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The reproductive health system addresses those body structures and processes that relate to physiological sexual function and reproduction. Case studies selected for this section represent high-risk patient situations that could dramatically alter future reproductive ability for the patient.
| REPRODUCTION | SEXUAL |
| birth process | impotence |
| fertility and infertility | puberty |
| lactation | sex hormones |
| menopause | sex organs |
| menstruation | sexual function |
| pregnancy | rape |
| pregnancy termination |
sexual dysfunction
altered sexuality patterns
ineffective breast-feeding
rape—trauma syndrome
rape—trauma syndrome: compound reaction
rape—trauma syndrome: silent reaction
| Reproductive Health system | |||
| Level 1 | Level 2 | Level 3 | Level 4 |
| Intermittent but not current swelling; no pain | Testicular swelling with pain | Testicular swelling; sudden onset severe pain | |
| Painless penile discharge; penile rash or lesion; positive STD contact | Penile discharge with moderate pain | ||
| Vaginal discharge; mild or no discomfort; itching | Vaginal discharge with normal menstrual history; VSS | Vaginal discharge with severe abdominal pain; last menses abnormal | |
| Painful menses | Vaginal bleeding; VSS; no orthostasis | Moderate vaginal bleeding with or without pain; orthostatic changes | Severe abdominal pain with or without severe vaginal bleeding; missed or abnormal menstrual cycle |
| Requests pregnancy test; no associated symptoms | Same as above with documented or suspected pregnancy | Same as above with documented or suspected pregnancy | Same as above with documented or suspected pregnancy, (all patients with pregnancy-related complaints who are more than 14 weeks pregnant by date of their last normal menses should be escorted to labor and delivery) |
| Genital trauma; no acute distress (NAD); “feels sore” | Genital trauma; swelling hematoma; or laceration | Genital trauma with significant bleeding and / or discomfort | |
| History of foreign body in anus, penis, or vagina; has been removed; mild discomfort | Foreign body in anus vagina, or penis with moderate discomfort | Foreign body lodged in anus, vagina, or penis with severe discomfort | |
| Sexual abuse more than 24 hrs ago | Sexual abuse 4-24 hr ago | Sexual abuse within 4 hr | |
James Jay Hoelz, RN, MS, CEN
Tommy Miller, 13 years old, presents to the triage desk of the ED at 7:00 PM ON Monday evening. Tommy is complaining of right testicular pain that he has had for 2 to 3 hr. The pain developed suddenly this evening. Tommy was playing football in gym class this afternoon but denies genital trauma. Tommy admits to three episodes of nausea with vomiting prior to arrival. He denies urinary symptoms such us burning on urination, urgency, or frequency. He is not sexually active and denies a penile discharge.
Tommy's vital signs are temperature 98° F, pulse 120 and regular, respirations 24, BP 130/90. He is slightly diaphoretic and his color is pale. He appears very uncomfortable. His abdomen is soft and his right testicle is enlarged and tender. Testicular torsion is suspected.
Triage Assessment, Acuity Level IV: Severe pain: sudden onset of testicular pain and swelling.
During development, the testis descends into the scrotum and is enveloped by the tunica vaginalis, a double-walled membranous lining. An uncovered area attaches to the scrotal wall and anchors the testicle to the scrotum. In some men, the tunica vaginalis envelops the entire testis and the epididymis. The testicle, therefore, is only anchored to the inner layer of the tunica vaginalis and not to the scrotal wall. This results in an unsecured testicle and a condition known as "bell-clapper" deformity.
When activity twists the testicle, blood supply to the area is compromised and pain occurs. The testis is much more prone to twisting in men with "bell-clapper" deformity. Prolonged twisting of the spermatic cord and blood vessels for more than 4 to 6 hr leads to extended vascular compromise and necrosis (1).
There is an 80% success rate of repair of the twisted cord if surgical intervention occurs prior to necrosis. After 6 hr, the success rate drops dramatically and removal of the testis is likely (2). The surgical procedure is an exploration and orchiopexy. Orchiopexy is often performed bilaterally, as a congenital anomaly may possibly exist on both sides and torsion might occur on the other side at some future point.
Epididymitis is an inflammation of the epididymis. most commonly caused by bacterial infection. Symptoms of epididymitis are similar to those of testicular torsion. Since torsion can lead to necrosis and is a surgical emergency, distinguishing between torsion and epididymitis is of the utmost importance. The most common age for testicular torsion to occur is during puberty, ages 12 to 20. Epididymitis is more common after sexual activity has begun. Patients presenting with torsion often complain of sudden onset of severe pain. Patients with epididymitis complain of prolonged, increasing pain and frequently have accompanying symptoms of dysuria and urethral discharge.
On physical exam, the patient with testicular torsion often has a testis that is in a transverse or horizontal position, while the patient with epididymitis has a testis in a vertical position. Another diagnostic tool is the presence of Prehn's sign. A positive Prehn's sign is present when the testicle is supported and elevated and there is relief of pain. Patients with testicular torsion have a negative Prehn's sign and experience no relief of pain with elevation of the testicle. A positive Prehn's sign often occurs with epididymitis (3).
Patients with epididymitis often have an elevated serum WBC count and urinary examination reveals pyuria or WBC in the urine. These indicators are not usually present with testicular torsion (4). A Doppler study will measure a decreased blood flow in the testicle that is twisted or torqued but will often show an increased blood flow with epididymitis (5).
Diagnosis: Pain related to ischemia of the involved testicle
Desired patient outcome: The patient will state that there is relief or reduction of pain and does not exhibit nonverbal cues of discomfort.
Diagnosis: Potential for fluid volume deficit related to fluid loss from vomiting
Desired patient outcome: The patient will have no orthostasis: will maintain a systolic BP > 90 mm Hg. HR < 100 beats/mm. and urinary output > 30 ml/hr: good skin turgor; and moist mucous membranes. The patient will have relief of nausea and vomiting.
Diagnosis: Knowledge deficit related to normal testicular physiology, occurrence of torsion, and need for surgery
Desired patient outcome: The patient (and family) will be able to verbalize a basic understanding of the anatomy of the male reproductive system and the Pathophysiology of testicular torsion. The patient will verbalize a basic understanding of hospitalization and surgery such that he will participate in activities of daily living (ADLs) and normal postoperative activities.
Diagnosis: Fear related to impending surgery
Desired patient outcome: The patient will gain an understanding of the surgical procedure and will describe his fears: the patient will use effective internal and external coping mechanisms to manage fear; the patient will state that he is less fearful.
The pain associated with testicular torsion is very often severe. The nurse should gather information on Tommy's coping mechanisms for pain and his family's expectations about controlling emotions when pain occurs. Tommy is 13 years old and will likely try to respond in a manner that will meet his parents' expectations. These responses will give the nurse an opportunity to identify verbal and nonverbal cues to determine if adequate analgesia has occurred. The physician may opt to delay pain medication until a diagnosis has been reached. The nurse should support Tommy and his parents through this period by offering empathy for Tommy's pain and by explaining the rationale for withholding pain medication. Once the diagnosis has been made. Tommy should be medicated as ordered with a strong analgesic, usually Demerol.
TIP: For children, it may be helpful to reinforce that the pain is temporary and will go away, much like going to the dentist or skinning a knee.
Testicular torsion is relatively unknown to the lay population, and time should be set aside early by the physician and the nurse to explain the Pathophysiology of the condition and the steps that will be taken to repair it. The nurse should be preparing Tommy and his family for the likelihood of surgery. An unhurried attitude and adequate time will encourage Tommy and his family to feel comfortable asking questions.
Special consideration should be given to Tommy's stage of development. As an early adolescent. Tommy is developing a sense of self-concept and is adapting to changes in body image. He is probably extremely sensitive about his "private region" and is self conscious in speaking about genitalia. Tommy is also at an age when many young men have begun to masturbate. Tommy may be feeling guilty that his actions have somehow caused the torsion. These feelings should be considered when caring for Tommy, and it may be helpful to spend some time interviewing Tommy without his parents so that he can feel comfortable sharing his concerns (6).
Testicular torsion is a surgical emergency. Familiarity with the signs and symptoms of the disease process should ensure that the patient is identified as a high-risk patient at triage so that his care is expeditious. Failure to provide expeditious care could result in a poor patient outcome.
Laura Ann Kress, RN, BSN
Denise is an 18-year-old white female who presents to the triage desk complaining of severe lower abdominal pain that has lasted for 2 days. Denise describes the pain in the midabdominal area, just below the umbilicus. She denies any vomiting but has felt nauseated and has had a decrease in appetite. She also reports fever and malaise since yesterday. Denise's last menstrual period (LMP) was 1 week prior to this visit and was unusually long. She complains of continued spotting with a foul-smelling. yellowish vaginal discharge. She denies use of any birth-control methods.
Denise is accompanied by her boyfriend of 2 months. She is casually dressed, and the zipper of her jeans is open. She is holding her stomach and rocking in the chair Her temperature is 102°F. BP 120/78. pulse 110. and respiratory rate 22. Denise is not not orthostatic.
Triage Assessment. Acuity Level III: Abdominal pain. temperature > 102° F, moderate pain.
Denise is taken to the treatment area by the triage nurse. The triage nurse report to the treatment nurse that pelvic inflammatory disease (P1D) is suspected.
PID is a common complication for women who do not seek treatment after exposure to a sexually transmitted disease (STD). PID is an infectious process affecting the ovaries, pelvic peritoneum, pelvic vascular system, pelvic connective tissue, and most commonly the fallopian tubes. Patients at high risk are those with multiple sexual partners, who use an intrauterine device (IUD) for birth control, or have had recent instrumentation of the cervix (i.e.. abortions. C-section deliveries, or cervical curettage).
Since PID can affect only some or all of the pelvic structures, patients present with a wide range of symptoms. Most patients complain of mild to moderate abdominal pain, fever, irregular bleeding. and adnexal tenderness. An increase in pain usually occurs following menses. Other signs and symptoms may include nausea and vomiting, malaise, urinary frequency, and vaginal discharge. During the early stage of the disease the patient is relatively asymptomatic. with no pain and only a moderate discharge. Therefore, early treatment is usually not sought.
The incidence of PID is not known. However, in the United States each year more than 900,000 women are diagnosed with the disease (1). Nesseriam gonorrhoeae is an anaerobic. Gram-negative diplo-cocci that causes gonorrhea in both men and women. Although not all PID is caused by N. gonorrhoeae, the percentage of those cases due to N. gonorrhoeae infection is estimated at 20 to 80% (1).
The second bacteria involved in PID is Chlamydia trachomatis and is responsible for between one-fourth and one-half of all cases of PID (1). The incidence of Chlamydia infection is estimated at three to Five million Americans each year (2). The major threat of both types of infections is that infected individuals are usually asymptomatic and do not receive treatment until pain and complications occur. This may be as late as 3 to 4 weeks after the initial contact, and the individual may have spread the infection to other partners.
TIP: Frequently gonorrhea and Chlamydia are present simultaneously. Therefore. while cultures are important for specific diagnosis, it is equally important to treat for both bacterium until the culture results are known.
Although mortality is rare, the morbidity of the disease can cost the health care system millions of dollars every year. Women diagnosed with PID increase their risk of infertility and ectopic pregnancy due to scarring of the fallopian tubes. One long-term study showed that 25% of all women who had PID were unable to conceive children during the subsequent 10 years (1). Moreover, the risk of having an ectopic pregnancy is 6 to 10 times greater (1). The overall incidence of ectopic pregnancy has increased between 1970 and 1983, accounting for a large number of maternal-related deaths, second only to toxemia (3).
In the treatment area Denise is placed in a room and prepared for a pelvic exam by the physician. The physician will obtain samples of the discharge to culture for gonorrhea and Chlamydia and may also ask for a serological test for syphilis, since more than one disease can occur simultaneously. The physician will also do a bimanual exam to detect any pelvic masses that may suggest an abscess or ectopic pregnancy. This part of the exam may be extremely painful for Denise since any movement of the cervix causes an increase in abdominal pain. This "cervical motion tenderness" is sometimes described as a "classic" sign of PID.
Patients diagnosed with PID may be treated on an outpatient basis. Patients routinely hospitalized are those women with peritoneal signs such as abdominal pain with rebound tenderness, temperature greater than 103°F, and decreased intestinal motility. Patients who have a history of pelvic abscesses or pregnancy and who have demonstrated or who currently demonstrate an inability to follow an outpatient regimen are also candidates for admission. Prompt antibiotic treatment is recommended before cultures are available. There is evidence that infertility follows salpingitis (infection of the fallopian tubes) less frequently when treatment is started within 2 days of the beginning of symptoms (4). Current Centers for Disease Control (CDC) guidelines (5) for outpatient management of patients with PID are listed in Table 6.2.1.
Diagnosis: Pain related to inflammation of the cervix, uterus, and fallopian tubes
Desired patient outcome: The patient will state that there is a relief or a reduction of pain and does not exhibit nonverbal cues of discomfort.
Diagnosis: Infection related to N. gonorrhoeae or C. trachomatis located in the pelvic cavity
Desired patient outcome: The patient's infection will show evidence of resolution demonstrated by temperature of 98.6 to 99.6°F, skin cool, and reported relief of malaise.
Diagnosis: Knowledge deficit related to how the disease occurs, drug therapy, and safe sex practices
Desired patient outcome: The patient and her significant other will be able to verbalize a basic understanding of the transmission of sexually transmitted diseases and safe sex practices. The patient will also verbalize an understanding of the proper way to take her medications, including frequency, length of treatment, and side effects. The patient will describe her plan to receive follow-up therapy.
Diagnosis: Potential for fluid volume deficit related to fever, infection, and decrease in appetite
Desired patient outcome: The patient will remain hydrated with systolic BP > 90 mm Hg, HR < 100 beats/min. and urinary output > 30 ml/hr. The patient will drink 1000 ml of fluid during this visit.
Table 6.2.1 Recommendations for Outpatient Treatment of PID
| Drug | Dose | Patient Education |
| Cefoxitin or Amoxicillin Or |
2.0 g i.m. | 1.Instructions for taking medicine, including dosage timing, length of treatment. Patient needs to understand that all medication should be taken, even if symptoms subside. |
| Ampicillin or Aqueous procaine penicillin G with probenecid Or |
3.5 g oral 4.8 million U i.m 1.0g oral |
2. Advise patient to return for follow-up for side effects or other difficulty with medication or if symptoms continue or increase in severity. |
| Ceftriaxone | 250 mg i.m. | 3. Patients should abstain from sexual activity or, if unable to do so, se of condoms is necessary until treatment is completed. |
| Followed by Doxycycline Or |
100 mg oral b.i.d x 10-14 days |
4. Advise patient to stop sexual activity if similar or other STD symptoms recur and return to clinic for health care. |
| Tetracycline HCL (contraindicated in pregnancy and less
active against certain anaerobes) Alternative regimens Erythromycin base or stearate or Eythromycin ethyl succinate |
500 mg oral q.i.d x 10 days 500 mg oral q.i.d x 7 days 800 mg oral q.i.d. x 7 days |
5. Encourage use of barrier contraceptive methods, especially condoms, to prevent STDs |
| From Shattuck JC Pelvic inflammatory disease; Education for maintaining fertility Nurs Clin North Am 23(4) 903, 1988 (Adapted originally from CDC Guidelines, August 1985.) | ||
In order for Denise to be treated on an outpatient basis, she will need specific instructions about her treatment and disease process. Denise should be instructed to maintain pelvic rest during her treatment phase. This requires reclining in a semi-Fowler's position with the feet elevated in order to avoid strain on adjacent pelvic structures. The semi-Fowler's position also helps to prevent the infection from spreading upward. The use of acetaminophen for fever and pain control can be prescribed. The importance of maintaining adequate fluid and nutritional intake is also important in the healing process.
Explicit instructions on taking the medications should include dosage, timing, and length of treatment. Denise should have a follow-up exam in 2 to 3 days when the culture results are known and at the completion other antibiotic course. Denise needs to be instructed to return to the ED if her symptoms have not subsided or become worse in 2 to 3 days.
Denise needs to be educated on safe sex principles. These should include abstinence of intercourse until both she and her boyfriend have completed treatment. Birth-control methods such as condoms and vaginal contraceptive creams and jellies used in combination can be an effective barrier against bacteria, decreasing her risk of recurrent infection. She should be advised to report any suspicious symptoms in order to obtain earlier treatment decreasing the chance for further complications of infertility and chronic pelvic pain.
Patricia C. Bent, RN, CEN
Denise is a 23-year-old black female who presents to the ED accompanied by her husband. She is complaining of sudden onset of right lower quadrant abdominal pain that woke her from sleep 1 hr prior to arrival. She describes the pain as "knife-like" in nature without radiation. She has nausea, but no vomiting. Her LMP was 6 weeks ago, and her past menstrual period (PMP) was normal. She denies any vaginal bleeding at present, but states that she had some spotting about I week ago. She discontinued using an IUD 6 months ago in order to become pregnant with her first child. Her vital signs are pulse 110, BP 60 by palpation, respirations 24.
Triage Assessment. Acuity Level IV: severe abdominal pain with missed menstrual cycle, systolic BP < 90 mm Hg, and increased HR.
Denise is escorted immediately to the treatment area as the triage nurse suspects an ectopic pregnancy. Her repeat vital signs are temperature 36.7° C. pulse 122. respirations 24, BP 54/P. Two large bore peripheral catheters are placed with 0.9% NS infusing at a wide open rate. Blood samples are drawn and sent to the lab for chemistry. hematology. blood bank sample, and B human chorionic gonadotropin (HCG) test. Spun hematocrit is 30%, A room air ABG is obtained, and oxygen at 4 liters nasal cannula is administered. Denise is placed in a modified Trendelenburg position for placement of a right subclavian line with another liter of 0.9% ,NS run a! a wide open rate. After 500 ml of fluid, Denisc's BP is 106/60. with an HR of 112. A Foley catheter is inserted with an initial output of less than 50 ml. A consultation with a gynecologist is obtained by the ED physician.
The physical exam repealed by the gynecologist reveals a pale-looking, anxious female with severe abdominal pain. Her lungs are clear. The cardiac monitor shows sinus tachycardia. Her abdomen is slightly distended, very firm with minimal bowel sounds and severe pain and guarding on gentle palpation. Her rectal exam is negative for occult blood. The pelvic exam shows a normal uterus with a right ad-nexal mass. A culdocentesis is performed with aspiration of nonclotting blood. The serum pregnancy test is reported as positive. The diagnosis is made of a ruptured ectopic pregnancy. The patient is immediately prepared to be taken to the OR for exploration and repair.
Implantation of a fertilized ovum at a location other than the uterine cavity is known as an ectopic pregnancy. The implantation may be tubal (most common), abdominal, or ovarian. Any woman of childbearing age is susceptible to an ectopic pregnancy. Clinical characteristics include a mean age of 28 years, prior pregnancies, previous ectopics, and nonwhite women (1). There has been an overall increase in the incidence of ectopic pregnancy between 1970 and 1983 (4.5 to 14.0 ectopic pregnancies per 1000 pregnancies). Death due to ectopic pregnancy is the second leading cause of pregnancy related deaths after toxemia. An ectopic pregnancy may result from a number of different causes. These include, but are not limited to, previous intra-uterine infections, inflammatory changes such as previous ectopics. IUD usage, tubal ligation, and previous gynecological surgeries (2. 3).
Damage to fallopian tubes from previous episodes of PID is the most common cause of ectopic pregnancy (3). This may be due to incomplete healing and scarring of tubal mucosa, creating a partial tubal obstruction and impediment to the passage of an ovum (4). The risk of ectopic pregnancy in patients who have undergone tubal ligation and subsequently become pregnant is approximately 50% (5). Present or recent past use of an IUD may stop the egg from implanting in the uterine lining, making the fallopian tube a more favorable spot (6). Hormones may impede ovum transport thereby mechanically stopping the forward motion of the egg in the fallopian tube (7).
In a majority of cases, slight to moderate vaginal spotting may occur after a missed period. Bleeding occurs when the endocrine support of the endometrium becomes inadequate (8). Nausea and vomiting occur as well as abdominal distention when intraperitoneal bleeding occurs. Cullen's sign (a blue discoloration around the umbilicus) is uncommon. but can be diagnostic of hemoperitonium. When an ectopic pregnancy occurs or ruptures, pain is present most of the time. The pain may van. in type, location, and duration. The pain may be unilateral or bilateral. continuous or intermittent, sharp or cramping. Excruciating abdominal pain in a young, healthy female strongly suggests a ruptured ectopic pregnancy (9). Cardiovascular changes due to hypovolemia may or may not be present in early rupture. When 10% of the circulating blood volume or approximately two units of blood is lost, objective signs of shock may be noted. Loss of circulating blood volume initiates the chain of physiological reactions (tachycardia, vasoconstriction) that occur with a decrease in cardiac output.
TIP: Brown-skinned persons may appear yellow-brown, while black-skinned individuals appear ashen gray when vasoconstriction occurs as a compensatory mechanism in shock (10).
Routinely, a B-HCG will be drawn to determine the presence of a pregnancy. Levels usually rise within 7 days after ovulation and double every 48 hr.
TIP: ß-HCG aids in confirming that a pregnancy exists or did exist over the past 1 to 3 weeks.
The patient is placed in a lithotomy position (knees and hips flexed and heels resting on foot rests) and an unlubricated speculum is inserted. A needle attached to a 20-ml syringe is inserted through the posterior fornix into the cul-de-sac. This area is then aspirated to determine the presence of blood. A culdocentesis is said to be positive if the nonclotting blood is found in the cul-de-sac. The nurse's role includes gathering the necessary instruments, positioning the patient. and offering support throughout the procedure. The nurse can help the patient relax by having her breathe through her mouth and relax her abdominal muscles.
Nursing diagnoses for this patient are identified by characteristics of hypotension and severe blood loss, significant discomfort, fear related to sudden illness, and knowledge deficit related to the need for surgery. Denise is also losing a pregnancy that she desired.
Diagnosis: Fluid volume deficit related to ruptured fallopian tube with escape of blood into the abdominal cavity
Desired patient outcome: The patient will maintain a systolic BP > 90 mm Hg, HR < 100 beats/min, and urinary output > 30 ml/hr; the patient will remain oriented to person, place, and time; skin will remain warm and dry.
Diagnosis: Pain related to ruptured intrauterine structures causing peritoneal irritation
Desired patient outcome: The patient will state that there has been a reduction in pain; the patient will appear more comfortable until she is transported to the OR and sedated.
Diagnosis: Knowledge deficit related to what an ectopic pregnancy is and why surgery is necessary
Desired patient outcome: The patient will be able to state the reason for surgery, actions, and events that will occur and her role in the recovery process.
Diagnosis: Fear related to potential complications of the surgical procedure
Desired patient outcome: The patient will verbalize a good understanding of the surgical procedure and will state that she feels less fearful.
Diagnosis: Anticipatory grieving related to loss of pregnancy
Desired patient outcome: The patient will discuss the loss of her pregnancy and, as able, will begin the experience of grieving in a supportive environment.
As with any patient situation in which there is a decrease in cardiac output, maintaining circulating blood volume and ensuring adequate tissue perfusion is essential. The nurse will routinely assist the physician in establishing two large bore intravenous catheters for rapid volume replacement and blood administration. A central venous pressure (CVP) catheter is usually inserted to serve as a guide for fluid replacement. Rapid infusions are administered until the CVP rises 5 cm H20 above baseline, or the patient's clinical condition improves. The patient is placed in a desirable supine position by elevating the head with a pillow, and elevating the lower extremities 20 to 30°, keeping the knees straight. Oxygen is administered to augment the oxygen-earning capacity of arterial blood. Care should be taken not to overheat the patient since unnecessary vasodilatation could occur. A Foley catheter is inserted to monitor urine output. Pain is a difficult problem for a patient with an ectopic pregnancy, since the use of narcotics is not recommended. Other means should be tried to make the patient more comfortable. A quiet soothing tone of voice and careful positioning are nursing actions that may help alleviate some discomfort. Distraction is also helpful particularly if a family member is present and capable of offering emotional support. The patient's knowledge deficit may also be contributing to pain and anxiety. Explain the procedure in simple. concise terms, allowing the patient time to ask questions. The important role of patient participation in postoperative recovery should be included. The patient should be allowed to express her feelings of anger or sadness at the loss of the pregnancy if she desires. Her husband should be included in this process if she identifies him as a source of support for her. She should be encouraged to view her feelings as a normal reaction and part of the grieving process.
After a diagnosis of ruptured ectopic was made, Denise was rapidly transported to the OR. A laparotomy was performed, and 1500 ml of blood was found in her abdominal cavity. The right ovary and fallopian tube were removed. She received four units of blood during the procedure. Her postoperative course was uncomplicated, and she was discharged on the fourth postoperative day.
The role of the emergency nurse in assessment and intervention should not be underestimated, since early recognition of ectopic pregnancy may be the single greatest factor in preventing death, irreversible tubal damage, and complete loss of reproductive ability in a very young woman (11).