NR 508 Week 2 Discussion: Claudia, Age 26 Come to the Nurse Practitioner

NR 508 Week 2 Discussion

NR 508 Week 2 Discussion: Claudia – Claudia is a 26-year-old mother of two G2P2, she recently delivered her last child 9 months ago, and has been using condoms for birth control for the last 7 months. Today she is requesting a more reliable birth control, she is not sure of her current pregnancy plans, however, she does not wish to discuss sterilization. No religious contraindications for treatment. Previous methods include condoms, and oral contraceptive pills.

• PMH: positive for mild hypertension with first pregnancy, seasonal allergies.
• Surgeries: Right inguinal hernia and tonsillectomy.
• Family history: Mother HTN and Father colon CA both living
• Social History: Denies tobacco use, wine one to two glasses a week, denies recreational drugs, exercises twice a week.
• Drug allergies-Sulfa causes a rash. Current medications-MVI with Fe, Calcium chews, prn Allegra for allergies. Height 65 inches, weight 137 pounds, BP 110/75, P 70, R 16. PAP collected today, breast exam WNL, urine pregnancy negative.
• Physical exam is normal.

NR 508 Week 2 Discussion: Claudia Guide

1. What are your treatment goals for Claudia today?
2. What are two possible contraceptive methods for Claudia? Please give brief rationale for each.
3. Pick one method and list five (5) patient-centered teaching points for the method you chose today.
4. What would your contraceptive choice be if Claudia smoked 10-15 cigarettes per day? Explain your answer.

NR 508 Week 2 Discussion

1. What are your treatment goals for Claudia today?

The treatment goal for Claudia is to provide her with a birth control method that is effective in preventing pregnancy and also take in consideration of her religious affiliation and medical history. Claudia also needs to be educated on the different birth control methods and be given a suitable option that will achieve the patient’s request and health status. Education must include contraceptive use and ways to prevent the transmission of sexually transmitted diseases (STDs).

2. What are two possible contraceptive methods for Claudia? Please give brief rationale for each.

The first alternative is implantation (Nexplanon, Etonogestrel), which has a 99% effective rate lasting up to three years. It is a tiny, thin rod about the size of a matchstick 4cm by 2mm made of ethylene vinyl acetate and contains 68 mg of estrogen. “It’s mechanism of action is through ovulation suppression and thickened cervical mucus. In U.S. trials, just six pregnancies were recorded in 20,648 cycles” (Staff, 2016, p. 76). The implant is placed in the arm under the skin so there may be some tenderness and a small scar. There are a few contraindications for Nexplanon; unexplained, unevaluated abnormal vaginal bleeding, systemic lupus erythematosus (SLE), severe cirrhosis, benign or malignant liver tumors, breast cancer current or past, ritonavir-boosted protease inhibitors, and certain anticonvulsants. Hypertension is not a contraindication for use. Implants are one of the most effective methods you can get because there is almost no way you can mess it up. A patient cannot forget to use it or use it incorrectly. Implants are “set-it-and-forget-it” birth control. It works until it expires or is removed. Should a patient desire to become pregnant again, this becomes possible after removal of the implant.

The second alternative method is the depo injection (Depo-Provera), which has a 94% effective rate lasting up to three months. Therefore, to continue this contraceptive method requires the injection every three months. Depo-Provera (Medroxyprogesterone), is a “synthetic progestin 15 times more potent than progesterone; used for endocrine disorders; prevents endometrial hyperplasia from HRT with estrogens; acts as a respiratory stimulant in some pulmonary conditions; depot injections are used for contraception or for endometrial or renal cancer” (Staff, 2018). Remembering to receive the depo injection on-time provides effective birth control. This injection is convenient and private and does not require to be taken just before intercourse. Depo-Provera can make the patient receive their menses less often after about one year. For the first twelve months, the patient may bleed more often than usual and have spotting between periods. But will return to normal a few months after its usage. Other possible side effects of the shot include nausea, weight gain, headaches, breast tenderness, depression, slight bruising where the injection was administered, very rarely, and a small, permanent dent in the skin where the injection was administered. After stopping the depo injection, the following are some common effects experienced by patients: sore breasts, changes to a patient’s period including irregular bleeding or not getting it back right away, mood changes, weight changes, delayed return to fertility (up to 6-10 months), and increased bone density.

3. Pick one method and list five (5) patient-centered teaching points for the method you chose today.

Implant contraceptives

1. The implant should only be inserted when the woman is sure that she is not pregnant, as it would interfere with any existing pregnancy. Prior to insertion of the implant, it is important to verify the following with the patient: are they pregnant, liver problems, arterial disease, ovarian cyst or abnormal vaginal bleeding, SLE, any ectopic pregnancies or developed jaundice during pregnancy, breast cancer or cancer associated with a sex hormone, porphyria, allergic reaction to medication, and any medications including OTC and herbal which may interfere with the actions of Nexplanon.
2. Implants do not prevent the transmission of additional sexually transmitted diseases. Receiving the greatest benefit from the implant involves understanding for the first few months after placement of the implant; irregular menses is common and may even stop altogether. If irregular bleeding continues, contact the health care provider, this may be due to an infection. Since weight gain is common, eating a well-balanced diet and regular exercise can help minimize the weight gain. Check breasts regularly for lumps and bumps and contact the health care provider if changes are noticed. Should the patient suspect they are now pregnant, notice changes in the feel of the implant or changes in skin color, schedule an appointment for an evaluation. Avoid medications for epilepsy, fungal infections or herbal preparations for the treatment of warts or tuberculosis. Remember, the implant will not protect against sexually transmitted diseases.

1. The recommendation for this patient is the Nexplanon implant due to the 99% effectiveness and least amount of complications and side effects. Patient education is centered around Nexplanon contraceptive implant and , prior to insertion of the implant, how the implant is inserted, getting the most from the implant, and problems associated with the implant’s use. Nexplanon is a progestogen, which is a female sex hormone similar to the progesterone hormone made naturally by your ovaries.
2. It is recommendable that the women abstain from sex for a period of 5 days before having sex in order for the contraception to be effective in preventing pregnancy. An implant containing Nexplanon is a long-acting, effective and convenient form of contraception. The implant is a small flexible tube, which is placed under the surface of the skin on the upper arm. It releases etonogestrel slowly into the bloodstream. It works mainly by stopping ovulation (the release of an egg from the ovary). It also changes the lining of your womb (uterus) to make it less likely that an egg would attach to it, even if an egg were fertilized. Also, the mucus which forms a plug in your cervix becomes thicker. This stops sperm getting through to the uterus to fertilize an egg.
3. The contraceptive option is safe to use for lactating mothers but may have additional side effects on the mother such as vaginal bleeding. Explain the insertion process to the patient. The insertion is performed by an individual specially trained and then checked for proper placement. Once inserted, it is effective immediately. The insertion will occur within five days of the patient’s last known menses to ensure the patient is not pregnant. The implant will be placed in the inner side of the patient’s upper arm. The patient will be given an injection of local anesthetic to numb the skin, and a special needle will be used to put the implant in place. The area around the implant may bruise and be sore for a few days, but the wound will soon heal just like any other small cut. The patient will be given a User Card, which contains some details for them to keep. This will note the date the implant was inserted and recommend a suggested date for it to be removed/replaced. There have been some very common side-affects reported with the use of Nexplanon. These side-affects are headaches, vaginal infections, acne, weight gain, breast tenderness and irregular menses. Common, but not as very common, are changes in appetite, a decrease in libido, mood changes, hot flushes, hair thinning, and flu-like symptoms.

4. What would your contraceptive choice be if Claudia smoked 10-15 cigarettes per day? Explain your answer.

Although smoking comes with its own set of problems and issues and should strongly be discouraged, there is no empirical evidence to support a correlation affect with the use Nexplanon and smoking. Therefore, should the patient continue to smoke and use the recommended contraceptive, there should be no issue.

NR 508 Week 2 Discussion Reference:

Curtis, K., Jatlaoui, T., Tepper, N., Zapata, L., Horton, L., Jamieson, D., & Whiteman, M. (2016). U.S. Selected Practice Recommendations for Contraceptive Use, 2016 (pp. 1-66). Atlanta: Centers for Disease Control and Prevention.

Jacobstein, R., & Polis, C. (2014). Progestin-only contraception: Injectable and implants. Best Practice & Research Clinical Obstetrics & Gynaecology, 28(6), 795-806. 

Staff. (2016). Update on contraceptive implant – What family planners need to know. Contraceptive Technology Update, 37(7), 76-77.

Staff. (2018, January 31). Medroxyprogesterone Acetate – Drug Summary. Retrieved from Prescribers Digital   Reference: