Women's Health Nurse Manual TABLE OF CONTENTS: 1. FOREWORD 2. INTRODUCTION Background Rationale 3. EDUCATION 4. PROFESSIONAL DEVELOPMENT 5. SERVICE PROVISION Principles Aims Objectives Quality Improvement 6. MANAGEMENT STRUCTURE 7. ROLE AND FUNCTION Job Description - Women's Health Nurse Job Description - Women’s Health Clinical Nurse Consultant 8. MEDICAL SUPPORT 9. SERVICE IMPLEMENTATION 10. CLINICAL PROTOCOLS AND PROCEDURES  Breast Examination  Contraceptive advice  Diaphragm Fitting Procedure  Mammograms  Menstrual Cycle Advice  Menopause Advice  Papanicolau Tests (including bi-manual examination  Pelvic floor muscle assessment  Post Natal Checks  Pregnancy testing, counselling and referral  Post Termination Check  Screening for Sexually Transmissible Diseases 11. COUNSELLING 12. HEALTH CARE SERVICES PROVIDED TO MINORS 13. BROKEN APPOINTMENTS 14. REFERRALS 15. CLIENT RECORDS 16. PATHOLOGY 17. INFECTION CONTROL 18. EQUIPMENT FOR CLINICS     1. FOREWORD: These Clinical Practice Guidelines, Protocols and Procedures outline the standards of practice for women’s health nurses in SWSAHS. They were adapted from the Women’s Health Nurses Clinical Practice Guidelines, Protocols and Procedures (1996/97) published by the Australian Women’s Health Nurse Practitioners Association to incorporate the SWSAHS Policies in relation to women’s health. 2. INTRODUCTION: Background In March, 1984 the N.S.W. State Government commissioned a review of women's health services. The Review Committee's brief was : to critically evaluate existing health policies as they related to women and girls to assess the adequacy of existing services and to identify gaps requiring new approaches to service delivery. The Final Report of the Womens' Health Policy Review Committee, 1985 recommended that: "the Department of Health, N.S.W. in conjunction with relevant nursing bodies, establish a new category of Registered Nurse, that is, a women’s health nurse, to provide gynaecological preventative health services as well as educational and counselling services for well women"(Pg.63). The Report went on to state that: "the Committee believes that suitably trained nurses are capable of developing an independent practitioner role in delivery of preventative health care to well women" and that "specially trained nurse practitioners could offer a cost effective and accessible service for well women" (Pg.63). This recommendation arose from consultations and discussions by the Committee with a wide cross section of women in the community in an attempt to quantify and qualify health matters of importance to women. Issues included aspects of health related to women's roles and their position in society, in addition to the social, emotional and physical health needs expressed by women. The Report went on to state that: "the lack of easily accessible and relevant information about their gynaecological health care was raised repeatedly by women of all ages during the community consultations. It was stressed that adequate health education was essential for women either side of their chosen period of child bearing, i.e. teenagers and women over 35 years are often neglected" (Pg.147). This recommendation was adopted and a Working Party was convened to implement the recommendation and a two year pilot program was established in 1985/86 whereby registered nurses with midwifery qualifications and relevant experience were selected and educated to provide Pap test screening, pelvic examinations, breast examinations, counselling and education/information programs for women about contraception, menopause, sexually transmissible disease, gynaecological health and related matters. In January 1986, eleven nurses were employed in seven Areas and Regions. A further eleven nurses were employed in February 1987, twelve in 1988 and twelve in 1989, enabling limited services to be offered on a State-wide basis plus services in Areas and Regions already involved in the pilot program. An educational program, the Women’s Health Nurse Practitioner Course, was developed and evaluated by the Women’s Health Nurse Working Party which included a gynaecologist, representatives of relevant educational bodies and the Areas and District Health Services. This educational program has developed into a twelve weeks course. The course consists of both theoretical and clinical components with subsequent assessment of the nurses skills in areas relevant to their advanced clinical practice. The N.S.W. Department of Health had overall responsibility for the first two pilot courses in 1986 and 1987. The N.S.W. Family Planning Association was involved in the sexual and reproductive health aspects as well as providing the clinical component of these two courses. The N.S.W College of Nursing also provided educational input into these two pilot courses. In 1988,1989 the N.S.W. Department of Health contracted the N.S.W. Family Planning Association to plan and implement the entire educational and clinical training program. This has continued annually since 1991. Rationale The women’s health nurse program in N.S.W. builds upon a nursing tradition which values highly the skilled care and professional commitment demonstrated by community health nurses and midwives. It extends this tradition of primary health care into the area of health promotion and the prevention of ill health which women in the community have identified as important for their health and well being. Women's Health Nurses aim- To enable women to take responsibility for their own health by making informed decisions as health care consumers To increase women's awareness of and access to health promotion programs To work co-operatively with other health workers to improve women's health service provision 3. EDUCATION Women's Health Nurses require education which promotes an understanding of the broad political, cultural and social context in which women live their lives. The education program should prepare them to work with a primary health care focus in both clinical and non-clinical settings. The minimum requirements for nurses to practice as women's health nurses are that they- be a registered nurse with a minimum of two years post graduate experience be female have satisfactorily completed and demonstrated competencies equivalent to those outlined in the context of Family Planning NSW Women's Health Nurse Course have had clinical supervision and instruction in appropriate contexts by accredited or qualified clinical instructors 4. PROFESSIONAL DEVELOPMENT Assessment of individual professional development needs will be undertaken as part of an annual staff performance appraisal. The Community Health Accreditation Standards Program (C.H.A.S.P.) recommendation for community health staff is 40 hours professional education per annum. 5. SERVICE PROVISION Principles The principles underlying the provision of community based women's health nurse services are outlined in ‘The Manual of Standards for Women’s Health Centres’ (WHIRRCA 1995) and include- 1. A social view of health as emphasised by the World Health Organisation and endorsed by the Government in all Australia through the endorsement of the National Women's Health Policy (1988). This view recognises that: health is determined by a broad range of social, environmental, economic and biological factors; differences in health status and health outcomes are linked to gender, age, socio-economic status, ethnicity, disability, location and environment, racism, sex role stereotyping, gender inequality and discrimination, ageism, sexuality and sexual preferences; health promotion, disease prevention, equity of access to appropriate and affordable services and strengthening the primary health care system are necessary, along with high quality illness-treatment services; and information, consultation, advocacy and community development are important elements of the health process. 2. To acknowledge that health needs of women and girls span their life time, and reflect women's various roles in Australian society, not just their reproductive role. 3. To promote participation of women in debate and decision making about health issues, their own health care , health service policy, planning, delivery and evaluation. 4. To aim to provide a broad range of services and strategies within a preventative and holistic framework which: are provided by women for women; value women's own knowledge and experience; facilitate the sharing of women's skills, knowledge and experience; link women's individual experience and health needs to the social and cultural context of women's lives; will empower women challenge sex role stereotyping and gender discrimination which affect health; increase the accessibility, sensitivity and acceptability of health services for women; that relate to the identified health priorities at a local and state level. recognises women's rights, as health care consumers, to be treated with dignity in an environment which provides privacy, informed consent, confidentiality and safety Aims To reduce the morbidity and mortality associated with women's reproductive and sexual health by the promotion of health education and illness prevention screening. To ensure equity and accessibility of services without financial, cultural, geographic and or other barriers. To increase women's access to health information, enabling women as health care consumers to make informed decisions about their own health care. To increase community and health care workers awareness of women's physical, emotional and social health issues. Objectives To provide a screening, information and counselling service for women, by women, that is free, confidential and accessible To acknowledge that informed decisions about health and health care require accessible information which is appropriately targeted for different socio-economic, educational and cultural groups To advocate for improvement in delivery of health services for local women To utilise existing data, research and policy concerning women's health, as well as incorporating women's views about their own health and the best strategies to address their health needs in service planning and development To target the health needs of specific groups of women for service provision e.g. Aboriginal women, migrant women, women in refuges, women in the workplace, older women etc. To provide community based, mobile and outreach clinical and educational services to women To provide a wide range of health education programs to women of all ages To work collaboratively with existing services and provide an alternative to those women who do not choose or are not able to make use of existing services. To provide a consultation service to local health workers and community agencies on matters relating to women's health Quality Improvement Quality Assurance is an important part of the women’s health nurse program. Women’s health nurses should participate in an annual appraisal of clinical, theoretical and administrative skills. The Institute of Clinical Pathology and Medical Research (ICPMR) at Westmead Hospital analyses all Pap tests received by women’s health nurses as a quality assurance mechanism. Women’s health nurses should be be involved in ongoing quality improvement activities. Statistical data should be evaluated regularly to ensure the women’s health nurse service is reaching identified target groups. Quality improvement activities may include: client satisfaction surveys development of policies and procedures at a local level review of client failure to attend. use of client information as an indicator setting of target groups and evaluation of successs / failure to meet targets record of opportunities for working with other health care providers record of referral patterns demonstration of professional relationships, self support networks evaluation of time spent in the different aspects of the role Women’s health nurses are part of the SWSAHS Women’s Health Team and contribute to the developmnent of the Area Women’s Health Plan. The team also has annual planning meetings where the basis of our annual service plans, goals, objectives, strategies and performance indicators are formulated. The area women’s health team meetings provide support, information about other women’s health initiatives undertaken by the team, further education through peer presentions and promote our working as a team. These meetings and are held six weekly. Women’s health nurses also have a meeting every two months to discuss issues relating to the clinical aspects of the women’s health nurse role, to share information and resources and provide peer support. Performance Appraisal. It is customary for every employee to participate in an annual staff performance appraisal. The initiation of this appraisal is the responsibility of the employer. Any issues which need to be addressed as a result of the apprisal should be done collaboratively with the objective of enhancing staff performance and service delivery. It is recommended that for women’s health nurses a review (peer or individual) of clinical practice, include follow up procedures, an audit of the client files and review of health promotion activities. The clinical review for women’s health nurses should be done by the women’s health clinical nurse consultant. Clinical nurse consultants should have their review done by another women’s health clinical nurse consultant. 6. MANAGEMENT STRUCTURE In South Western Sydney Area Health Service each women’s health nurse will have her own local organisational structure. Women’s health nurses must be professionally responsible to a senior nurse. As SWSAHS has two women’s health clinical nurse consultants it is appropriate that women’s health nurses be professionally responsible to them. The clinical nurse consultants should be professionally responsible to a senior nurse eg . the Director of Nursing or the Area Director of Nursing / Assistant Director of Nursing. In this model women’s health nurses have line responsibility to the Team Leader / Manager; professional nursing responsibility through the Women’s Health Nurse Clinical Consultant to the Area Director of Nursing and provides reports / information to Women’s Health Co-ordinators in relation to the Women’s Health Plan. Women’s health nurses are responsible to the local health service and women’s health coordinator for women’s health service planning. Aims/direction of services should comply with the Area Women’s Health Plan and address local issues. 7. ROLE AND FUNCTION Women’s Health nurses function from a primary health care model in providing clinical and health promotion services. The women’s health nurse service delivery is directed by the National Women’s Health Policy, the Area Women’s Health Plan and local plan for women’s health services. Job Description - Women's Health Nurse Registered Nurse Classification: Registered nurse or Clinical Nurse Specialist Essential Qualifications: List A, Registered Nurse Women's Health Nurse Certificate or equivalent (which includes both theoretical and clinical components) Midwifery Certificate or two years Women's Health experience. 2 years post graduate nursing experience An understanding of women's health issues Drivers Licence Desirable Qualifications: Experience in community health, health promotion and/or women's health education Communication skills Responsible to: Professional nursing responsibility to appropriate nursing personnel Line responsibility to team leader / service co-ordinator Responsibility to Area Women’s Health Coordinator for service planning / delivery in local area. Responsible for: a) Clinical Services: Provision of "Well Women's Health" clinics offering gynaecological screening (which includes Pap tests, screening for sexually transmitted diseases, breast checks, pelvic floor assessment, pregnancy testing etc.), counselling, information and referral on women's health issues. Provide accessible and appropriate clinical services to well women who find it difficult to access or are not using existing services eg. isolated, migrant, older women. Ensure clinical services target the identified needs in the community through the provision of routine and outreach clinics. Liaison with the Clinical Nurse Consultant re maintenance of professional nursing standards in women's health clinics. Provision of appropriate referral, in consultation with the client, when necessary to other service providers eg. GP's, Counsellors, Legal Services, Home Help etc. b) Health Promotion: Provision of community education, information and resources on women's health issues. Provision of health promotion programmes relevant to the needs of women which focus on prevention, early intervention and support. Individual client education in the clinical setting re the prevention of ill health. Participation in training for other health workers on women's health issues. c) Planning and Evaluation: Planning and implementation of Women's Health Nurse services based on local needs assessment in accordance with state/national policies. Monitoring and ongoing evaluation of service delivery. Maintenance of quality assurance standards and protocols in consultation with appropriate personnel. Participation in women's health research as appropriate. Liaise with allied health professionals and advocate for the provision of programs and services which address women's health needs. Job Description - Women’s Health Clinical Nurse Consultant Registered Nurse Classification: Clinical Nurse Consultant Essential qualifications: List A General Nursing Certificate (Diploma, Degree) Midwifery Certificate - or two years Women's Health experience. Women's Health Nurse Practitioners Certificate (or equivalent which includes both theoretical and clinical components). 5 years post graduate nursing experience with 3 years experience in specialty area. An understanding of migrant, aboriginal and women's health issues. Previous experience in delivery of clinical women's health services Commitment to EEO principles Drivers Licence Desirable Qualifications Experience in community health, health promotion and/or women's health education. Knowledge of women's health policy and practice in NSW Previous experience in research, program design, implementation and evaluation. Responsible to: Professional nursing responsibility to nominated senior nurse. Line responsibility to team leader/service coordinator Responsible to Area Women's Health Coordinator for local service planning and delivery Responsible for: a) Clinical services: Maintaining a high level of clinical expertise by providing, as appropriate, gynaecological health screening clinics (which includes pap tests, screening for sexually transmitted diseases, breast checks, pelvic floor assessment, pregnancy testing etc), counselling, information and referral on women's health issues. Acting in a consultant/advisory role for women's health nurses, other nurses and health workers dealing with women's health issues. Planning and evaluating clinical service delivery within the context of national, state and local policies and priorities. Liaison with other health care providers concerning client management. b) Health Promotion: Acting as a resource for other workers and women in the community on women's health issues. Providing clinical training, where appropriate, to other women's health nurses. Advising and/or providing training as appropriate on women's health issues both within the local health service and/or in conjunction with other tertiary bodies. Participating in Women's Health Promotion initiatives. Providing consultation to allied health/welfare workers, Government Departments and non-Government organisations on women's health issues. c) Planning and evaluation: Provision of advice and advocacy where appropriate in the development of area/district plans eg. drug and alcohol, early childhood Participation in the development, implementation and evaluation of area women’s health plans. Maintaining individual quality assurance standards and protocols. Monitoring and advising on the implementation of the area/district quality assurance programmes as they relate to women's health. d) Research: Initiation and participation in specific research designed to improve women's health or prevent their ill health. Fostering collaborative research projects with academic staff from tertiary nursing faculties 8. MEDICAL SUPPORT Women’s health nurses should have formal access to a medical practitioner from whom thay can seek advice and support in relation to clinical issues as they arise. 9. SERVICE IMPLEMENTATION Undertake a needs assessment of the population of the area by researching local demography e.g. population size and type, health status indicators, morbidity and mortality data, minority/disadvantaged groups, services and resources already available if this has not already been done as part of an area/district women's health strategic plan Identify target groups e.g. adolescents, isolated women, migrant women, Aboriginal women, women in the middle years, older women Develop a needs profile and establish service priorities Develop service implementation plans according to community needs profile and service priorities identified Identify suitable clinic venues and availability Identify suitable model or models of service delivery e.g. outreach clinics, community based clinics (neighbourhood centres, early childhood centres, community health centres), hospital based clinics, family planning clinics, doctor's surgeries, home visits Order portable specialist equipment, both stock and non-stock items for clinical practice within budgetary limitations in consultation with line manager Identify where suitable support services are available for pathology, sterilisation of equipment etc. Make arrangements for provision of pathology services other than Pap tests where appropriate Identify referral networks Arrange for clinic booking system, recalls, reminders Identify local community support networks Prepare publicity material and identify appropriate avenues for distribution to target groups. Establish distribution networks using existing community resources. Prepare press releases for and give interviews to local media. 10. CLINICAL PROTOCOLS AND PROCEDURES. Women's health nurses provide a service to well women. Clinical functions are performed in the context of nursing practice which emphasises enhancing women's knowledge and choices about their own health through providing information, discussion, counselling and referral. All women who have abnormal pathology on clinical examination are referred appropriately.   Protocols relevant to all clinical procedures Promotes a safe environment: Provide a supportive and non-judgemental environment so clients can freely express opinions and feelings and explore a range of options in reaching health care decisions. Ensure client's privacy, safety and comfort, Maintain client confidentiality at all times, gaining written permission prior to the transfer of any information from the client's medical record to a second person or agency. ( N.S.W. D.O.H. Circular 95/42‘Guidelines for Essential Documentation, Management, Storage and Disposal of Health Care Records’ and Circular 90/126 ‘Confidentiality of Health Care Records’) Utilise effective communication skills, incorporating active listening, feedback and clarification when interacting with clients. Demonstrates respect for client's dignity. Ensures verbal consent for all clinical procedures. Ensures a comprehensive and relevant client history Women's health nurses use a standard history form which guides the client interview and becomes the medical record. The history form provides a logical sequence to the questioning and establishment of relevant information. All observations and client contact will be recorded and all test results and copies of referral letters are attached. Provides education and information(verbal and written) appropriate to the consultation. Information and education will encourage clients to accept responsibility for their own health care by becoming familiar with health care options and being actively involved in health care decisions. Follows requirements relating to documentation Clinical findings documented in medical record according to legislative requirements Follows infection control guidelines and legislative requirements in relation to pathology collection Referrs appropriately all clients with abnormalities or pathology on consultation or examination Has established written protocols for the initiation of S2 and S3 substances and standing order protocols for the initiation of S4 and S8 substances as appropriate to local policy and service needs Breast Examination The women’s health nurse will provide an opportunity for the woman to develop an understanding of the problems and prevailing attitudes which may prevent women from undertaking breast examinations. Breast self examination and regular clinical examination will be promoted. Young women under 25 years old attending the women’s health nurse clinic will not be offered a clinical breast examination unless it is requested or it is indicated by family history or client history. Breast awareness and breast self examination will be promoted. The women’s health nurse will: First take a history including: .   brief history of breast development .   changes in size, shape or colour of breast. any breast surgery .   soreness of breasts or nipples, particularly in relation to the menstrual cycle .   pain .   any discharge or secretions (describe colour and consistency) .   any lumps, masses, cysts or tumours (when noticed, how detected, how treated) .   family history of breast cancer or breast disease .   any previous mammogram results .   knowledge of breast self examination Discuss advantages of regular breast self examination and the role of screening and/or diagnostic mammography and breast ultrasound for women in specific risk groups. Thoroughly explain procedure and obtain consent. Ensure privacy and comfort Wash and warm hands Ask client to remove appropriate clothing Observe and palpate both breasts. Discuss the anatomy and physiology of the breast with client and the common non-pathological changes which may occur in breast tissue. If the patient suspects a lump or mass in one breast, examine the other breast first so that you will have a basis for comparison. Visual Check: Stand or sit client. Observe breasts carefully as the woman assumes the following positions - arms hanging at her sides, arms over her head, hands pressed against her hips and arms held straight ahead as she leans forward. Manual Check: Ask the client to lie down. When the client is supine, place a small pillow under the scapula on the side being examined, ask her to raise her arm above her head on the side you are examining. Note the following characteristics: .  size, shape and symmetry of breasts .  direction of both breasts and nipples .  colour (e.g. persistent patches of redness or inflammation) .  skin texture (e.g. dimpling or puckering of the skin, 'orange-peel' skin, prominent blood vessels) .  retraction or inversion of the nipples .  any spontaneous discharge from the nipples .  persistent sores, lesions, rashes or ulcerations .  any swelling, redness, inflammation, lesions or masses of the upper arm or axillae Palpation of the breasts may be conducted with the client either sitting and/or lying. Use the flat of the fingers together, with a circular motion and a firm pressure. Ensure that the entire breast surface is covered in the examination, from the clavicle to the axillary tail. Repeat for the other side. If any abnormality is detected, discuss findings and referral options. Record findings in client records. Contraceptive advice During all consultations, the women’s health nurse is expected to demonstrate an understanding of human sexuality as it relates to fertility control and sexual health. This will be achieved by: Understanding the physiological and psychological factors inherent in human sexual development, including: . primary hormonal differences . secondary sexual changes Understanding the nature of sexual arousal, including: . stages of human sexual response . nature of sexual stimulation . range of sexual behaviours . conditions that influence sexual response Understanding the psychosocial issues of human sexuality, including: . gender roles . sexual preferences . range of human relationships . cultural considerations . incest and sexual abuse/assault Women’s health nurses will: Be sensitive to social/cultural values in relation to the different contraceptives Provide comprehensive written and verbal information, tailored to the woman’s needs, to promote an adequate understanding of the effective use of the method of contraception Discuss the advantages and disadvantages of the contraceptive methods available Discuss the indications and contraindications of the methods of contraception Describe the mode of action of the contraceptive and its efficacy Discuss any potential problems or situations which may reduce the effectiveness of the method of contraception including the availability of post coital contraception. Discuss care and disposal of the different contraceptives Discuss appropriate referral sources Discuss the cost and availability of the different methods   NATURAL CONTRACEPTIVE METHODS Breastfeeding Be aware of the potential problems or situations which may reduce the effectiveness of breastfeeding as a method of contraception. Withdrawal Discuss the use of withdrawal in relation to the experience and commitment of her partner. Natural Family Planning Discuss the use of the combination of the sympto-thermal method, ovulation detection (Billings) method and rhythm method. Consider the additional use of barrier methods during the fertile period. Discuss the use of natural methods in relation to the commitment of both client and her partner.   BARRIER CONTRACEPTIVE METHODS Spermicides Discuss use, cost and efficiency Condoms Allow client to handle and to gain confidence in using the method and discuss use of lubricants. Diaphragms Discuss the different sizes in relation to women’s anatomy , change in weight and effect of childbirth. Discuss use of spermicides, and allow client to handle the diaphragm.   INTRA UTERINE DEVICE Assess current risk factors. The following shall be considered absolute contraindications to insertion of an intra uterine device: . existing or suspected pregnancy . active pelvic inflammatory disease . chronic or recurrent pelvic inflammatory disease . uterine abnormalities causing distortion of the cavity (congenital or acquired) . cervical abnormalities (congenital or acquired) . uterine cavity length of less than 5 cms . recent irregular and undiagnosed uterine bleeding . carcinoma of the uterus or cervix The following shall be considered relative contraindications to insertion of an intra uterine device: . nulliparous women . woman under 25 years of age . history of severe dysmenorrhoea or menorrhagia . previous history of pelvic inflammatory disease . previous ectopic pregnancy . multiple or changing partners or likely to be exposed to sexually transmissible disease Describe procedure and care following insertion. Refer to medical practitioner for insertion   HORMONAL METHODS OF CONTRACEPTION Oral Contraception (combined oral contraception and progestogen only contraception) Consider any possible risk factors, drug interactions and in particular the risk of cardio vascular disease: Absolute Contraindications: previous stroke, heart attack or deep venous thromboses everely impaired liver function/active liver disease undiagnosed vaginal bleeding Relative contraindications: high blood pressure (140/90 or above), diabetes, gallbladder disease, certain blood disorders, epilepsy or tuberculosis breast feeding cancer of the breast or reproductive system Over 35 and a smoker / under 35 and smoke more than 15 cigarettes a day Discuss pill taking, missed pills regimes. Be conversant with current available oral contraceptives. Discuss social issues relating to the use of oral contraception where indicated (eg. lack of protection from STDs). Referral to medical practitioner for prescription if required Depo provera Discuss the advantages and disadvantages, benefits and risks, of Depo Provera to ensure client makes an informed decision. Referral to a medical practitioner for injection is required Contraindications: Thrombophlebitis, thromboembolitic disorders, cerebal apoplexy Impaired liver function Undiagnosed vaginal or urinary tract bleeding Undiagnosed breast pathology Missed abortion Pregnancy Severe uncontrolled hypertension   POST COITAL CONTRACEPTION (Intra Uterine Device, Morning After Pill ) Discuss with clients the use of post coital contraception in conjunction with the other forms of contraception as well as its use in case of unprotected sex or contraceptive failure. Be aware of services that provide post coital contraception   SURGICAL METHODS OF CONTRACEPTION (Tubal Occlusion and Vasectomy) Sterilisation should be considered as permanent and should only be recommended after thorough counselling, which should take into account medical, social and emotional factors, as well as considerations of failure rates and complications Diaphragm Fitting Procedure Discuss the different sizes in relation to women’s anatomy , change in weight and effect of childbirth. Discuss use of spermicides. Allow client to handle the diaphragm. * Fully explain the procedure using visual aids if available, demonstrating equipment to be used. * Obtain consent * For comfort, client should have an empty bladder prior to procedure * Position client on couch. Offer client a cover * In order not to contaminate 'clean' area, all requirements for the diaphragm fitting must be taken to the client. This includes practice diaphragms in assorted sizes, lubricating gel and tissues. * Wash hands and put gloves on both hands. * Separate the labia with two fingers of one hand and, using a small amount of water based lubricant, gently insert the finger/s of the other hand into the vagina. * Follow the posterior vaginal wall down and back until you can feel the cervix. Determine probable diaphragm type and size. * Remove finger/s. Take practice diaphragm of appropriate size, lubricate with warm tap water. Gently insert, explaining procedure, checking fit and to see that cervix is covered * Ask client to sit and then stand to check for comfort of diaphragm. If fit is correct, client should not be consciously aware of diaphragm in position * Instruct client in checking that the diaphragm is in the correct position and that the cervical os is covered. Instruct client in removal of diaphragm and ask client to remove same. Offer client a tissue to wipe fingers. If diaphragm fit is correct, rinse practice diaphragm in warm tap water and ask client to reinsert. If diaphragm fit is incorrect, repeat above procedure until correct fit is obtained * When client has reinserted and checked position of correct fit diaphragm, position client on couch and using a small amount of water based lubricant, gently insert finger/s of gloved hand into vagina, checking that the diaphragm is in the correct position and that the cervix is covered. * Repeat the above procedure and reinsert practice diaphragm until such time as client is confident performing procedure * Upon completion of diaphragm fitting, offer the client a tissue to wipe vulva and fingers. * Remove and dispose of gloves. Wash hands * Write observations in notes * Client may be given a practice diaphragm to trial at home for an appropriate period of time. If possible, the client should use the diaphragm during sexual activity. The client must use other contraceptive cover during practice period. It is advisable for the client to wear the diaphragm for 6-12 hours during the practice period to check for comfort * Instruct client in care of diaphragm. Arrange for follow up appointment. If possible, the client should be asked to wear the practice diaphragm to the clinic for her follow up appointment so that the women’s health nurse can assess its position and fit. * Practice diaphragms must be autoclaved between use. Mammograms Diagnostic mammograms Women who present with symptoms eg. lump, nipple discharge etc. are to be referred to the medical practitioner of their choice for appropriate management. Women who have a family history of breast cancer may require individual assessment and may require a referral from their medical practitioner for diagnostic mammogram and or ultrasound. Screening mammograms Breast Screen Australia provides free screening mammograms for women aged 40-70 years (targetting the >50s) and recommends two yearly screening intervals. There is no charge to attend the clinic, nor is a referral required. Screening availability varies across the sector. Menstrual Cycle Advice Many women experience changes in physical and psychological symptoms in relation to their menstrual cycle. For some women these changes are problematic, and may affect their quality of life. Women’s health nurses should- Promote the client's understanding of female anatomy and physiology, the menstrual cycle and menstrual problems. Discuss the biological, social and emotional aspects of the menstrual cycle and their affect on each woman as an individual Discuss the available options for women in management of menstrual cycle difficulties such as dysmenorrhoea, menorrhagia and premenstrual syndrome, including medications, natural therapies, diet, exercise and general lifestyle changes Establish contact with local support groups and encourage clients to use them eg. Endometriosis Support Group. Refer appropriately in consultation with the client. Menopause Advice Many women experience symptoms in relation to the cessation of their menstrual cycle. For some women these changes are problematic, and may affect their quality of life. The women’s health nurse should- Discuss the biological, social and emotional aspects of the menopause and their affect on each woman as an individual. Provide comprehensive written and verbal information, tailored to the woman’s needs, to ensure that the client has adequate understanding with regard to reproductive physiology and the changes that occur around the time of the menopause. Discuss the available options for women in management of the menopause, without bias, including hormone replacement therapy, diet, exercise and general lifestyle changes and alternative therapies to assist women to make decisions about their menopause management. Reinforce the need for participation in health screening programs e.g. regular Pap tests, breast examination and mammography. Establish contact with local support groups and encourage clients to use them Refer appropriately in consultation with the client.   Hormone Replacement Therapy Hormone replacement therapy is one management option available to women, in the peri-menopausal, menopausal and post-menopausal years. Discuss with women the circumstances under which a woman may safely receive hormone replacement therapy, the possible short and long term advantages and disadvantages, together with the different regimens and medications available   Osteoporosis Following natural or surgical menopause, women are at risk of developing osteoporosis. Discuss with the client her positive risk factors (e.g. family history of osteoporosis, smoking, early menopause), hormone replacement therapy as a management option to minimise risk, non-hormonal therapies such as calcium and lifestyle options e.g. exercise and diet. Papanicolau Tests (including bi-manual examination) Cervical cancer is one of the most preventable cancers in women, given early detection of abnormalities via regular Pap test screening. Cervical cancer is unique among cancers in that it is preceded by a precancerous stage which can mostly be detected by a Pap test and appropriate treatment given. The National Policy for the Prevention of Cervical Cancer (November 1991:3) states that: Routine Pap test screening should be carried out every two years for women who have no symptoms or history suggestive of cervical pathology. All women who have ever been sexually active should commence having Pap tests between the ages of 18 to 20 years, or one to two years after first sexual intercourse, whichever is later. In some cases, it may be appropriate to start screening before 18 years of age, and Pap tests may cease at the age of 70 years for women who have had two normal Pap tests within the last five years. Women over 70 years who have never had a Pap test, or who request a Pap test, should be screened. (Page 3) The policy also indicates that women who have had a hysterectomy do not require vaginal vault tests unless: The cervix was not completely removed at hysterectomy The exact reason for hysterectomy is not known Previous test results are not known There is a history of CIN or HPV changes on Pap test, or genital warts There is a history of invasive gynaecological malignancy The woman is immunosuppressed due to disease and/ or therapy. (Commonwealth Department of Health, Housing and Community Services, Screening For The Prevention of Cervical Cancer, November 1991) Management of Pap test results The WHNs follow the National Health and Medical Research Council (NH&MRC) 'Guidelines for the management of women with screen detected abnormalities', 1994. At a concensus meeting convened by the (then) Commonwealth Department of Human Services and Health, in 1994, a standardised reporting format was proposed which utilises the NH&MRC categories but also includes a specific diagnosis and recommendation for management. Pap test reports should contain the following elements: a heading indicating the diagnostic category a descriptive comment enlarging on the heading a comment on the endocervical component a recommendation for management The headings used are- Negative Low Grade Epithelial Abnormality High Grade Epithelial Abnormality Inconclusive Technically unsatisfactory All results should be evaluated taking into consideration the clients clinical and sexual history. Pap test The result should be recorded in thePap test record form and in the clients file. If required the result should be photocopied for the clients medical practitioner. Normal result Notify the client by letter, of the date and normal result of her Pap test. Translated letters are to be sent with an English version. Endocervical material absent (EMA) Endocervical material or cells absent . The recommended follow up for pap tests with ‘endocervical cells absent’ remains an issue on which oppinions differ. The NHMRC guidelines state that any negative test is to be "repeated at two years irrespective of the endocervical status of the test" ('Guidelines for the management of women with screen detected abnormalities', 1994, page 14). Women’s health nurse should consider whether the pap test technique was adequate if she has had a pap test with the past 5 years whether she is at high risk ( previous abnormal pap tests) Abnormal result Women’s health nurses need to follow the recommendations of the cytologist and refer the woman to her general practitioner for investigation and treatment prior to resmear. All clients with an abnormal result must be referred for further assessment. Contact the client as soon as practicable eg. phone , letter or home visit to discuss management. Follow the protocols recommended in Section xxx ‘Referral’s (page xxx ). If a referral back to the women’s health nurse clinic is made and the client does not attend, follow the protocols recommended in Section xxx "Broken Appointments’ (page xxx) Record the outcome of the contact in client's file and Pap test record form. NSW Cervical Cytology Register All clients who attend for a Pap test will automatically be enrolled on the NSW Cancer Council Pap Test Register as per current legislation. Clients must be informed and offered the opportunity to "opt-off" ie. not be placed on the register. Cancer Council will notify all practitioners of the protocols and obligations in relation to this register. The women's health nurse must explain the service (ie. the opt -off system) to the client and note clients decision to enrol / or not enrol on the Pap test register in her file Principles for follow up of Pap test results: All women should be notified of their results, normal or abnormal. If appropriate include a copy of the results with an explanation of the terminology. Access to their own results allows women to keep a record of Pap test attendances and encourages women to take responsibility for their own health Each service will need to develop their own system for follow-up based on local needs. The system developed must be one which ensures that women are contacted within the shortest time possible if further investigation is needed All clients with abnormal results should be notified as a matter of priority. All attempts to contact clients must be documented in the clients file. If the client has an abnormal result and is not able to be contacted discuss this with senior management When notifying abnormal results, areas to be covered should include: . full and adequate explanation of the client's particular result . possible further investigations which may be required . emphasis on preventive nature of Pap test screening . current treatment options for cervical abnormalities, dysplasia and neoplasia. Pap test Procedure Issues to be aware of before commencing procedure: Pap tests taken during normal menstruation may not provide an adequate sample. Pap tests may be taken during pregnancy, but a cytobrush should not be used. Clients should not douche or use vaginal suppositories/creams for 24 hours prior to taking having a Pap test Pap tests should not be taken when there is evidence of marked vaginal infection. To take a Pap test, a speculum is inserted into the woman's vagina to hold the vaginal walls gently apart so that the cervix can be visualised. Loose cells are wiped from the surface of the cervix (neck of the womb), from the area called the transformation zone. These cells are then placed onto a glass slide and sent to cytology. The glass slides, plastic spatulas, cytobrushes and pathology request forms for taking Pap tests are obtained from Douglas Hanley Moir Clinical Procedure: Prior to taking the Pap test, fully explain the procedure. For comfort, client should have an empty bladder prior to procedure Complete pathology request form, noting any significant history. Label glass slide in pencil. Ensure fresh fixative is readily available (90-95% alcohol is recommended) Position client on couch. Offer client a cover. Position light. Have equipment near client prior to commencing the procedure. This includes labelled slide, speculum, spatula, cervix brush or cytobrush, lubricating gel, swabs, tissue etc. Inspect the abdomen for contour and palpate the abdomen with both light and deep techniques in order to detect any abnormalities. Start the procedure by using the pads of your fingers to press lightly to a depth of about ½" to determine skin temperature and any large masses or areas of tenderness. To palpate deeply, instruct the client to relax and breathe normally while you press the fingertips of one or both of your hands to a depth of about 3", checking for any enlargement of liver, spleen or kidneys. Wash hands and put gloves on both hands. Use disposable gloves. During all phases of your assessment, be alert for facial or verbal expressions of pain and for abdominal guarding Inspect vulva, examining external genitalia for any conditions that might require further investigation, including changes in vaginal moisture, discharges, lesions etc. Warm and check speculum temperature on client's thigh . Insert closed speculum slowly and gently, following posterior wall of vagina. Visualise cervix and note appearance and orientation. Observe vaginal walls If discharge is present in vagina, note appearance, amount and odour. If discharge is abnormal, a vaginal swab is indicated (or a wet film if such facilities are available). If mucopurulent discharge is present at external cervical os, tests for chlamydia and gonorrhoea are indicated. Pap tests are not done when there is evidence of vaginal infection (refer her for treatment). Insert spatula or cervix sampler into external cervical os. Firmly and gently rotate it 360 degrees in the same direction twice. Carefully remove the spatula or cervix sampler, taking care not to touch vaginal walls or speculum. Wipe immediately onto glass slide use a single motion for each side of the spatula (or cervix sampler). Alternatively, use a cytobrush in conjunction with either the spatula or cervix sampler. If the cytobrush is also used -use half of the slide for the cytobrush and the other half for the spatula or cervix sampler. A cytobrush should be used for a post-menopausal woman and for women in whom previous tests have shown an absence of endocervical cells. Slides should be immediately placed into fresh fixative and left undisturbed for a minimum of fifteen minutes. Explain each step of the procedure and findings to client as it is carried out. An explanation of contact bleeding may be required. When removing speculum, check anterior and posterior vaginal walls ensuring you do not pinch the skin or hairs. Rinse or soak speculum in clean tap water prior to sterilisation. Refer to NSW Department of Health Infection Control Policy Circular 95/13 ( See Section xxx ‘Infection Control’ (page xxx) and local protocols. Turn off the light. Commence Bimanual Examination. Separate the labia with two fingers of one hand and, using a small amount of water based lubricant, gently insert the two fingers of the other hand into the vagina. Follow the posterior vaginal wall down and back until you can feel the cervix Localise the cervix. Note the position, size and consistency of the cervix and os Place your abdominal hand on the lower abdomen, in the midline above the symphysis and press down firmly to steady the pelvic organs in the pelvis, while you locate them with the vaginal hand With the fingers of the vaginal hand, elevate the cervix, press upwards gently towards the abdominal hand and palpate the uterus between the two hands, when the uterus is anteverted If you cannot feel the uterus anteriorly, place the vaginal fingers behind the cervix with firm pressure from the abdominal hand displacing the pelvic contents posteriorly and gently palpate the posterior fornix to feel the uterus in the retroverted position If the uterus is in the mid position, it may be more difficult to feel especially in an obese client and more firm abdominal pressure is necessary to locate and attempt to mobilise the fundus When you have found the uterus, divide the two vaginal fingers into a 'V' or insert both fingers into the fornices in turn and with the fingers on either side of the cervix, feel the outline of the uterus. Note its size, shape, position and mobility Place your fingers to each side of the cervix and gently displace the cervix laterally. If this produces pain, it may indicate inflammation in the adnexae (the fallopian tubes, ovaries and broad ligaments) Palpate the adnexae (ovaries + tubes) ie. move your abdominal hand to one side of the uterus and use the vaginal fingers in the relevant lateral fornix, to press the adnexae upwards towards the abdominal hand. Try to feel the ovaries at the side of the uterus and to assess any masses or tenderness. Repeat on the other side * With your vaginal fingers in the posterior fornix, palpate the Pouch of Douglas for masses or tenderness. Check the anterior fornix and anterior vaginal wall to assess unusual bladder/urethral tenderness A pelvic floor assessment is done at this time as appropriate: * Upon completion of your examination offer the client a tissue to wipe vulva . * Document observations fully in notes. If any abnormality is detected, discuss findings with client when client is dressed and seated. Appropriately refer any abnormalities in consultation with client. * Advise client of arrangements for notification of Pap test results. Advise recommended interval for Pap tests, taking into account the individual history and risk factors. * Ask the client if she would like a photocopy of the result to be sent to her General Practitioner, if yes make a note in the record form and ask client to sign it as a consent. * Discuss the NSW Cervical Cytology Register and explain the service (ie. the opt -off system) to the client. All clients attending for a Pap test will automatically be placed on the register unless clients choose otherwise. Record in the clients file her decision to enrol / or not enrol on the Pap test register. * Record the pap test in women’s health nurse Pap test record Pelvic floor muscle assessment Women’s health nurses encourage clients attending the women’s health nurse clinic to practice pelvic floor muscle exercises as appropriate. Offer pelvic floor muscle assessment to clients when a pelvic examination is performed as appropriate. Obtain consent Provide written and verbal information to ensure that the client has an understanding of the effective use of pelvic floor muscle exercises to promote continence Fully explain procedure, use visual aids if available, demonstrating equipment to be used. For comfort, client should have an empty bladder prior to procedure Provide privacy for the woman to undress. Underwear from waist down need only be removed. Position client on couch. Offer client a cover Position light and turn on Wash hands, put gloves on both hands. Use disposable gloves (these need not be sterile) Inspect vulva, examining external genitalia for any conditions that might require further investigation. Observe vulva, vaginal introitus, perineum and anus for any abnormality. While looking, ask client to cough, and check for any bulging or leakage of urine. Observe for any abnormalities. Separate the labia with two fingers of one hand and, using a small amount of water based lubricant, gently insert the two fingers of the other hand into the vagina Separate the two fingers inside the vagina scissor fashion, side to side and top to bottom. With fingers held apart, ask the client to contract her pelvic floor muscles to try to squeeze your two fingers together and to hold the contraction. Instruct the client to relax and then repeat the exercise Grade pelvic floor muscle tone Grade Contraction Description Nature of Contraction 0 Nil Nil Nil 1 Flicker ( at stretch) Very poor Flicker only 2 gravity neutral, poor contraction poor weak squeeze, no hold, no lift 3 anti-gravity fair moderate squeeze, lift hold for 3 seconds, repeat three times (rest for 3 secs between contractions) 4 anti-gravity good good squeeze,. ,lift hold for 5 seconds, repeat 5 times (rest 5 secs between contractions) 5 normal very good strong squeeze, lift, hold for ten seconds, repeat ten times (rest 10 secs between contractions) *****NB for grades 0-2 hold fingers apart to ensure accurate grading**** Remove fingers. Remove and dispose of gloves. Wash hands Upon completion of your examination, offer the client a tissue to wipe vulva Write observations in notes. Discuss findings with client when client is dressed and seated. Clients whose pelvic floor muscle tone is graded as 4 - 5 should be encouraged to continue regular pelvic floor muscle exercises. Clients whose pelvic floor muscle tone is graded as 3 should be given an exercise regime and an appointment made for reassessment. At the follow up appointment, assess complete bladder routine. Clients whose pelvic floor muscle tone is graded as 0 - 2 should be referred for further assessment. Appropriately refer in consultation with client. Provide clients with appropriate written information on pelvic floor exercises and healthy bladder habits Post Natal Checks The post natal check is done six to eight weeks after the birth of the child. This is an optimal time to ensure that the woman is physically recovering, the baby is thriving, to provide contraceptive advice and to discuss any issues that may have arisen for her in the past weeks. The women’s health nurse will: First take a history including: Type of delivery, any complications Vaginal discharge (duration/colour/quantity) Lochia typically is brownish with occasional pinkish or light red discharge, it usually ceases by the 4th-5th week post partum (earlier if breast feeding) but may continue to 6 weeks. In non breast feeding women the first period occurs between 4-7 weeks post partum but may be later ie. 12 weeks. Any vaginal bleeding Any pelvic pain or discomfort Difficulties with continence Post natal sexuality, issues with sexual intercourse Post natal exercises Breast discomfort or difficulties with breast-feeding Any feeding problems, aware of the local Early Childhood Centre Discuss issues such as social support (alone/partner/other children), coping mechanisms such as child care, attending gym or groups. Be aware of the signs, symptoms, risk factors associated with post natal depression and management of women with positive scores (see "The Edinburgh Postnatal Depression Scale guidelines for use in Primary Health Care", N.S.W. Department, 1994). Signs and symptoms; a disturbance of mood, sleep, appetite, gastrointestinal function, menstrual function, loss of energy, concentration, interests, confidence, libido, feelings of inadequacy, hopelessness, helplessness, exhaustion, panic, fear, anger, guilt, sadness, shame, unworthiness, thoughts of harm/death befalling the baby or partner, running away. Risk factors include a history or family history of anxiety or depressive problems, older maternal age, previous obstetric loss, a history of infertility, marital problems, a life crisis during pregnancy, social isolation. Those particularly at risk are the young mothers; single mothers; those who have a baby early in the relationship;those with chronic life difficulties-financial, marital and relationship problems; those lacking a confidante. Characteristics that may be identified by Maternity Units as indicators for the need for follow up include: history or family history of affective disorders (including PND); continuous ‘blues’, sleep disturbance, detached/negative feelings towards baby; high anxiety, feeding difficulties. Screening - the Edinburgh Post Natal Depression Scale is used as a screening technique if the women’s health nurse has adequately trained in its use and in counselling/management of women with positive scores. Clients are referred to an appropriate health professional chosen by the woman. Do a medical examination record BP breast examination abdominal examination check abdominal muscle tone and that the divarication of recti has closed by asking client to place hands across chest and then sit upright. Discuss need for post natal exercises. check caesarian scar if appropriate check perineum to ensure it has healed do a vaginal examination ectopic columnar epithelium often persists and does not require treatment red stained lochia beyond six weeks requires follow up to exclude choriocarcinoma. a Pap test is done if client has not had a Pap test within the past two years. a bi-manual is done to ensure the uterus has returned to its normal shape, size and position. The pelvic floor muscle is assessed and pelvic floor muscle exercises discussed as appropriate. Discuss post natal sexuality and post natal contraception. Pregnancy testing, counselling and referral * Explore client attitude toward a possible pregnancy * Take a menstrual and sexual history to establish pregnancy potential, including any signs and symptoms of pregnancy * Outline the reasons for a false positive or false negative result * Be aware of the drugs that may alter a pregnancy test result * Perform a urine test (or take blood) for pregnancy testing, observing appropriate infection control protocols (see Infection Control Protocol) * Convey pregnancy test results personally to client * Advise client personally of pregnancy test results * Provide a supportive non-judgemental environment to allow the client to freely express her reactions to the test result and discuss a range of alternative courses of action if necessary * Explore the short and long term implications of the course of action chosen with the client if necessary * Be aware of and develop links with a range of pregnancy services in the community including those providing emotional support, financial assistance, practical assistance, antenatal care, birthing services (traditional and alternate) and termination of pregnancy * Refer appropriately in consultation with the client * Be familiar with and alert to the signs and symptoms of ectopic pregnancy * Identify those clients at particular risk and mobilise appropriate support as required. Post Termination Check A post termination check is done 2 weeks after termination of pregnancy to ensure the termination was successful and without complications. It also provides an opportunity to discuss issues that may have arisen for the client. The women’s health nurse will; Take history of; bleeding patterns. Some women experience light bleeding from day one for a fortnight and for others the bright red bleeding starts at the 3rd-6th day. It may be dark or brownish in colour. Some women have no bleeding at all. pain may be a mild analgesic like Panadol any vaginal discharge duration colour quantity itchiness/pain any fever did client take the antibiotics supplied by the clinic how many weeks pregnant was she any symptoms of continuing pregnancy (e.g., nausea, breast tenderness - these symptoms usually subside over 2-3 days and have disappeared a week after the termination.) Do a vaginal examination and check; for any mucopurulent discharge the uterus has returned to its normal shape, size and position for tenderness on rocking the cervix or adnexal tenderness *if the clients 2nd yearly Pap test is due, it should not be done until 10-12 weeks after the termination. Discuss contraception Discuss how she feels about her decision to terminate. Some women feel relieved and others feel a sadness 2-6 days after the procedure. Screening for Sexually Transmissible Diseases Diagnosis of a sexually transmissible disease often raises many concerns for the client due to the stigma. The diagnosis of a sexually transmissible disease may also impact on the client's relationships and raise concerns regarding future sexual activity and fertility. The women's health nurse can do much to alleviate these concerns by adopting a positive and non-judgemental attitude towards the client and the sexually transmissible disease; by acknowledging the client's concerns and providing reassurance; by giving accurate information on the nature, transmission, incubation period and treatment of the infection; and providing advice on the safe resumption of sexual activity and any changes in lifestyle that may help prevent future infection. women's health nurses may provide counselling and support for clients who are experiencing difficulties accepting the diagnosis of a sexually transmissible disease and/or refer appropriately. Sexually transmissible disease screening is appropriate for women who are at risk even though they are asymptomatic. Discuss with the client the possibility of any increased risk. The women's health nurse will: * be familiar with the signs and symptoms of all sexually transmissible diseases and current treatment options. * record an adequate sexual health history including: . a description of any abnormalities, the duration, onset, relevant past history and any previous treatment. . sexual history (where relevant) including whether sexually active, number of partners, sexual difficulties, previous sexually transmissible diseases and contraceptive method used . vaginal discharge including duration, quantity, appearance (colour, consistency), odour, related symptoms (itch, irritation, soreness), relationship to menstrual cycle, relationship to intercourse . pelvic pain including onset, duration, distribution, character, relationship to menstrual cycle, relationship to intercourse. The women's health nurse will: conduct a thorough clinical examination specifically noting: any abnormalities of the vulva any abnormalities of the vagina or any discharge any abnormality of the cervix e.g. cervicitis, mucopurulent discharge or any tenderness on rocking any adnexal mass or tenderness (describe size, consistency) take specimens ( follow local protocols for pathology collection by women’s health nurses). record in the client's record any abnormality detected. Any abnormality should be appropriately referred. discuss assessment procedure and current treatment options. clients will be encouraged to follow through and complete the treatment recommended. These policy and procedure guidelines refer to screening procedures, the women’s health nurse does not diagnose or provide treatment for a woman with a sexually transmissible disease, but rather provides appropriate referral to a Medical Officer of the woman's choice.   HIV Antibody testing (pre-counseling) The women’s health nurse shall provide information about and testing for sexually transmissible diseases. Goals of pre-test counselling include the minimisation of transmission of HIV and maximisation of the general physical and emotional health of those infected by HIV. The concept of pre-test counselling was introduced to minimise adverse reactions to HIV antibody testing. Pre-test counseling endeavours to ensure that individuals are fully informed of the physical, psychological, legal and social implications of their HIV status. Account must be taken of the three month seroconversion period. Procedure Assess risk Provide medical information on: - transmission of the virus; - implications of the seroconversion period; - progression of the disease. Discuss safer sex and safer IDU use in relation to clients risk factors. Explore support networks Explore previous coping mechanisms Give information regarding social and legal consequences of a positive HIV antibody status: - life insurance implications - possible decreased emotional/physical support - possible discrimination - legal obligation to tell all sexual partners Assess relative factors that can affect progression of the disease. Ensure informed consent with documentation, including the opportunity to decline HIV antibody testing. Discuss issues of anonymity and confidentiality Explain consent form for HIV Antibody Test Encourage a support person to be present at time of collection of results 11. COUNSELLING The following principles should be applied when appropriate for clients presenting with a range of counselling needs including domestic violence, sexual assault, infertility, sexual problems, relationship problems. Develop a range of interviewing and counselling skills and understand the principles of communication theory Be able to distinguish between passive, aggressive and assertive responses Be able to utilise problem solving skills Use the processes of active listening, feedback and clarification in interactions with clients Be aware of the barriers to effective communication such as personal bias, values and attitudes Be aware of personal and role limitations when providing client counselling Provide a supportive, non-judgemental environment in which the client may freely express their feelings and explore a range of problem solving options Be able to develop with the client short and long term goals and alternative strategies for meeting those goals Be aware of and develop links with a range of generalist and specialist crisis and counselling services in the local area Refer appropriately in consultation with the client. Follow the Area policies on Domestic Violence, Sexual Assault and Child Abuse. 12. HEALTH CARE SERVICES PROVIDED TO MINORS The women's health nurse provides gynaecological health screening, education and counselling to all women requesting her services. This may include clients under the age of sixteen (16) years. Minors (Property and Contracts) Act 1970 (NSW) Section 49 of the Minors (Property and Contracts) Act 1970 (NSW), seeks to clarify consent regarding the treatment of minors in NSW. Consent generally and consent by minors is also covered in the NSW Department of Health Circular 92/21 ‘Consent to Medical Treatment’ (pg9) If the minor is less than 14 years of age, then consent of a parent or guardian is necessary. If the women’s health nurse is required to provide services to persons under the age of 14 years then written local protocols must be developed by the employing body to guide women’s health nurse practice. If the minor is 14 to 16 years of age, the minor may give consent in their own right, providing that, in the professional judgement of the women’s health nurse, the minor is considered to have understood the advantages , risks, benefits, efficacy and regimen involved. It is preferred, however, that the consent of the parent or guardian is also obtained. Over the age of 16 years, a minor does not require parental consent and may consent to a procedure themselves. It is important that the women’s health nurse only acts on the consent of a minor if it is apparent that the minor demonstrates a capacity to understand both the nature and the consequences of following the advice; undergoing the treatment; or taking the prescribed drugs; ie the minor demonstrates a maturity appropriate to the level of complexity and seriousness of the procedure or advice involved. Confidentiality Confidentiality is to be maintained at all times (as with any client). To disclose the fact that a minor of any age has attended a Women's Health Clinic or to give any person any information regarding that minor, may leave the nurse liable in an action for breach of contract or defamation. Inciting the criminal act of carnal knowledge It is the role of the women’s health nurses to facilitate support and education which will foster responsible decision making by the minor. Provision of information such as different methods of contraception and safer sex techniques, along with provision of barrier contraceptive protection to a minor does not constitute aiding or inciting the criminal act of carnal knowledge, providing the women’s health nurse is satisfied that the provision of the service is in her professional judgement, necessary to promote the minor’s physical and mental health, and is not accompanied by the encouraging of sexual intercourse. Further reading: Staunton P.J.& Whyburn,B "Law for Nurses" (1989) Bailliere Tindall, Sydney. Skene, L (1990) " You, Your Doctor and the Law " Oxford University Press, Australia, pp 148-156 Spencer, L (ed) (1991)" The Law Handbook ", RLC Publishing, p 168 Women's Legal Resource Centre (1994) " Girls and the Law ", p 47 Dix, A. et al (1988)" Law for the Medical Profession " Butterworths, Sydney pp 314-318, pp 86-88. 13. BROKEN APPOINTMENTS Whilst women’s health nurses encourage women to take responsibility for their own health, broken appointments raise duty of care issues. The manner in which broken appointments are addressed will be determined by the reasons for the appointment being made in the first place. A broken appointment may indicate that a women has changed her mind or forgotten about attending the women’s health nurse clinic. In this case no further action is required. If the client has been referred to the women’s health nurse by another health worker it is appropriate for the women’s health nurse to notify the health worker that the client has failed to attend. Broken appointments that do require follow up include: * appointments made for a repeat test * where a client's appointment was a follow up visit considered necessary by the women's health nurse at the previous visit A client may be contacted personally, by phone or by letter as appropriate. If a client does not respond to the initial attempt a second attwempt should be made. The women's health nurse must document all attempts to contact the client - both successful and unsuccessful. On contacting a client it must be explained to the client why an appointment was considered necessary and options available. If a woman chooses not to return to the women's health clinic this must be documented in the client's record. Following two contacts with the client by the women's health nurse and appropriate explanations of the need for follow up and options available, the nurse can consider that the client is taking responsibility for her own actions. Local (sector) protocol may require further action of the women's health nurse such as notifying their clinical nurse consultant or senior nurse. 14. REFERRALS Making a referral: The women’s health nurse provides a screening service for well women. It is anticipated, however, that occasions will arise during consultation and clinical evaluation when referral of the client for further assessment will need to be made.Referrals may be either informal (word of mouth) or formal (written referral). The following principles will apply to referrals being made from the women’s health nurse. Referrals will be made in consultation with the client. The need for further assessment will be fully explained, together with the likely management and treatment options The client will be advised objectively and without bias, of the appropriate services available in her local area The client will be encouraged to take responsibility for her own health care by making an informed decision considering her own particular needs, likes and dislikes A letter of referral may accompany the client. Ideally, this should be written in front of the client and presented to the client for her to read. In any event, any letter of referral should be given to the client in an unsealed envelope. A copy of the letter of referral is to be kept with the client's medical record. If the client declines a referral letter this is to be noted in the client's record. A referral feedback form can be in