8.12 Spotlight Application

This spotlight application will demonstrate how a nurse provides contraceptive counseling to a client in an outpatient setting.^[1]

Situation/Background

Sierra is a 30-year-old female who visits the women’s health clinic seeking information on long-acting reversible contraception (LARC) options. Sierra is interested in exploring reliable contraceptive methods that offer extended coverage without daily maintenance. In discussing her contraceptive needs further, Sierra reveals that her irregular menstrual cycles have been a source of frustration, causing occasional disruptions to her daily activities. She expresses concerns about unpredictable bleeding patterns and severe dysmenorrhea during her periods, impacting her overall quality of life. Sierra, otherwise healthy, maintains an active lifestyle and is not currently taking any medications.

Sierra states she is considering intrauterine contraception and wants to understand her options.

Critical Thinking Questions

1. Compare the mechanisms of action, duration of effectiveness, and potential side effects of LNG-IUCs (e.g., Mirena) and copper-containing IUCs (e.g., Paragard). How might the differences in these devices align with Sierra’s contraceptive needs and concerns about irregular bleeding?

LNG-IUCs (levonorgestrel-releasing intrauterine contraceptives) like Mirena and copper-containing IUCs like Paragard work through different mechanisms and have distinct effects on bleeding patterns and side effects.

Mechanisms of Action

• LNG-IUCs (Mirena, Kyleena, etc.): Release levonorgestrel, a progestin, which thickens cervical mucus (preventing sperm penetration), suppresses endometrial growth (reducing implantation likelihood), and in some cases, inhibits ovulation.
• Copper IUCs (Paragard): Release copper ions, which create an inflammatory reaction toxic to sperm and eggs, preventing fertilization without hormonal effects.

Duration of Effectiveness

• LNG-IUCs: Depending on the device, they can last 3–8 years before replacement is needed.
• Copper IUCs: Can last up to 10 years, making it the longest-lasting reversible contraceptive option.

Potential Side Effects

• LNG-IUCs:
  • Irregular bleeding and spotting in the first few months.
  • Lighter or absent periods over time due to endometrial thinning.
  • Hormonal side effects (e.g., headaches, breast tenderness, mood changes) but at a lower incidence than systemic hormonal methods.

• Copper IUCs:
  • Heavier, longer, and potentially more painful periods, especially in the first few months.
  • No hormonal side effects, making it a good option for those who prefer non-hormonal contraception.

If Sierra is particularly concerned about irregular bleeding, the choice depends on whether she prefers lighter periods or a completely hormone-free option:

• If Sierra wants lighter or no periods, an LNG-IUC like Mirena would be ideal, as it reduces and may eliminate menstrual bleeding over time.
• If Sierra wants a non-hormonal option, the concern would be that Sierra would need to tolerate heavier, crampier periods, then the copper IUC might be better as it does not contain hormones.

2. Sierra states she is also considering contraceptive implants. Compare the mechanism of action, duration of effectiveness, and potential side effects of Nexplanon with those of intrauterine contraception devices. How might these differences influence Sierra’s decision-making process, given her concerns about menstrual irregularities?

A comparison of Nexplanon and Intrauterine Contraceptive Devices (e.g., LNG-IUCs & Copper IUCs) is provided in the following box.

	Etonogestrel (Implant)	LNG-IUCs (e.g., Mirena)	Copper IUC (e.g., Paragard)
Mechanism of Action	Releases etonogestrel (a progestin), which inhibits ovulation, thickens cervical mucus, and thins the endometrium.	Releases levonorgestrel (a progestin), which thickens cervical mucus, suppresses endometrial growth, and sometimes inhibits ovulation.	Releases copper ions that create an inflammatory reaction toxic to sperm and eggs, preventing fertilization.
Duration of Effectiveness	Up to 3 years	3–8 years, depending on the specific device.	Up to 10 years.
Effects on Menstruation	Irregular bleeding is common; periods may be lighter, heavier, or absent. Some users experience prolonged spotting.	Lighter or absent periods over time; irregular spotting in the first few months.	Heavier, longer, and crampier periods, especially initially.
Potential Side Effects	Irregular bleeding, headaches, weight gain, mood changes, and breast tenderness.	Irregular bleeding initially, but reduced periods over time; possible hormonal side effects (mild mood changes, acne, breast tenderness).	No hormonal side effects, but heavier bleeding and increased cramping.

Given Sierra’s concerns about menstrual irregularities, each option has trade-offs that the nurse can further reinforce as she makes her decision:

• If Sierra wants to avoid irregular bleeding, an LNG-IUC (e.g., Mirena) would be the best choice, as it tends to reduce or eliminate periods over time after an initial adjustment period.

• If Sierra prefers a non-hormonal method, the copper IUC is an option, but it could worsen bleeding and cramping; therefore, it does not align with Sierra’s concerns regarding bleeding.

• If Sierra wants a long-acting but non-intrusive method, the etonogestrel implant is effective but most likely to cause unpredictable bleeding patterns, which would not align with Sierra’s concerns regarding bleeding.

3. The nurse applies the nursing process and creates a nursing care plan for Sierra. What assessment data should the nurse collect and document?

Subjective Data

• Menstrual History: Cycle length, duration, and variability; severity and nature of dysmenorrhea (cramping, pain scale 0-10, associated symptoms like nausea or headaches); impact on daily life and work.
• Reproductive and Sexual Health History: History of previous contraceptive use and experiences; sexual activity and partner considerations; desire for future pregnancy.
• Health and Lifestyle Factors: Any history of pelvic infections, sexually transmitted infections (STIs), or gynecological conditions; lifestyle habits (exercise, diet, stress levels).

Objective Data

• Vital Signs: Blood pressure, heart rate, weight, and BMI
• Review Diagnostic Tests: Cervical screening and STI testing

4. Based on the assessment data, what NANDA nursing diagnoses apply to this client?

• Readiness for Enhanced Knowledge related to contraceptive options as evidenced by the client’s expressed desire to learn about intrauterine contraception.
• Acute Pain related to severe dysmenorrhea as evidenced by reports of painful menstrual cramps affecting daily activities.
• Ineffective Health Management related to frustration with irregular menstrual cycles as evidenced by concern about unpredictable bleeding patterns.

5. Give examples of overall goals and SMART outcome criteria for this client.

Goal 1: Improved Contraceptive Knowledge. SMART Outcome Criteria: “By the end of the consultation, the client will verbalize understanding of the benefits, risks, and side effects of intrauterine contraception.”

Goal 2: Reduction in Dysmenorrhea. SMART Outcome Criteria: “Within one month of starting intrauterine contraception, the client will report a reduction in menstrual pain severity by at least 50%.”

Goal 3: Menstrual Cycle Regulation. SMART Outcome Criteria: “Within three months of using LARC, the client will report improved predictability in her menstrual cycles.”

Goal 4: Satisfaction in Contraceptive Choice. SMART Outcome Criteria: “By the three-month follow-up visit, Sierra will express satisfaction with her contraceptive choice.”

6. What nursing interventions can the nurse plan to implement to meet these goals and outcome criteria?

• Provide contraceptive counseling by explaining LARC options:
  • Hormonal IUDs (Mirena) – Reduce menstrual bleeding and cramps.
  • Non-Hormonal Copper IUD (Paragard) – Provides contraception but may cause heavier periods.
  • Implant (etonogestrel-Nexplanon) – Provides up to three years of contraception with possible menstrual changes.
• Discuss effectiveness, duration, side effects, and removal process for each contraceptive method. Address misconceptions and reassure client about safety and reversibility.
• Assist with decision-making by encouraging Sierra to consider her lifestyle, period preferences, and reproductive goals when selecting a method.
• Provide educational pamphlets or reputable online resources about LARC.
• Address dysmenorrhea management by explaining how hormonal IUDs may reduce period pain and lighten menstrual flow.
• Suggest NSAIDs (ibuprofen, naproxen) for cramp relief, if needed.
• Recommend heat therapy or gentle exercise to ease symptoms.
• Schedule a follow-up visit after IUD insertion to address any concerns.
• Provide health teaching about anticipated adjustment periods after IUD insertion and when to seek medical attention (e.g., severe pain, signs of infection, IUD displacement).

7. Explain how the nurse can evaluate if the interventions were effective.

The nurse plans on assessing effectiveness of the interventions by asking the client the following questions at follow-up visits:

• Knowledge and Decision-Making: “Do you feel confident in your understanding of intrauterine contraception? Does the LARC method fits needs?”
• Menstrual Symptoms: “Have you noticed any improvement in your menstrual cycle regularity with treatment? Has your discomfort improved since starting treatment?”
• Satisfaction with LARC Method: “Are you satisfied with your contraceptive choice, or do you have any concerns? Do you feel your LARC method aligns with your lifestyle and reproductive goals?”

The nurse reviews the identified outcome criteria and assesses if they were met, partially met, or not met by the timeframes indicated based on the data gathered during the follow-up visit.

Evaluation of SMART Outcome 1: “By the end of the teaching session, the client will verbalize understanding of the benefits, risks, and side effects of intrauterine contraception.”

The nurse evaluates this outcome was partially met based on the following data:

• Sierra confidently explained the differences between hormonal and non-hormonal IUDs. She verbalized understanding of side effects, insertion process, and effectiveness. She decided on using Mirena (hormonal IUD) based on her need for lighter periods and contraception.

Evaluation of SMART Outcome 2: “Within one month of starting intrauterine contraception, the client will report a reduction in menstrual pain severity by at least 50%.”

 The nurse evaluates this outcome was partially met based on the following data:

• One month after IUD insertion, Sierra reports her period pain has decreased from 8/10 to 3/10. She no longer takes NSAIDs as frequently but still has some discomfort.

Evaluation of SMART Outcome 3: “Within three months of using LARC, the client will report improved predictability in her menstrual cycles.”

The nurse evaluates this outcome was partially met based on the following data:

• Three months post-insertion, Sierra notices lighter periods, but they remain unpredictable. She expresses frustration with intermittent spotting but understands it may improve with time.

Evaluation of SMART Outcome 4: “By the three-month follow-up visit, Sierra will express satisfaction with her contraceptive choice.”

The nurse evaluates this outcome as partially met based on the following data:

• Sierra likes the contraceptive reliability but is still adjusting to mild cramping and irregular bleeding. She is undecided if she will keep the IUD long-term but will give it more time before making a final decision.

Nursing Actions

Based on the partially met outcome criteria, the nurse modifies the care plan by adding the following nursing interventions:

• Provide additional health teaching and reassurance about IUDs.
• Encourage patience with menstrual cycle changes and reinforce that full effects may take months to achieve.
• Reinforce nonpharmacological pain management strategies if dysmenorrhea persists.
• Discuss strategies for managing spotting (e.g., panty liners).
• Schedule a follow-up appointment with the health care provider to reassess concerns and ensure satisfaction with the contraceptive choice.