Pelvic Inflammatory Disease
i) What causes PID and what happens to the body when someone gets it? Pelvic In?ammatory Disease (PID) occurs when an infection of the cervix, or to a lesser extent the vagina progresses into the upper genital tract, PRODIGY (2005). Warell (2003) de?nes an infection as an invasion of the body by harmful organisms (or pathogens) such as bacteria, fungi, protozoa or viruses. In the case of PID the two most common causes of the initial infection are the bacterium Chlamydia Trachomatis or Neisseria Gonnorhoeae.
These two bacteria are most commonly referred to as the sexually transmitted infections (STIs) chlamydia and gonnorhea and are commonly passed through unprotected vaginal intercourse. Both infections present similarly, as in?ammations of the cervix and urethra with the associated symptoms of pain on urination and vaginal discharge. Some infected women however experience no symptoms (Caroline, 2008). Prodigy (2005) discusses how cervical mucus provides a relative barrier to the spread of the pathogens and the associated infections, but virulent microbes can traverse cervical mucus, which in any case, is lost during menses.
Other factors that may in?uence the spread of bacteria up the genital tract are, pregnancy terminations and the complications arising from dilatation and currettage. Wyatt (2003), discusses, in reference to PID, how once an infection spreads beyond the cervix it can present in various regions of the genital tract: uterus (endometritis), fallopian tubes (salpingitis), ovaries (oophoritis), peritoneum (peritonitis). The assocaited infections/in?ammations can cause various symptoms: Pelvic or lower abdominal pain.
Dyspareunia (pain during or after intercourse) Turbo-ovarian abscesses Abnormal vaginal discharge Pelvic peritonitis Perihepatitis (in?ammation of the peritoneum attached to the liver) The severity ranges from chronic low grade infection (with relatively mild symptoms) to acute infection (with severe symptoms) which may result in abscess formation. Salpingitis, or infection of the Fallopian tubes, is a particularly signi?cant feature of PID because of the long term effects after PID including infertility, ectopic pregnancy and pelvic pain.
0% of women develop tubal infertility after a single episode, 20% after a second and 40% after three episodes (Prodigy, 2005). In summary PID is a collective term that encompasses a variety of infections of the upper female genital tract. ii) what investigations are considered at hospital and what medications might be prescribed? Warrell (2003), states that there is no symptom, clinical sign, or labratory result that is is pathognomonic (exclusive/unique) in the testing and subsequent diagnosis of PID.
The hospital will therefore use a variety of investigations to rule out the likelihood of other diagnosis and allow the most appropriate treatment for cases of suspected PID. Wyatt (2003), advises Accident and Emergency (A&E) staff to ?rst consider whether a patient is presenting with any signs/symptoms of shock. If the infection has progressed and there are indications of sceptic or hypovalaemic shock such as tachycardia, pyrexia and assocaited blood pressure abnormalities then the initial treatment is to raise the patient’s legs, resuscitate with IV ?uids and immediately begin IV broad spectrum antibiotics.
Sanders (2006) advises other routine tests to help with the differential dianosis for PID which include; appendicitis, endometriosis, ovarian cysts, ectopic pregnancy, other STIs, HIV, urinary tract infection. These tests include: Urinalysis which can to help diagnose and/or rule out the presence of a UTI. A vaginal swab picks up a sample of cells from the vagina which are usually sent to a laboratory for testing. A full blood count (FBC) tests the levels of red cells, white cells and platelets.
Abnormalities in these readings can help differentiate between the presence of bacterial or viral infections and/or parasitic/fungal infections. Blood tests are limited in that they do not distinguish what has gone before from what is happening now however they can pick up HIV, hepatitis B and C, herpes virus and chlamydia. Wyatt (2003) also advises that a pregnancy test is needed and if positive, an ectopic pregnancy or other pregnancy complication must be considered. If the ectopic test is negative Ultrasound or endometrial biopsy examined for plasma cells is useful to increases the accuracy of diagnosis.
Where symptoms are severe or if initial treatment is unsuccessful a laparoscomy may be considered (Simpson, 2005). Here a rigid viewing instrument called a laparoscope is used to view the inside of the pelvis and the abdomen through small abdominal incisions. The procedure is always performed under a general anasthetic. Among 814 women who underwent laparoscopy because of a clinical diagnosis of PID, 12 per cent had intra-abdominal conditions other than PID: ectopic pregnancy, appendicitis, ruptured ovarian cysts, and endometriosis (Prodigy, 2005).
Medications are aimed at eradicating gonorrhea and chlamydia and recommended antibiotics include O?oxacin, Doxycycline and Metronidazole. Ibuprofen is a reccommended analgesia however the choice of analgesia and which route should be guided by clinicla judgement, Prodigy (2005). iii) Discuss Legal (authorised/permitted by law), Ethical (the philosphy of good/bad, right/wrong determined by our cultural/religious and philosophical beliefs) and Capacity (the power to learn or retain knowledge to understand the facts and signi?cance of your behaviour) issues surrounding Lizzy’s views and those of her mother.
A signi?cant factor in Lizzy’s case is whether she has capacity. Capacity is de?ned as the power to learn or retain knowledge, and to understand the facts and signi?cance of your behavior (Gillick, 1986). Assessing whether Lizzy has capacity places a responsibility on the practitioner to provide her with suf?cient information to inform her fully of the clinical importance of seeking immediate treatment. Then assessing whether she understands the risks involved and also if she is able to retain the knowledge long enough to make an effective decision.
In the case of Gillick, the court held that children who have suf?cient understanding and intelligence to enable them to understand fully what is involved in a proposed intervention will also have the capacity to consent to that intervention. This is sometimes described as being ‘Gillick competent’. A child of under 16 may be Gillick competent to consent to medical treatment that requires their consent.
If Lizzy is deemed Gillick competent and is able to give voluntary consent after receiving appropriate information, that consent will be valid and additional consent by a person with parental responsibility will not be required. It is, however, good practice to involve Lizzy’s family in the decision-making process, if she consents to her information being shared, DOH (2009). Another challenge arises as Lizzy states her reason for not consenting to travel to hospital is that she is scared her parents will ?nd out about her sexual activity and drug abuse.
When assessing capacity you should also ascertain if the patient is free from external pressure to make their own decision? In Lizzy’s case this appears in doubt as she has previously stated that she feels pressured by her mother. There is therefore an argument that Lizzy does not have capacity in these circumstances. There is also speci?c legislation on how to act when there is an issue of contraception , or sexual health in relation to children; Here it is advised that we should try to persuade Lizzy to inform her parents, or allow us to do so.
If however she cannot be persuaded, advice and/or treatment should still be given if it is considered that Lizzy is very likely to begin or continue to have sexual intercourse with or without advice or treatment, and that unless she receives the advice or treatment then her physical or mental health is likely to suffer. This is very relevant in Lizzy’s case and poses an ethical question on whether or not to respect Lizzy’s request of con?dentiality between her parents.
Each of these possibilities will challenge the practitioner and whilst it is essential that the law is followed it is important to adopt a dynamic approach to Lizzy’s situation and not forget that ultimately it is Lizzy’s ongoing health that is the priority in this situation. iv) discuss the psychological (affecting the mind) and/or social (living with others as oppose to in isolation – developing relationships) effects of peer pressure (social pressure by members of ones peer group to adopt certain values – to conform or to be accepted) in relation to underage alcohol abuse.
Since 1990 the amount of alcohol consumed by 11 to 15 year olds who drink has doubled and there has been increases in the numbers of children admitted to hospital as a direct result of their alcohol consumption. Early age of starting drinking is associated with higher trends of alcohol dependence in adulthood and a wider range of other adverse consequences (Donaldson, 2009). Peers play an important role in the onset of drinking behaviours. The effect of peers has been shown to be particularly powerful when parent– adolescent relationships are poorer in quality (Donaldson, 2009).
Kroger (2000) identi?es that Lizzy is at the stage of her childhood development where she is asking herself, “Who am I? ” Here adolescents establish sexual, political and career identities and/or may be confused about what roles to play. Identity crises can create storm and stress for the young person. Sociological theory suggest that changes within social roles cause con?ict, e. g. girlfriend and daughter, schoolgirl and work experience. In addition mass media and peers can cause con?icting values for this age; a factor that may be affecting Lizzy evidenced by the posters on her bedroom wall.
It can be a very dif?cult time for the young person going through this stage of development. Studies such as Adams et al (1994) have found that adolescents report an increase in the importance of peers in adolescence. The proportion of time spent with peers correspondingly increases. Peer relationships also become more intimate than those of preadolescence, with a new focus on sharing secrets and disclosing feelings. Peer groups assume particular importance.
Although Lizzy’s alcohol consumption is a concern it could be argued that this is an essential stage in development and here adolescent’s will begin to question whether their relationships are bene?cial or not. It is therefore possible that Lizzy’s drinking is temporary and her self realization of its effects on her life play an important part in how she develops relationships later in her life. v) discuss the advice you would offer promoting the health (action to maintain the best possible health and quality of life) of Lizzy considering all the various aspects of this presentation for her future well being.
Ambulance services in the United Kingdom are being compelled to move away from being a relatively uncomplicated patient transport system towards becoming part of a fully integrated, national healthcare service offering a holistic approach to patient care (DoH 2005, Ball 2005). Health promotion is the process of enabling people to increases control over, and to improve their health and heir-in health is de?ned as a state of complete physical, mental and social wellbeing (WHO, 1986).
The ?rst action to address Lizzy’s health would be to ensure that Lizzy attends hospital. There is evidence from her observations that Lizzy could eventually enter into sceptic shock, which is potentially life threatening therefore this should be the ?rst priority above all other health promotion considerations. If it was unable to ensure this at the scene then Clincial telephone Advice desk should be contacted along with a Duty Station Of?cer and consideration to contacting Lizzy’s GP. Health Education is a process with intellectual, psychological nd social dimensions relating to activities that increase the abilities of people to make informed decisions affecting their personal, family and community well-being.
This process, based on scienti?c principles, facilitates learning and behavioral change in both health and personnel and consumers, including children and youth (Ross, 1997). Of the three different methods of health education (Coercion, Persuasion or health empowerment) empowerment focuses on developing decision-making skills and the con?dence to bring about change; the decision on which health actions to adopt is the decision of the practioner.
However Lizzy could potentially bene?t more from being given the tools to help herself in this situation and help develop the know-how to help herself at this critical stage of her adolescent development (Hubley, 2008). This is reinforced in the DOH (2006) paper (with relation to year groups 10 to 11 ((14-16 year olds)): pupils develop self awareness and con?dence needed for adult life, further learning and work. They have opportunities to show that they can take responsibility for their own learning and career choices by setting personal targets and planning to meet them.
They develop their ability to weigh up alternative courses of action for health and wellbeing (DOH, 2006). The National Institute for Health and Clinical Excellence (NICE) has recommended that offering brief, one-to-one advice on the harmful effects of alcohol use, how to reduce the risks and how to ?nd sources of support is an effective approach for tackling harmful drinking among children and young people (Donaldson, 2009). Lizzy should be informed that contraceptive use in?uences PID rates. Barrier contraception reduces the risk of PID by preventing the acquisition of chlamydia and gonorrhea.
Lizzy has used condoms however it is likely that she acquired PID on the occasions where she failed to use them (Prodigy, 2005). Another useful approach with considerable potential is that of information shops. These provide health promotion on an informal ‘drop-in’ basis from accessible loctions in high streets and communities (Hubley, 2008). Lizzy should be encouraged to improve her attendance at school; The contribution of schools to public health education and health are mutually reinforcing. Education and learning promote health literacy and an increased capacity to make informed decisions on health matters.
A healthy child has a greater potential to bene?t from education than one who has poor health and misses schooling. Health promotion in education settings bene?ts public health in three ways: bene?ting directly the health of the child, promoting future health by providing the necessary understanding, skills values and competencies that they can use in later life, bene?ting the health of the community through the transfer of knowledge and skills from the school back into the home place and community (St Leger, 2001).