ADOLESCENCE AND PREGNANCY | Study Guides, Projects, Research Nursing

CHAPTER 10: Case Studies

S44 l JUNE JOGC JUIN 2013

CASE STUDY 1:

YOUTH AND SEXUAL HEALTH

Nita is 21 years old and lives in Toronto, where she attends

university and works part-time as a waitress. Her studies

keep her busy, and she is doing well. As often as possible she

returns to see her family in her community north-east of

Montreal. On a recent trip home, she makes an appointment

to see a family doctor at the community health centre, which

she prefers to the university clinic. She sees the visiting family

physician, Dr Pear, at the clinic, where she presents with

vaginal discharge and itching, but is otherwise healthy and

physically active. She has no fever or urinary symptoms and

has normal bowel movements. She lives with her boyfriend

and is taking birth control pills as prescribed.

Scenario 1

Dr Pear prepares to examine her. It is a busy day in the

clinic and he is running behind schedule. He asks if she is

sexually active, but does not take a full history. He proceeds

to examine her without much interaction and recommends

doing a Pap smear. He does not realize that she has regular

examinations, is in a stable relationship, and is taking good

care of herself. After finishing the examination, he says

that the exam is inconclusive and he is not sure what is

going on. He suggests that she might have an STI, does

not explain other possibilities, and says that the nurse will

call her when the results are back. He arranges for the

nurse to come in and talk to her about birth control.

Scenario 2

Dr Pear greets Nita and asks her a few questions about

herself. She tells him how she is doing in university, that

she is in a happy and stable relationship, and about her

symptoms. Dr Pear explains that he is going to do an

examination to see what is going on. He leaves the room so

that she can undress and asks her to drape herself so that

she will feel more comfortable. He returns and prepares

to examine her, going slowly and gently, and explaining

what he is doing as he goes along. After finishing the

examination, including taking a sample and examining the

slide, he tells her that it seems she has bacterial vaginosis.

He explains what this is and that it can be easily treated.

He gives her a prescription for antibiotics and reminds her

that if she has a Status card, she should show it to the

pharmacist since her medication is covered.

Dr Pear asks Nita if she has any questions. He also asks

if she has regular health checks and if she has ever had a

Pap smear. Nita explains that she has regular examinations

and knows the importance of staying healthy, but that

she doesn’t really like going to the clinic on campus.

Dr Pear lets her know about Anishnawbe Health Toronto,

an Aboriginal community health centre.

Learning Points

• Do not make assumptions about a young woman’s

sexual activity, such as that she has multiple partners or

dysfunctional relationships.

• Always explain what you are doing during procedures

and why.

• Ask about Status as it relates to medication coverage.

Be familiar with the medications that are covered by

the NIHB, or have a reference readily accessible.

• Ask open-ended questions, since these often give

patients the opportunity to disclose things they are

uncomfortable with.

• Ask the patient if there is anything else you should

know or anything else they would like to talk about.

CASE STUDY 2:

ADOLESCENCE AND PREGNANCY—

MIDWIFERY CARE

Tracy is a 16-year-old woman from a semi-remote First

Nation community. She is 36 weeks pregnant and attending

a prenatal visit with her community midwife. This is her

first pregnancy and she has attended all previous visits with

her mother and/or Frank, the father of her baby. Tracy

is very quiet and makes limited eye contact during these

visits. Tracy’s pregnancy has been fairly uneventful. Her

weight gain has been 23 pounds. Laboratory values and

blood pressure have been within normal limits. A 20-week

ultrasound found no abnormalities of fetal anatomy. At

her last visit the midwife told her they would be discussing

place of birth today. Tracy’s options are to deliver in one

CHAPTER 10

Case Studies

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S44 l JUNE JOGC JUIN 2013 CASE STUDY 1: YOUTH AND SEXUAL HEALTH Nita is 21 years old and lives in Toronto, where she attends university and works part-time as a waitress. Her studies keep her busy, and she is doing well. As often as possible she returns to see her family in her community north-east of Montreal. On a recent trip home, she makes an appointment to see a family doctor at the community health centre, which she prefers to the university clinic. She sees the visiting family physician, Dr Pear, at the clinic, where she presents with vaginal discharge and itching, but is otherwise healthy and physically active. She has no fever or urinary symptoms and has normal bowel movements. She lives with her boyfriend and is taking birth control pills as prescribed. Scenario 1 Dr Pear prepares to examine her. It is a busy day in the clinic and he is running behind schedule. He asks if she is sexually active, but does not take a full history. He proceeds to examine her without much interaction and recommends doing a Pap smear. He does not realize that she has regular examinations, is in a stable relationship, and is taking good care of herself. After finishing the examination, he says that the exam is inconclusive and he is not sure what is going on. He suggests that she might have an STI, does not explain other possibilities, and says that the nurse will call her when the results are back. He arranges for the nurse to come in and talk to her about birth control. Scenario 2 Dr Pear greets Nita and asks her a few questions about herself. She tells him how she is doing in university, that she is in a happy and stable relationship, and about her symptoms. Dr Pear explains that he is going to do an examination to see what is going on. He leaves the room so that she can undress and asks her to drape herself so that she will feel more comfortable. He returns and prepares to examine her, going slowly and gently, and explaining what he is doing as he goes along. After finishing the examination, including taking a sample and examining the slide, he tells her that it seems she has bacterial vaginosis. He explains what this is and that it can be easily treated. He gives her a prescription for antibiotics and reminds her that if she has a Status card, she should show it to the pharmacist since her medication is covered. Dr Pear asks Nita if she has any questions. He also asks if she has regular health checks and if she has ever had a Pap smear. Nita explains that she has regular examinations and knows the importance of staying healthy, but that she doesn’t really like going to the clinic on campus. Dr Pear lets her know about Anishnawbe Health Toronto, an Aboriginal community health centre. Learning Points

Do not make assumptions about a young woman’s sexual activity, such as that she has multiple partners or dysfunctional relationships.
Always explain what you are doing during procedures and why.
Ask about Status as it relates to medication coverage. Be familiar with the medications that are covered by the NIHB, or have a reference readily accessible.
Ask open-ended questions, since these often give patients the opportunity to disclose things they are uncomfortable with.
Ask the patient if there is anything else you should know or anything else they would like to talk about. CASE STUDY 2: ADOLESCENCE AND PREGNANCY— MIDWIFERY CARE Tracy is a 16-year-old woman from a semi-remote First Nation community. She is 36 weeks pregnant and attending a prenatal visit with her community midwife. This is her first pregnancy and she has attended all previous visits with her mother and/or Frank, the father of her baby. Tracy is very quiet and makes limited eye contact during these visits. Tracy’s pregnancy has been fairly uneventful. Her weight gain has been 23 pounds. Laboratory values and blood pressure have been within normal limits. A 20-week ultrasound found no abnormalities of fetal anatomy. At her last visit the midwife told her they would be discussing place of birth today. Tracy’s options are to deliver in one

CHAPTER 10 Case Studies

JUNE JOGC JUIN 2013 l S CHAPTER 10: Case Studies of two tertiary care centres in a large city 9 hours away, or at a hospital in a smaller city closer to home. Tracy arrives for her visit with her mother and her midwife notices that they seem to be more serious than usual today. Scenario 1 Her midwife Mandy quickly asks them what is wrong. When there is little response, she asks if Tracy is starting to experience some fears around labour and birth, and quickly goes on to reassure Tracy that they will discuss all the options for coping. Tracy does not make eye contact. After an uncomfortable silence Mandy begins to enquire about fetal movement, changes in vaginal discharge, whether Tracy is taking her prenatal supplement, headaches, etc. Tracy answers with yes or no. Mandy explains Tracy’s options for delivery, and asks her whether she has thought about which hospital she would prefer to give birth in. After a moment, Tracy’s mother replies that she will give birth at ______ tertiary care hospital and that she will be escorting Tracy. Tracy’s mother informs Mandy that Tracy is upset because she does not want to leave Frank behind when she flies into the city to give birth. Mandy asks Tracy how she feels about that and she shrugs her shoulders. Mandy proceeds to explain the next steps in setting an appointment with a referral physician and arranging transportation. Scenario 2 Although her midwife Mandy suspects that there may be something bothering Tracy, she begins the appointment by asking about Tracy’s sister and her 1-year-old son, who she helped to deliver. Mandy casually asks whether there are any plans yet for who will be able to attend Tracy’s birth, knowing that the family is very close and Tracy would like more than one person to be there. There are some vague responses. When Mandy asks a question, she speaks directly to Tracy’s mother until Tracy initiates eye contact. She goes on to ask about fetal movements and jokes about how active the baby is at 1:00 a.m., saying that the baby is just like her mother. Tracy smiles a little and makes brief eye contact with Mandy, which Mandy sees as an indication that she is ready to speak about today’s concerns. When she feels that Tracy has relaxed, she asks about Frank and how they are doing as a couple. Tracy answers that she is worried about having to choose between bringing her mother or Frank with her to the city to give birth. Tracy’s mother then asks when Tracy will be “sent out.” Mandy reviews Tracy’s options for where to give birth and asks them if they have discussed their plans and considerations. Tracy’s mother replies that Tracy will give birth at ________ tertiary hospital and that she will be escorting her. Mandy glances at Tracy to see how she reacts. She reassures them that she will request funding for Frank to be able to accompany them. The referral appointment is booked for one week from the current visit. The day following Tracy’s scheduled appointment in the city, Tracy calls Mandy to tell her that she has noticed blood in the toilet and that she is still in the community. The midwife arranges to meet Tracy at the clinic to assess her. Frank comes with Tracy to the clinic. Scenario 1 A medivac flight is organized to transport Tracy to the hospital to query early labour. Her mother arrives at the clinic with a suitcase and escorts Tracy. There are vague plans for Frank to travel later with Tracy’s father. Scenario 2 Mandy comments on how Frank and Tracy are treating each other well and how important this is for Tracy and the baby. A medivac flight is organized to transport Tracy to the hospital, to query early labour. Her mother arrives at the clinic with a suitcase and escorts Tracy. There are vague plans for Frank to travel later with Tracy’s father. Mandy asks Tracy and her mother to keep in touch. Learning Points

Indirect questioning about feelings is often more effective, allowing the underlying story to emerge.
Noticing eye contact is an important aspect of reading body language since it is an invitation to communicate. Young people may initially hesitate to make eye contact.
When accompanied by her mother or another Elder, a young woman will often defer to her mother or Elder when questions are asked. Politely address the Elder directly in the conversation and respect and recognize her role as decision maker while carefully considering the patient’s perspective.
When a mother has to leave her community to give birth it can cause considerable stress in her intimate relationship. This stress can sometimes present as conflicted feelings about being with the partner or complying with guidelines and recommendations for leaving. This is especially difficult for young women in new relationships, and it is important to recognize that they are not deliberately being irresponsible; they are generally willing to be guided by caring adults in making significant decisions in their lives.

JUNE JOGC JUIN 2013 l S CHAPTER 10: Case Studies At their next visit, when Dr London has the results of the ultrasound, he explains that there is a tumour in her uterus and that she will need surgery. He asks the nurse to give Jaci her appointment dates and leaves the room to attend to his next appointment. Scenario 2 Dr London greets Jaci and asks her where she is from, about her family, and how many children she has had. He asks if she travelled far to get to the appointment and if she understands the reason she was sent to see him. He explains that her bleeding symptoms are not normal because she has already experienced her change of life (i.e., menopause), and that the family doctor who comes to her community did a test that showed that the lining in her womb was not well. He explains that it is important to examine her uterus to understand the cause of the bleeding and that he will do this examination for her today. With Jaci’s daughter’s help, Dr London tries to find the word for uterus in Jaci’s language, so that Jaci can better understand what is happening. Jaci’s daughter helps her mother prepare for the examination, covering her as instructed by Dr London. He proceeds with the examination and warns her that it might be uncomfortable at times. When conducting the examination, Dr London explains each part of the examination and talks and examines slowly, so that Jaci’s daughter can translate what he is saying. Dr London finishes the examination and leaves the room so that Jaci can get dressed. He then returns and tells Jaci that she will need to have an ultrasound, ensuring that she and her daughter understand why and how this will be arranged. At the appointment to discuss the ultrasound results, Dr London sits down across from Jaci and explains that the ultrasound showed some growth in the uterus. Dr London explains that the growth could be serious or not dangerous at all, but it is important to be sure, so he needs to do an operation to take out the uterus. He asks if Jaci understands what he is saying and if she has any questions. Jaci and her daughter both agree that they understand. Jaci asks when she needs to have the operation and how long will she have to stay here. Dr London carefully explains the next steps. Learning points

Having a uterus is an important part of most women’s sense of identity, including Aboriginal women, even as grandmothers.
Be sensitive to shyness, modesty, and high rates of sexual abuse. Being aware of the legacy of the residential school system is particularly important when working with older Aboriginal women.
Always drape appropriately, taking a gentle approach and explaining each step of the procedure.
Use a professional interpreter if needed and ask if the patient is comfortable with the service. If using a family member to translate, be sure to use accessible language so that they understand what you are saying.
Check with your patient regularly to make sure that she understands what you are doing and what is happening with her. Do not assume that silence indicates agreement or understanding.

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CHAPTER 10

Case Studies