disease, and in women who • Sudden, severe headache, especially if
smoke.) associated with dizziness; difficulty with
speech; numbness in the arm or leg;
difficulty with vision (possible stroke)
• Warmth, redness, swelling, or tenderness
in the calf or pain on walking (possible
thrombophlebitis)
• Teach the patient to monitor blood pressure
periodically and report any reading above
140 slash 90 milligrams of mercury or per parameters set by the

health
140 / 90care mmHg provider.

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Nursing Practice Application (5 of 15)
Interventions and (Rationales) Patient-Centered Care
• Encourage smoking cessation and provide • Advise the patient of the risk of smoking while
information about smoking cessation using estrogens or progestins. Provide
programs. (Smoking greatly increases the risk referral to appropriate support groups and
of adverse effects of hormone therapy.) literature on smoking cessation programs.

• Monitor blood glucose levels in patients with • Teach the woman with diabetes to monitor
diabetes more frequently. (Estrogens may capillary blood glucose frequently while on
affect carbohydrate metabolism, leading to drugs containing estrogen or progestin and to
increased glucose levels. Progestins may report consistent elevations to the health care
affect endogenous insulin levels.) provider.

• Monitor hepatic function tests and symptoms • Instruct the patient to return periodically for
of liver dysfunction, lipid profile studies, and laboratory tests.
thyroid levels periodically. (Estrogens are • Teach the patient to immediately report any
associated with a rare risk of benign liver symptoms of abdominal or right upper
tumors and may adversely affect cholesterol quadrant discomfort or pain, yellowing of the
synthesis, lipid levels, and thyroid function in skin or sclera, fatigue, anorexia, darkened
sensitive patients.) urine, or clay-colored stools.

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Nursing Practice Application (6 of 15)
Interventions and (Rationales) Patient-Centered Care
• Monitor concurrent drug therapy. (Many drugs • Teach the patient to advise all health care
decrease or alter the effectiveness of providers of the use of estrogens or
estrogens and progestins including drugs in progestins for contraception or for hormone
the penicillin, barbiturate, antiseizure, replacement therapy before beginning any
antidepressant, and benzodiazepine classes. new prescription. If a prescription is required,
Check for drug interactions that may affect discuss the need for alternative treatment or
hormone effectiveness before any new birth control measures as appropriate.
prescription is started.)
• Monitor routine Pap tests, H PV screening, • Teach the patient how to perform breast self-
and breast exams as ordered. (Routine exams and encourage monthly exams. For
screenings, including mammography as women over 40, advise the patient on the
appropriate, will monitor for the development need for follow-up mammography as per the
of breast tumors, cervical cancer, or H PV health care provider.
infection.) • Advise the patient on the need for regularly
scheduled gynecologic exams to ensure
continued health.

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Nursing Practice Application (7 of 15)
Interventions and (Rationales) Patient-Centered Care
• Monitor the occurrence of any breakthrough • Teach the patient that slight spotting may
bleeding. Report any continuous, unusual, or occur midcycle while on hormone drugs but
heavy bleeding. (Small amounts of “spotting” to report any unusual changes in the amount
may occur at midcycle, especially with low- or if bleeding continues.
dose hormone therapy. Any continuous,
unusual, or heavy bleeding may indicate
adverse effects or disease and should be
reported.)
Patient understanding of drug therapy: • The patient should be able to state the
• Use opportunities during administration of reason for the drug, appropriate dose and
medications and during assessments to scheduling, and what adverse effects to
provide patient education. (Using time during observe for and when to report them.
nursing care helps to optimize and reinforce
key teaching areas.)

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Nursing Practice Application (8 of 15)
Interventions and (Rationales) Patient-Centered Care
Patient self-administration of drug • Teach the patient to take the drug following
therapy: appropriate guidelines:
• When administering the medication, • Oral drugs should be taken at the same time
instruct the patient, family, or caregiver each day to help remember the dose. If a dose
in the proper self-administration of the is missed, follow the directions on the package
drug (e.g., consistently at the same insert specific to the type of OC taken.
time each day to help remember the • Intravaginal rings are placed in the vagina and
dose). (Proper administration increases removed after 3 weeks for 1 week before a
the effectiveness of the drugs and new ring is inserted.
helps to reinforce teaching.) • Extended formulations (e.g., Seasonique or
Seasonale) are taken for approximately 3
months (84 days) and then followed by 7 days
of either inert pills or low-dose hormone pills.
• Transdermal patches (e.g., Ortho-Evra) are
changed weekly for 3 weeks followed by no
patch for 1 week.

See Table 46.1 (see slides 9-11)for a list of drugs to which these nursing actions apply.

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Emergency Contraception (1 of 2)
• May be administered within 72 hours after unprotected
sex

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Emergency Contraception (2 of 2)
• Prevents ovulation and implantation of fertilized egg;
does not induce abortion
– Administer as soon as possible
– Plan B One Step: OTC; 1.5 mg levonorgestrel in
single dose
– Plan B: OTC; levonorgestrel in two doses, 12 hours
apart; less effective 120 hours (5 days) after
unprotected sex; ineffective at 7 days
– Ulipristal (Ella): prescription; mixed progesterone
agonist/antagonist; effective up to 5 days after
unprotected sex

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Pharmacologic Abortion
• Agents to abort implanted embryo
– Mifepristone (Mifeprex)
– Misoprostol (Cytotec)

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Table 46.3 Drugs for Emergency Contraception
and Pharmacologic Abortion (1 of 2)

Note: Italics indicate common adverse effects; underlining indicates serious adverse effects.

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Table 46.3 Drugs for Emergency Contraception
and Pharmacologic Abortion (2 of 2)

Note: Italics indicate common adverse effects; underlining indicates serious adverse effects.

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Menopause
• Natural process of aging
• Progressive decrease in estrogen secretion by the
ovaries
• Permanent cessation of menses
• Sometimes accompanied by hot flashes, night sweats,
irregular menstrual cycles, bone mass loss

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Table 46.4 Potential Consequences of
Estrogen Loss Related to Menopause
Stage Symptoms/Conditions
Early Menopause Mood disturbances, depression, irritability
Insomnia
Hot flashes
Irregular menstrual cycles
Headaches
Midmenopause Vaginal atrophy, increased infections, painful intercourse
Skin atrophy
Stress urinary incontinence
Sexual disinterest
Postmenopause Cardiovascular disease
Osteoporosis
Alzheimer’s-like dementia
Colon cancer

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Hormone Replacement Therapy (H RT)
• Over past 50 years, estrogen–progestin combinations
commonly prescribed during and after menopause
• To treat unpleasant symptoms of menopause
• Prevents long-term consequences of estrogen loss

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Hormone Replacement Therapy (1 of 5)
• Women's Health Initiative (WHI) and Heart and
Estrogen/Progestin Replacement Study (HERS) showed
– Estrogen-progestin combination
▪ Increased risk of MI, stroke, breast cancer,
dementia, and venous thromboembolism
▪ Decreased risk of hip fracture and colorectal
cancer
– Estrogen alone
▪ Increased risk of stroke and thromboembolism
▪ No increased breast cancer or MI

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Hormone Replacement Therapy (2 of 5)
• Pluses and minuses of HRT
– Cardiac problems, stroke, breast cancer, dementia
– HRT may decrease risk of hip fractures and colorectal
cancer
• Women encouraged to discuss risks with health care
provider

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Hormone Replacement Therapy (3 of 5)
• Prototype drug: conjugated estrogens (Cenestin,
Enjuvia, Premarin)
• Mechanism of action: replacement for female sex
hormones
– To exert positive metabolic effects

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Hormone Replacement Therapy (4 of 5)
• Primary use: for postmenopausal replacement therapy
– Also to treat abnormal uterine bleeding due to
hormonal imbalance

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Hormone Replacement Therapy (5 of 5)
• Adverse effects: nausea, fluid retention, edema
– Also breast tenderness, abdominal cramps, and
bloating
– Acute pancreatitis, appetite changes, acne
– Mental depression, decreased libido, headache
– Fatigue, nervousness, weight gain

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 Prototype Drug: Conjugated Estrogens
(Cenestin, Enjuvia, Premarin) (1 of 6)
Therapeutic Class: Hormone
Pharmacologic Class: Estrogen; hormone replacement therapy
Actions and Uses
Conjugated estrogens (Premarin) contain a mixture of different natural
estrogens. Conjugated estrogen A (Cenestin) and conjugated estrogen
B (Enjuvia) contain a mixture of 9–10 different synthetic plant
estrogens. The primary indication for conjugated estrogens has been to
treat moderate to severe symptoms of menopause caused by
diminished estrogen secretion by the ovaries. Topical preparations may
bring some benefit to menopausal women suffering from vulvar and
vaginal atrophy. Other replacement therapies include treatment of
female hypogonadism and use after oophorectomy.

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 Prototype Drug: Conjugated Estrogens
(Cenestin, Enjuvia, Premarin) (2 of 6)
The drug is approved for the palliative treatment of prostate cancer and
certain types of breast cancer.
Conjugated estrogens exert several positive metabolic effects,
including an increase in bone density and a reduction in L DL
cholesterol. It may also lower the risk of coronary artery disease and
colon cancer in some patients. When used as postmenopausal
replacement therapy, estrogen is typically combined with a progestin.
Conjugated estrogens may be administered by the I M or intravenous (I
V) route for dysfunctional uterine bleeding.

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 Prototype Drug: Conjugated Estrogens
(Cenestin, Enjuvia, Premarin) (3 of 6)
Administration Alerts
• Use a calibrated dosage applicator for administration of vaginal cream.

• For IM or IV administration of conjugated estrogens, reconstitute by first

removing approximately 5 m L of air from the dry-powder vial, then slowly
inject the diluent into the vial, aiming it at the side of the vial. Gently agitate to
dissolve; do not shake.
• Administer IV push slowly, at a rate of 5 mg/min.

• Both are pregnancy category X.

Pharmacokinetics (PO)

Onset Peak Duration

Unknown Unknown Unknown

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 Prototype Drug: Conjugated Estrogens
(Cenestin, Enjuvia, Premarin) (4 of 6)
Adverse Effects
Adverse effects of conjugated estrogens include nausea, fluid
retention, edema, breast tenderness, abdominal cramps and bloating,
acute pancreatitis, appetite changes, acne, mental depression,
decreased libido, headache, fatigue, nervousness, and weight gain.
Adverse effects are dose dependent and increase in patients over age
35.
Black Box Warnings: Estrogens, when used alone, have been
associated with a higher risk of endometrial cancer in postmenopausal
women. Although adding a progestin may exert a protective effect by
lowering the risk of uterine cancer, studies suggest that progestin may
increase the risk of breast cancer following long-term use. When used
alone, estrogens increase the risk of stroke, D VT, MI, and pulmonary
emboli. Estrogens should not be used to prevent cardiovascular
disease or to treat dementia.
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 Prototype Drug: Conjugated Estrogens
(Cenestin, Enjuvia, Premarin) (5 of 6)
Contraindications: Conjugated estrogens are contraindicated in
pregnant patients and in women with known or suspected carcinoma of
the breast or other estrogen-dependent tumor. Caution should be used
when treating patients with a history of thromboembolic disease,
hepatic impairment, or abnormal uterine bleeding.
Interactions
Drug–Drug: Drug interactions include a decreased effect of tamoxifen,
enhanced corticosteroid effects, and decreased effects of
anticoagulants, especially warfarin. The effects of estrogen may be
decreased if taken with barbiturates or rifampin, and there is a possible
increased effect of tricyclic antidepressants if taken with estrogens.

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 Prototype Drug: Conjugated Estrogens
(Cenestin, Enjuvia, Premarin) (6 of 6)
Lab Tests: Values of the following may be increased:
prothrombin time, certain coagulation factors,
thyroidbinding globulin, PBI, T4, platelet aggregation, and
triglycerides. Values of the following may be decreased:
antithrombin III, T3, folate, and vitamin B12.

Herbal/Food: Red clover and black cohosh may interfere

with estrogen therapy. Effects of estrogen may be
enhanced if combined with ginseng.
Treatment of Overdose: There is no specific treatment for
overdose.

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Role of the Nurse: Hormone Replacement
Therapy
• Monitor patient closely for signs and symptoms of
thrombus or embolus
• Encourage patient to report signs of depression,
decreased libido
– Also headache, fatigue, weight gain
• Controversy surrounds long-term use of these drugs
– Teach women to be aware of current research

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Role of the Nurse: Hormone Replacement
Therapy in Males
• Inform patients that secondary female characteristics
may occur
– Higher voice, sparse body hair, increased breast size
– Impotence may also occur

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Dysfunctional Uterine Bleeding (1 of 2)
• Hemorrhaging that occurs on noncyclic basis or in
abnormal amounts
• Health problem frequently reported by women
– Common reason for hysterectomy
• Variety of causes; often an imbalance between estrogen
and progesterone

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Dysfunctional Uterine Bleeding (2 of 2)
• Estrogen causes proliferation of endometrium
• Progesterone limits and stabilizes endometrial growth
• Drugs for uterine bleeding: conjugated estrogens followed
by medroxyprogesterone
– NSAIDs sometimes adjunct therapy

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Table 46.5 Drugs for Uterine Abnormalities
and Hormone Replacement Therapy (1 of 3)

Note: Italics indicate common adverse effects; underlining indicates serious adverse effects.

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Table 46.5 Drugs for Uterine Abnormalities
and Hormone Replacement Therapy (2 of 3)

Note: Italics indicate common adverse effects; underlining indicates serious adverse effects.

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Table 46.5 Drugs for Uterine Abnormalities
and Hormone Replacement Therapy (3 of 3)

Note: Italics indicate common adverse effects; underlining indicates serious adverse effects.

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Drugs for Dysfunctional Uterine Bleeding
—Progestins (1 of 3)
• Prototype drug: medroxyprogesterone (Depo-Provera)
• Mechanism of action: inhibits effect of estrogen on
uterus
– Restores normal hormonal balance

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Drugs for Dysfunctional Uterine Bleeding
—Progestins (2 of 3)
• Primary use: to treat dysfunctional uterine bleeding,
secondary amenorrhea, contraception
– Medroxyprogesterone may be given subcutaneously
or IM for palliation of metastatic uterine or renal
carcinoma

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Drugs for Dysfunctional Uterine Bleeding
—Progestins (3 of 3)
• Adverse effects: breakthrough bleeding, breast
tenderness
– Weight gain, depression, hypertension
– Nausea, vomiting, dysmenorrhea, and vaginal
candidiasis
– Most serious side effect: increased risk for
thromboembolic disease

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 Prototype Drug: Medroxyprogesterone (Depo-
Provera, Depo-SubQ-Provera, Provera) (1 of 5)

Therapeutic Class: Hormone; drug for dysfunctional uterine

bleeding
Pharmacologic Class: Progestin
Actions and Uses
Medroxyprogesterone is a synthetic progestin with a prolonged
duration of action. As with its natural counterpart, the primary
target tissue for medroxyprogesterone is the endometrium of the
uterus. It inhibits the effect of estrogen on the uterus, thus
restoring normal hormonal balance. Indications include
endometriosis, amenorrhea, uterine bleeding, and contraception.

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 Prototype Drug: Medroxyprogesterone (Depo-
Provera, Depo-SubQ-Provera, Provera) (2 of 5)

Medroxyprogesterone may also be given by sustained release I

M (Depo-Provera) or subcutaneous (Depo-SubQProvera) depot
injection. This is available in two doses: a lower dose for
contraception and a higher dose for the palliation of inoperable
metastatic uterine or renal carcinoma.
Administration Alerts
• Give PO with meals to avoid gastric distress.
• Observe IM sites for abscess: presence of lump and
discoloration of tissue.
• Pregnancy category X.

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 Prototype Drug: Medroxyprogesterone (Depo-
Provera, Depo-SubQ-Provera, Provera) (3 of 5)

Pharmacokinetics (PO)
Onset Peak Duration
Unknown 2–4 h Unknown

Adverse Effects
The most frequent adverse effects of medroxyprogesterone are
breast tenderness, breakthrough bleeding, and other menstrual
irregularities. Weight gain, depression, H TN, nausea, vomiting,
dysmenorrhea, and vaginal candidiasis may also occur. The
most serious adverse effect is an increased risk for
thromboembolic events.

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 Prototype Drug: Medroxyprogesterone (Depo-
Provera, Depo-SubQ-Provera, Provera) (4 of 5)

Black Box Warning: Progestins combined with conjugated estrogens

may increase the risk of stroke, D VT, MI, pulmonary emboli, and
invasive breast cancer. Women age 65 or older have an increased risk
of dementia when treated with progestins. Women who are receiving
injectable medroxyprogesterone are at significant risk for loss of bone
mineral density.
Contraindications: Medroxyprogesterone is contraindicated during
pregnancy and in women with known or suspected carcinoma of the
breast. Caution should be used when treating patients with a history of
thromboembolic disease, hepatic impairment, or undiagnosed vaginal
bleeding. The drug should be used cautiously in patients with a history
of depression, and the drug should be discontinued at the first sign of
recurring depression.

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 Prototype Drug: Medroxyprogesterone (Depo-
Provera, Depo-SubQ-Provera, Provera) (5 of 5)

Interactions
Drug–Drug: Serum levels of medroxyprogesterone are
decreased by aminoglutethimide, barbiturates, primidone,
rifampin, rifabutin, and topiramate.
Lab Tests: Medroxyprogesterone may increase values for
alkaline phosphatase, glucose tolerance test (G TT), and HDL.
Herbal/Food: St. John’s wort may decrease the effectiveness of
medroxyprogesterone and cause abnormal menstrual bleeding.
Treatment of Overdose: There is no specific treatment for
overdose.

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Role of the Nurse: Progestin Therapy (1 of 3)
• Common side effects
– Breakthrough bleeding, nausea
– Abdominal cramps, dizziness
– Edema, weight gain

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Role of the Nurse: Progestin Therapy (2 of 3)
• Monitor for amenorrhea; sudden, severe headache
– Also for signs of pulmonary embolism: sudden severe
chest pain, dyspnea
– Report symptoms to health care provider immediately

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Role of the Nurse: Progestin Therapy (3 of 3)
• Can cause photosensitivity
– Monitor for pruritus, sensitivity to light, acne, rash,
alopecia
– Phototoxic reactions and sunburn

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Uterine Contractions and Lactation
Stimulation
• Several agents used
– Oxytocics stimulate uterine contractions and promote
induction of labor
– Tocolytics inhibit uterine contractions during
premature labor

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Table 46.6 Uterine Stimulants and
Relaxants (1 of 2)

Note: Italics indicate common adverse effects; underlining indicates serious adverse effects.

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Table 46.6 Uterine Stimulants and
Relaxants (2 of 2)

Note: Italics indicate common adverse effects; underlining indicates serious adverse effects.
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Oxytocics
• Natural hormones secreted by posterior pituitary
• Stimulate uterine contractions to induce labor
• Suckling stimulates release of oxytocin
– Causes more milk ejection

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Figure 46.4 Oxytocin and Breast-Feeding

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Uterine Stimulant—Oxytocics (1 of 2)
• Prototype drug: oxytocin (Pitocin)
• Mechanism of action: to induce labor by increasing
frequency and force of uterine contractions
• Primary use: as drug of choice for inducing labor

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Uterine Stimulant—Oxytocics (2 of 2)
• Adverse effects: complications in fetus include
dysrhythmias or intracranial hemorrhage
– Serious complications in mother may include uterine
rupture, seizures, coma

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 Prototype Drug: Oxytocin (Pitocin) (1 of 5)
Therapeutic Class: Drug to induce labor; uterine stimulant
Pharmacologic Class: Hormone; oxytocic
Actions and Uses
Oxytocin (Pitocin), identical to the natural hormone secreted by the
posterior pituitary gland, is a preferred drug for inducing labor. Oxytocin
is given by different routes depending on its intended action. Given
antepartum by IV infusion, oxytocin induces labor by increasing the
frequency and force of uterine contractions. It is timed to the final stage
of pregnancy, after the cervix has dilated, membranes have ruptured,
and presentation of the fetus has occurred. Doses in an IV infusion are
increased gradually, every 15–60 minutes, until a normal labor pattern
is established.

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 Prototype Drug: Oxytocin (Pitocin) (2 of 5)
Oxytocin may also be administered postpartum to reduce
hemorrhage after expulsion of the placenta and to aid in returning
normal muscular tone to the uterus. This drug is approved at higher
doses for the adjunct management of incomplete or inevitable abortion.
Intranasal forms once used to promote milk letdown are no longer
available in the United States.
Administration Alerts
• Dilute 10 units of oxytocin in 1,000 mL IV fluid prior toadministration.
For postpartum administration, may add up to 40 units in 1,000 m L
IV fluid.
• Incidence of allergic reactions is higher when given I M or by IV
injection, rather than IV infusion.
• Pregnancy category X.
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 Prototype Drug: Oxytocin (Pitocin) (3 of 5)
Pharmacokinetics

Onset Peak Duration

immediate IV; 3–5 min I M Unknown 1h

Adverse Effects
The most common adverse effects of oxytocin are rapid, painful uterine
contractions and fetal tachycardia. When given IV, vital signs of the
fetus and mother are monitored continuously to avoid complications in
the fetus, such as dysrhythmias or intracranial hemorrhage. Serious
complications in the mother may include uterine rupture, seizures, or
coma. Risk of uterine rupture increases in women who have delivered
five or more children.

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 Prototype Drug: Oxytocin (Pitocin) (4 of 5)
Black Box Warning: Oxytocin is not indicated for the elective induction
of labor (the initiation of labor in a pregnant patient who has no medical
indications for induction).
Contraindications: Antepartum use is contraindicated in the following:
significant cephalopelvic disproportion; unfavorable fetal positions that
are undeliverable without conversion before delivery; obstetrical
emergencies in which the benefit-to-risk ratio for the fetus or mother
favors surgical intervention; fetal distress when delivery is not
imminent; when adequate uterine activity fails to achieve satisfactory
progress; when the uterus is already hyperactive or hypertonic; when
vaginal delivery is contraindicated, such as invasive cervical
carcinoma, active genital herpes, total placenta previa, vasa previa,
and umbilical cord presentation or prolapse of the cord.

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 Prototype Drug: Oxytocin (Pitocin) (5 of 5)
Interactions
Drug–Drug: Vasoconstrictors used concurrently with oxytocin
may cause severe HTN.
Lab Tests: Unknown.
Herbal/Food: None known.
Treatment of Overdose: Overdose causes strong uterine
contractions, which may lead to uterine lacerations or rupture.
Immediate discontinuation of the drug is necessary, along with
symptomatic treatment.

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Role of the Nurse: Uterine Stimulant
Therapy (1 of 2)
• Frequently assess patient in labor
– Oxytocin increases frequency and force of uterine
contractions
– Discontinue infusion if fetal distress detected
– Hypertensive crisis may occur if combined with local
or regional anesthesia

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Role of the Nurse: Uterine Stimulant
Therapy (2 of 2)
• Assess for symptoms of water intoxication
– Drowsiness, listlessness, headache
– Confusion, anuria, weight gain
• Side effects of oxytocin
– Anxiety, maternal dyspnea, hypotension or
hypertension
– Nausea, vomiting, neonatal jaundice
– Maternal or fetal dysrhythmias

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Nursing Practice Application (9 of 15)
Pharmacotherapy With Oxytocin
Assessment Potential Nursing Diagnoses*

Baseline assessment prior to administration: • Acute Pain

• Obtain a complete health history including length of • Deficient Knowledge (drug therapy)
current pregnancy; presence of preeclampsia or • Risk for Injury, patient or fetus, related to adverse drug
eclampsia; recent labor; type effects
of delivery; history of labors or caesarean sections; • Risk for Excess Fluid Volume, related to adverse drug
cardiovascular, neurologic, hepatic, or renal disease; effects
diabetes; and breast-feeding.
• Obtain a drug history including allergies, current
prescription and O TC drugs, herbal preparations,
alcohol use, and smoking. Be alert to possible drug
interactions.
• Evaluate appropriate laboratory findings (e.g., C B C,
platelets, coagulation studies, electrolytes, glucose,
magnesium level, hepatic and renal function studies).

*NANDA I © 2014

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Nursing Practice Application (10 of 15)

Assessment Potential Nursing Diagnoses*

• Obtain baseline height, weight, and vital signs. blank

• Obtain fetal heart rate and intrauterine positioning.
• Check for the presence of cervical dilation and effacement.
Monitor quality and duration of any existing contractions.
Monitor fetal response to contractions, noting any sign of fetal
distress.
• Check for postpartum bleeding and note the number of pads
saturated.
Assessment throughout administration: blank
• Assess for desired therapeutic effects depending on the
reason the drug is given (e.g., strong, regular contractions
supportive of labor).
• Continuously monitor the timing, quality, and duration of
contractions. Immediately report sustained uterine
contractions to the health care provider.
• Continuously monitor the fetal heart rate and response to
contractions. Immediately report signs of fetal distress to the
health care provider.

*NANDA I © 2014

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Nursing Practice Application (11 of 15)

Assessment Potential Nursing Diagnoses*

• Continue periodic monitoring of C BC, platelets, blank

electrolytes, glucose, and magnesium level.
• Monitor vital signs frequently and immediately and
report any blood pressure above 140/90 mmHg or
less than 90/60 m mHg, especially if accompanied
by tachycardia, or per parameters, to the health
care provider.
• Continue to monitor postpartum bleeding and pad
count. Notify the health care provider if more than
two full-size pads are saturated in 2 hours’ time.
• Assess for adverse effects: nausea, vomiting, and
headache. Immediately report tachycardia,
palpitations, and H TN, especially associated with
angina, severe headache, or dyspnea.
Immediately report any severe abdominal pain,
sustained uterine contraction, diminished urine
output, dizziness, drowsiness, confusion, changes
in level of consciousness, or seizures.

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Nursing Practice Application (12 of 15)
Implementation
Interventions and (Rationales) Patient-Centered Care

Ensuring therapeutic effects: • Instruct the patient about the rationale for all IV
• Monitor appropriate medication and monitoring equipment and the need for
administration for optimal results. IV frequent monitoring to allay anxiety.
oxytocin must be given via an infusion • Teach the patient that labor contractions will
pump to allow for precise dosing. (Infusion gradually increase and that the drug will be
pumps allow for rapid dosage adjustments decreased or stopped once contractions reach
to maintain uterine contractions supportive an optimal level.
of labor and cervical dilation reaching • Encourage the patient in labor to use pain-
approximately 5 to 6 cm.) control measures (e.g., therapeutic breathing) or
use pain control drugs as needed and ordered.

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Nursing Practice Application (13 of 15)

Interventions and (Rationales) Patient-Centered Care

Minimizing adverse effects: • Teach the patient that labor contractions will
• Monitor the timing, quality, and duration of increase in strength and duration and will be
contractions continuously. Immediately monitored throughout. Instruct the patient to
report any sustained uterine contractions immediately report any sustained contraction or
to the health care provider. Stop the any severe abdominal pain.
infusion, infusing normal saline or solution
as ordered, and place the patient on her
side until follow-up orders are obtained if
sustained contractions continue. (Oxytocin
may cause sustained uterine muscle
contraction with potential uterine rupture.
Uterine contractions must be continuously
monitored.)

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Nursing Practice Application (14 of 15)
Interventions and (Rationales) Patient-Centered Care

• Continuously monitor the fetal heart rate and response • Teach the patient that the fetal heart
to contractions. Immediately report signs of fetal rate will also be monitored along
distress to the health care provider. (Uterine with uterine contractions. Explain
contractions can affect the amount of blood flow the purpose for all monitoring
through the placenta with diminished oxygenation to the equipment to allay anxiety.
fetus. Changes in fetal heart rate may signal fetal
distress and the patient should be placed on her side,
oxygen administered, the infusion stopped, and the
health care provider notified.)
• Monitor vital signs and urine output frequently and • Instruct the patient to immediately
report any blood pressure above 140/90 mmHg or less report any headache, dizziness,
than 90/60 mmHg, especially if accompanied by disorientation or confusion,
tachycardia or diminished urine output, to the health palpitations, or chest pressure or
care provider immediately. (Oxytocin has pain.
vasoconstrictive properties and water-retention
properties. Blood pressure or pulse rate exceeding
parameters, increasing disorientation or confusion, and
diminished urine output may signify adverse drug
effects or possible complications.)

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Nursing Practice Application (15 of 16)
Interventions and (Rationales) Patient-Centered Care

• Monitor fundal firmness and location and postpartum • Instruct the patient to report any
bleeding and pad count. (Oxytocin may be given to sudden increase in lochia, dizziness
control postpartum bleeding. Lochia (usual postpartum or light-headedness, or if more than
bleeding) that increases, or if two or more pads are two pads are saturated after 2
saturated over a 2-hour period, should be reported to hours.
the health care provider immediately.)
Patient understanding of drug therapy: • The patient should be able to state
• Use opportunities during administration of medications the reason for the drug, appropriate
and during assessments to provide patient education. dose and scheduling, monitoring
(Using time during nursing care helps to optimize and needs, and what adverse effects to
reinforce key teaching areas.) observe for and when to report
them.

See Table 46.6 (see slides 75 and 76) for a list of drugs to which these nursing actions apply.

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Tocolytics
• Slow uterine contractions to delay labor
• Used in patients with premature labor
• Delay labor by 24–72 hours, often enough time for fetus
to develop normal lung function
• Adverse effects include tachycardia in both mother and
fetus

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Treatment of Female Infertility (1 of 2)
• Causes of female infertility are varied
– Pelvic infection
– Physical obstruction of uterine tubes
– Lack of ovulation

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Treatment of Female Infertility (2 of 2)
• For infertility with an endocrine etiology, pharmacotherapy
may be of value
– Can occur at level of hypothalamus, pituitary, or ovary
– Pharmacotherapy targeted to specific cause of
dysfunction

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Table 46.7 Drugs for Female Infertility and
Endometriosis (1 of 2)

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Table 46.7 Drugs for Female Infertility and
Endometriosis (2 of 2)

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Treatment of Female Infertility
• Clomiphene (Clomid, Serophene) is a drug of choice for
female infertility due to lack of ovulation
– Stimulates release of LH
– Results in maturation of increased number of ovarian
follicles
– Rise in LH level sufficient to induce ovulation in 80%
of treated women

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Copyright

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