Pelvic inflammatory disease (PID) is a polymicrobial infectious disease of the pelvic cavity and the reproductive organs. PID may be localized and confined to one area, or it can be widespread and involve the whole pelvic region including the uterus (endometritis), fallopian tubes (salpingitis), ovaries (oophoritis), pelvic peritoneum, and pelvic vascular system. The infection can be acute and recurrent or chronic. PID can be a life-threatening and life-altering condition. Complications of PID include pelvic (or generalized) peritonitis and abscess formations, with possible obstruction of the fallopian tubes. Obstructed fallopian tubes can cause infertility or an ectopic pregnancy. Other complications of PID are bacteremia with septic shock, thrombophlebitis with the possibility of an embolus, chronic abdominal pain, and pelvic adhesions.
The causes of PID vary by geogrphic location and population. Many types of microorganisms, such as a virus, bacteria, fungus, or parasite, can cause PID. Common organisms involved in PID include Chlamydia trachomatis, Neisseria gonorrheae, staphylococci, streptococci, coliform bacteria, mycoplasmas, and Clostridium perfringens. The means of transmission is usually by sexual intercourse, but PID can also be transmitted by childbirth or by an abortion. Organisms enter the endocervical canal and proceed into the upper uterus, tubes, and ovaries. During menses, the endocervical canal is slightly dilated, facilitating the movement of bacteria to the upper reproductive organs. Bacteria multiply rapidly in the favorable environment of the sloughing endometrium. Douching increases the risk for PID because it destroys the protective normal flora of the vagina, and it could flush bacteria up into the uterus. Associated risk factors for PID include: 16 to 24 years of age, unmarried, nulliparous, history of multiple sex partners, history of STIs, use of an intrauterine device (IUD) with multiple sex partners. Risk of reoccurrence of PID is possible with the use of latex condoms.
Nursing care plan assessment and physical examination
A thorough history of past infections, a sexual history, and a history of contraceptive use are essential to evaluate a woman with PID. The patient may describe a vaginal discharge, but the characteristics of the discharge (e.g., color, presence of an ordor, consistency, amount) depend on the causative organism. For example, a gonorrhea or staphylococcus infection causes a heavy, purulent discharge. With a streptococcus infection, however, the discharge is thinner with a mucoid consistency. The woman may also experience pain or tenderness, described as aching, cramping, and stabbing, particularly in the lower abdomen or pelvic region, or both. Low back pain may also be present. Other symptoms include dyspareunia (painful sexual intercourse); fever greater than 101°F; general malaise; anorexia; headache; nausea, possibly with vomiting; urinary problems such as dysuria, frequency, urgency, and burning; menstrual irregularity; and constipation or diarrhea.
Observe closely for vaginal discharge and the characteristics of this discharge. Inspect the vulva for signs of maceration. Note if the woman has experienced pruritus that has led to irritated, red skin from scratching. If vomiting is reported, inspect the skin for signs of fluid deficit, such as dryness or poor skin turgor. Rebound tenderness may be noted. When the cervix is manipulated, the woman may complain of pain in this area. Uterine adnexal tenderness is usually present. Auscultate the bowel; at first, the bowel sounds are normal, but as the disease progresses, if it is not treated, the bowel sounds are diminished or even absent if a paralytic ileus is present.
Because PID may be a life-threatening and life-altering disease, assess the patient’s emotional ability to cope with the disease process. In particular, explore the woman’s and her partner’s concerns about fertility. Because sexual partners need to be treated to prevent reinfection, the patient may have concerns about discussing her illness with her partner or partners.
Nursing care plan primary nursing diagnosis: Pain related to infectious process.
Nursing care plan intervention and treatment plan
Without treatment, this disease process can be lethal for women. The goal is to rid the patient of infection and preserve fertility if possible. Because no single antibiotic is active against all possible pathogens, the Centers for Disease Control and Prevention (CDC) recommends combination regimens. These regimens vary if the patient is hospitalized or treated on an outpatient basis. Usually, the treatment is with broad-spectrum antibiotics. Both the affected woman and her sexual partner(s) should be treated with antibiotics. Women with PID are usually treated as outpatients, but if they become acutely ill, they may require hospitalization. The hospitalized patient with PID usually is placed on bedrest in a semi-Fowler position to promote vaginal drainage. Priority should be given to timely administration of intravenous (IV) antibiotics to maintain therapeutic blood levels. IV fluids may be initiated to prevent or correct dehydration and acidosis. If an ileus or abdominal distension is present, a nasogastric tube is usually inserted to decompress the gastrointestinal tract. Urinary catheterization is contraindicated to avoid the spread of the disease process; tampons are also contraindicated. If the woman has an IUD, it is removed immediately.
If antibiotic therapy is not successful and the patient has an abscess, hydrosalpinx (distension of the fallopian tube by fluid), or some type of obstruction, a hysterectomy with bilateral salpingo-oophorectomy (removal of ovaries and fallopian tubes) may be done. A laparotomy may be done to incise adhesions and to drain an abscess. Signs of peritonitis, such as abdominal rigidity, distension, and guarding, need to be reported immediately so that medical or surgical intervention can be initiated. If the patient is poorly nourished, a dietary consultation is indicated.
Analgesics are prescribed to manage the pain that accompanies PID. Comfort measures can include the use of heat applied to the abdomen or, if they are approved by the physician, warm douches to improve circulation to the area.
Two outpatient oral/oral-parenteral antibiotic regimens are also newly recommended by the CDC: (1) ofloxacin 400 mg by mouth (PO) twice a day for 14 days or levofloxacin 500 mg PO daily for 14 days with or without metronidazole 500 mg PO twice a day for 14 days; or (2) ceftriaxone 250 mg intramuscular (IM) single dose or cefoxitin 2 g IM single dose and probenecid 1 g PO plus doxycycline 100 mg PO twice a day for 14 days with or without metronidazole 500 mg PO twice a day for 14 days.
Monitor vital signs and the patient’s symptoms to evaluate the course of the infection and its response to treatment. Always follow universal precautions; ensure that any item used by the patient is carefully disinfected. Provide perineal care every 2 to 4 hours with warm, soapy water to keep the area clean. Teach the patient that she needs to do these procedures as well. Allow the patient time to express her concerns. If appropriate, include the woman’s partner in a questionand- answer session about the couple’s potential to have children. Note that the inability to bear children is a severe loss for most couples, and they may need a referral for counseling.
Interventions that can help relieve pain include having the patient lie on her side with the knees flexed toward the abdomen. Massaging the lower back also increases her comfort. Use
diversions such as music, television, and reading to take the patient’s mind off the discomfort.
Teach the patient interventions to prevent the recurrence of PID: to use condoms, to have all current sexual partners examined, to wash hands before changing pads or tampons, and to wipe the perineum from front to back. Encourage her to obtain immediate medical attention if fever, increased vaginal discharge, or pain occurs. Discuss with the patient when sexual intercourse or douching may be resumed (usually at least 7 days after hospital discharge).
Nursing care plan discharge and home health care guidelines
To prevent a recurrence of PID, teach the patient the following: Take showers instead of baths. Wear clean, cotton, nonconstrictive underwear. Avoid using tampons if they were the problem. Do not douche. Change sanitary pads or tampons at a minimum of every 4 hours. If using a diaphragm, remove it after 6 hours. If any unusual vaginal discharge or odor occurs, contact a medical care provider immediately. Maintain a proper diet, with exercise and weight control. Maintain proper relaxation and sleep. Have a gynecologic examination at least annually. Use a condom if there is any chance of infection in the sexual partner. Use a condom if the sexual partner is not well known or has had another partner recently.
Ensure that the patient knows the correct dosage and time that the medication is to be taken and that she understands the importance of adhering to this regimen. Teach all patients who have had PID the signs and symptoms of an ectopic pregnancy, which are pain, abnormal vaginal bleeding, faintness, dizziness, and shoulder pain. Explain alternate means of contraception to the woman if she previously used an IUD.Ensure that the woman is familiar with the manifestation of PID, so she can report a recurrence of the disease.