Contraceptive Implant Insertion
Age: years old
Gender: female
HISTORY:
Presents for Nexplanon
Current contraception: for the last years
Reason for Nexplanon:
Last menstrual period: ago
Menstrual cycles: days,
Menstrual symptoms:
G P A
Desire for pregnancy in the next year:
Sexual activity: , partners,
Condom use:
History of STIs:
STI risk factors:
Last Pap smear: ago
HPV vaccination:
Contra-indications:
- Pregnancy
- Breast cancer
- Active liver disease
- History of DVT or PE
- Unexplained vaginal bleeding
EXAM:
General appearance: ,
Pelvic: external genitalia , vagina , cervix , uterus , adnexa ,
ASSESSMENT:
Contraceptive implant insertion,
PLAN:
Investigations:
- Pregnancy test prior to insertion
- STI screening prior to insertion
Nexplanon Insertion:
- Consent: informed of potential risks including infection, expulsion, or perforation, benefits of long-term contraception discussed, consent obtained
- Preparation: skin cleaned with
- Anesthesia: with cc of
- Procedure: Nexplanon inserted in the inner, upper, arm, bandage applied
- Tolerance:
- Instructions: keep bandage dry and in place for 24 hours, avoid heavy lifting with the arm for a few days, use backup contraception for the first week
- Advise to check the implant by touch regularly
- Counseling on condom use for STI prevention
Further care:
- Referral to gynecologist
- Follow-up if or if complications/concerns arise
- Return if side effects occur, such as persistent pain, redness, swelling, or if the implant can no longer be felt
HISTORY: EXAM: ASSESSMENT: PLAN: