Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696597180540.pdf (United States)
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols P-03166 (03/2023) Table of Contents Table of Contents .......................................................................................................................................... 2 Acronyms ...................................................................................................................................................... 3 Contraception in Advance of Exam ............................................................................................................... 5 Contraception Extension ............................................................................................................................. 12 Combined Hormonal Contraception ........................................................................................................... 17 Progestin-Only Pill ....................................................................................................................................... 26 Progestin-Only Injectable Contraceptive .................................................................................................... 33 Internal Condom ......................................................................................................................................... 41 External Condom......................................................................................................................................... 45 Fertility Awareness Based Method ............................................................................................................. 49 Periodic Medication Pick up ....................................................................................................................... 57 Emergency Contraception .......................................................................................................................... 62 Asymptomatic Sexually Transmitted Infection (STI) Screening Visit
 .......................................................... 68 Symptomatic Sexually Transmitted Infection (STI) Visit ............................................................................. 75 Chlamydia Treatment ................................................................................................................................. 82 Gonorrhea Treatment ................................................................................................................................. 89 Syphilis Treatment ...................................................................................................................................... 97 Trichomoniasis Treatment ........................................................................................................................ 104 Mycoplasma Genitalium Treatment ......................................................................................................... 109 HIV PrEP .................................................................................................................................................... 116 HIV nPEP .................................................................................................................................................... 124 Pregnancy Testing and Counseling ........................................................................................................... 131 Preconception Counseling and Basic Infertility Services .......................................................................... 137 RN Wellness Visit ...................................................................................................................................... 143 Expedited Partner Therapy ....................................................................................................................... 149 Acronyms Division of Public Health ACOG AHA ALT anti-HBc anti-HBs APNP ART ARV ASCCP AST BMI BUM CBC CDC CHC CIA CMP COC CrCl CSF Cu-IUD
 DMPA DMPA-IM DMPA-SC DNA DO DOT DUI EC ECP eCrCl eGFR EPT FABM FDA FSH FTC/TDF HbG A1C HBsAg HCG Hep B Hep C HIV HIV nPEP HIV PrEP HPV HSV IPV American College of Obstetricians and Gynecologists American Heart Association Alanine transaminase or Alanine aminotransferase Hepatitis B core antibody Hepatitis B surface antibody Advanced Practice Nurse Prescriber antiretroviral therapy antiretroviral American Society for Colposcopy and Cervical Pathology aspartate aminotransferase Body mass index Back up Method Complete blood count Centers for Disease Control and Prevention Combined Hormonal Contraceptives Contraception in Advance of Exam Comprehensive metabolic panel Combined estrogen-progestin oral contraceptives Creatinine clearance Cerebrospinal fluid Copper - Intra Uterine Device Depot-medroxyprogesterone acetate Depot-medroxyprogesterone acetate - Intramuscular Depot-medroxyprogesterone acetate - Subcutaneous Deoxyribonucleic acid Doctor of Osteopathic Medicine Direct observation therapy Driving under the influence Emergency contraception Emergency contraceptive pills Estimated creatinine clearance Estimated glomerular filtration rate Expedited Partner Therapy Fertility Awareness Based Methods U.S. Food and Drug Administration Follicle-stimulating hormone tenofovir disoproxil fumarate/emtricitabine Hemoglobin A1C Hepatitis B surface antigen Human chorionic gonadotrophin Hepatitis B Hepatitis C Human Immunodeficiency virus Human Immunodeficiency virus - Nonoccupational post-exposure prophylaxis Human Immunodeficiency virus - Pre-exposure prophylaxis Human papillomavirus Herpes Simplex Virus Intimate Partner Violence Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 3 Division of Public Health Acronyms IUD LARC LH LMP LNg-IUD MD MEC MPA MSM NAAT NP OCP PA PATH Model PCOS PID PNCC POP PRN RHFP RHNTC RLP RN RTC SSC STD STI T. pallidum TAF TDF/FTC UPA USPSTF VDRL WIC WPSI WSLH Intrauterine device Long-acting reversible contraception Luteinizing
 hormone Last menstrual period Levonorgestrel – Intra Uterine Device Doctor of Medicine/Medical Doctor The United States Medical Eligibility Criteria for Contraceptive Use Medroxyprogesterone acetate Men having sex with other men Nucleic Acid Amplification Test Nurse Practitioner/Nurse Prescriber Oral Contraceptive Pills Physician associates or Physician assistants Parenthood/Pregnancy Attitude, Timing, and How important pregnancy prevention is for a client Polycystic ovarian syndrome pelvic inflammatory disease Prenatal Care Coordination Progestogen-only pill “pro re nata” which means “as needed” Reproductive Health Family Planning Program Reproductive Health National Training Center Reproductive Life plan Registered Nurse Return to Clinic Selective screening criteria Sexually transmitted disease Sexually transmitted infection Syphilis (Treponema pallidum) Tenofovir alafenamide Tenofovir disoproxil fumarate/emtricitabine Ulipristal Acetate U.S. Preventive Services Task Force The venereal disease research laboratory Women, Infants and Children Nutrition Program Women's Preventive Services Initiative Wisconsin State Laboratory of Hygiene Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 4 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Contraception in Advance of Exam Effective Date: [Add Date] Definition and/or Scope: Clients seeking medical care at [Clinic Name] for Contraception in Advance of Exam (CIA) as a method of pregnancy prevention and/or to manage dysmenorrhea, acne, cycle control (excluding oligomenorrhea and/or amenorrhea as defined below) will be treated using best practice guidelines (see a, b, c in Links and Resources section below) and in compliance with Title X required components of care.
Procedure: 1.

Subjective: a. Assess client’s goals for contraception start, switching or continuing a method using client-centered counseling and shared decision making.

Refer to APNP, PA, MD, DO for medical evaluation if contraception requested to manage symptoms other than acne, dysmenorrhea, or irregular menses occurring less than 3 months apart.

b.

Completion of a comprehensive health history and assessment including: i.
Reproductive life plan using the PATH model or other client- centered counseling technique.

ii.

Contraceptive history, including client priorities and past use and/or discontinuation of contraception.

iii.

Possible pregnancy, assessing last menstrual period (LMP) and recent sexual activity.

iv.

Assess for unacceptable health risks and/or contraindications to hormonal or LARC contraception per Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use, n.d. v. Personal health history vi.
Family health history (mother, father, sister, brother) vii.

Review of systems for symptoms currently present: a.

Chest pain and/or palpitations b. Migraines with aura c. Breast lump and/or pain d. History of shortness of breath (not related to asthma) viii.

Review current medications for possible drug interactions with hormonal contraception per the CDC - Summary - USMEC - Reproductive Health, 2019.
Drugs that can decrease the effectiveness of combined hormonal contraceptive (CHC) included below, may not be a comprehensive list: a. Anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxycarbazepine) b. Rifampin c. St John’s Wort Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 5 Division of Public Health d. HIV antiviral e. CHC that can affect other drug levels (lamotrigine) c. Assess potential risk of pregnancy and implement RHFP RN Clinical Protocol for Pregnancy Testing and Counseling as needed.
d. Assess need for emergency contraception (EC) and implement the RHFP RN Clinical Protocol for EC as needed.

2.

Objective: a.

Review blood pressure history within the last 12 months and obtain and document vitals if client onsite.

i.

Recommend client come to clinic for blood pressure if not obtained with the last 12 months.

b. Assess for urgent physical and mental distress.

3.
3.

Assessment: a. Protocol applies, proceed to method specific RN Protocol b. Protocol applies following consultation with MD, APNP, PA regarding possible contraindication or MEC level 3 contraindications, proceed to plan with provider approval c. Protocol does not apply, or provider indicates need for further evaluation, refer to MD, APNP, PA 4.
Plan: Option A: No CDC MEC 3 or 4 contraindications to estrogen or progesterone, all contraceptive options appropriate and reviewed with client using shared decision making and clinic formulary.

Client and clinician select Contraceptive Method.

Implement RN protocol for CHC or LARC referral.

Apply applicable contraception method RN protocol or make referral as appropriate following method selection.
Option B: MEC 3 or 4 Contraindications to estrogen identified, progesterone options and intrauterine device (IUD) appropriate and reviewed with client, using shared decision making and clinic formulary.

Apply applicable progesterone method RN protocol or make referral as appropriate following method selection.

Option C: MEC 3 or 4 Contraindications to Estrogen and Progesterone, non- hormonal options and IUDs reviewed with client using shared decision making and clinic formulary.
Apply applicable non-hormonal method RN protocol or make referral as appropriate following method selection.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 6 Division of Public Health a.

Offer the following contraceptive supplies: i. EC using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

5.
5.

Physician, APNP, PA management or consultation required during visit: a.

Any client with definite contraindications to contraceptive method who still wishes to use.

b.

Persistent borderline hypertension while on combined hormonal contraception.

c. Nurse clinician or nurse practitioner discretion.

d. Indications other than cycle control, contraception, dysmenorrhea, or acne.

e. If provider management and/or consultation not available, RN should provide referral.

6.

Nursing skills: a.

Skills: i.


Blood pressure ii.

Client interviewing and education skills.

iii.

Client-centered counseling skills b.

Clinical content knowledge: i. Pharmacology and characteristics of various forms of contraceptive method.

ii.

CDC - Summary - USMEC - Reproductive Health, 2019 iii.

Side effects and adverse effects of contraceptive method.

iv.

Health conditions and their relationships to use of contraceptive methods.

v. Quick start option for contraception initiation vi.
Contraceptive instructions on all methods, transitioning between methods, perfect use instructions, missed pill use recommendations, impact on efficacy and indications for back up methods per CDC - Summary - US SPR - Reproductive Health, 2019 vii.

Insurance impact on method coverage; skills to provide assistance with pharmacy benefits, prior authorization, Family Planning Only Services, 2014. viii.

ASCCP Management Guidelines Web Application, n.d., for pap screening guidelines ix.
Indications for routine immunization indicated by the CDC.

x. CDC STI Screening Recommendations and Considerations Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 7 Division of Public Health 7.

Follow-up: a.

The client should be encouraged to return to the clinic annually for contraceptive follow up and/or at any time to discuss side effects.

b.

At any routine visit health-care providers seeing contraceptive users should do the following: i.

Review the reproductive life plan.


ii.

Assess the client’s satisfaction with their contraceptive method and whether the client has any concerns about method use.

iii.

Assess any changes in health status, including medications that would change the appropriateness of contraception for safe and effective continued use based on based on CDC - Summary - USMEC - Reproductive Health, 2019 (e.g., category 3 and 4 conditions and characteristics).

iv.
iv.

Review primary care or medical home status with all clients and refer as necessary.

v. Assess weight changes and counsel clients who are concerned about weight changes perceived to be associated with their contraceptive method.

8.

Referral to provider is required for: a.
For LARC insertion b. Gallbladder disease; current, medically treated, no surgery c. Hypertension: After three separate visits blood pressure >140/90 d. Diabetes with nephropathy, retinopathy, or neuropathy or other vascular disease or diabetes of >20 years duration e. Undiagnosed breast mass in a client wishing to start a method, requires follow up prior to initiation f. Client with new onset or worsening of migraines g. Pregnancy h. Urgent physical or mental distress 9.

Links and Resources: a.


Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use.

(n.d.).

https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us- medical-eligibility-criteria_508tagged.pdf b. CDC – Summary – USMEC – Reproductive Health.

(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html c. CDC – Summary – US SPR – Reproductive Health.

(2019).
(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html d. Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/fpos/index.htm e. Recommendations and Reports Disclosure of Relationship.

(2016).

https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6503.pdf f. U.S.

Selected Practice Recommendations for Contraceptive Use, 2016 Morbidity and Mortality Weekly Report Recommendations and Reports.

(2016).
(2016).

https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6504.pdf g. Frieden, T.R., Jaffe, H.W., Iademarco, M.F., Moran, J.S., Leahy, M.A., Martinroe, J.C., Spriggs, S.R., & Starr, T.M.

(2014).

Providing Quality Family Planning Services Morbidity and Mortality Weekly Report Centers for Disease Control and Prevention Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 8 Division of Public Health MMWR Editorial and Production Staff (Serials) MMWR Editorial Board.
Recommendations and Reports, 63(4).

https://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf h. Combined Hormonal Birth Control: Pill, Patch, and Ring.

(n.d.).

Www.acog.org.

Retrieved December 14, 2022, from http://www.acog.org/Patients/FAQs/Combined- Hormonal-Birth-Control-Pill-Patch-and-Ring i. Hatcher, R.A. (2018).

Contraceptive technology.


Ayer Company Publishers, Inc. j. Curtis, K.M., Tepper, N.K., Jatlaoui, T.C., Berry-Bibee, E., Horton, L.G., Zapata, L.B., Simmons, K.B., Pagano, H.P., Jamieson, D.J., & Whiteman, M.K.

(2006).

U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.

MMWR.

Recommendations and Reports, 65(3), 1-103. https://www.cdc.gov/mmwr/volumes/65/rr/rr6503a1.htm k. World Health Organization.

Reproductive Health and Research, & K4health.

(2011).
(2011).

Family planning: a global handbook for providers: evidence-based guidance developed through worldwide collaboration.

World Health Organization, Department of Reproductive Health And Research; Baltimore.

l. Epocrates.

(2019).

Epocrates Online MultiCheck.

Epocrates.com.

https://online.epocrates.com/interaction-check m. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.


http://www.myplate.gov APPROVAL – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: a.

Intimate partner violence, domestic violence, sexual assault b.
Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: Education is to be documented in the client’s health record.
Method explained by counselor at group or individual education session, includes but not limited to: a. Method-specific instructions, apply selected RHFP RN protocol contraceptive method protocol as applicable Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 9 Division of Public Health b.
Referral education including planned procedure, pregnancy prevention prior to procedure, clinic location, and insurance coverage c. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.

Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.


Discussion inadvisability of smoking d. Determine appropriateness of quick start, review instructions in contraceptive method RN protocol for quick start and advise on the need for a pregnancy test just before starting second cycle of contraception (regardless of bleeding): i.

Use your first pill, ring, or patch the day of your appointment with your provider; regardless of where you are in your menstrual cycle.

ii.
ii.

Use condoms or another back up method of birth control for seven days after starting.

iii.

Repeat a pregnancy test just before starting the second cycle of contraception (include instructions on how to obtain pregnancy test at the clinic or home).

iv.

You may experience unexpected bleeding in the first 3 months of hormonal contraceptive use; continue taking your hormonal contraception even if unscheduled bleeding occurs.
Contact your clinician if unscheduled bleeding persists beyond the first 3 months of contraceptive use.

e. If client has simple migraines (without aura), RN should instruct client to monitor and report worsening of headaches (increased frequency or severity) or new onset focal neurologic symptoms and return to clinic if occurs.

i.

Client with new onset or worsening of migraines should be scheduled by the nurse for an appointment with MD, APNP, or PA. 3.
Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 10 Division of Public Health c. Discuss emergency contraception options and availability discussed.
d. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI screening.

e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox f. Provide information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.
g. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 11 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Contraception Extension Effective Date: [Add Date] Definition and/or Scope: Clients seeking prescription contraception refill request from [Clinic Name] from the pharmacy or patient request whose initial prescription is passed 12 months from the previous annual exam date.
Procedure: 1.

Subjective: a.

Registered nurses may renew contraception for 3 months according to the following guidelines: i.

The requests for a prescription extension are received from a patient or pharmacy as a phone call, fax, or chart message.

ii.

The last prescription was provided by the RHFP site receiving the request and was between 11 months to 15 months ago.

iii.

Assess potential risk of pregnancy and implement RHFP RN Clinical Protocol for Pregnancy Testing and Counseling as needed.

iv.
iv.

Assess for unacceptable health risks and/or contraindications to hormonal contraception per Summary Chart U.S. Medical Eligibility for Contraceptive Use, n.d. v. Review of systems for symptoms currently present: 1.

Chest pain and/or palpitations 2.

Migraines with aura 3.

Breast lump and/or pain 4.

History of shortness of breath (not related to asthma) vi.
Medication dosage and frequency are verified in the chart and any discrepancy should be clarified with the pharmacy, patient, or prescriber as needed.

vii.

The chart is reviewed to determine if there are documented contraindications to the requested contraception.

viii.

Assess need for emergency contraception (EC) and implement the RHFP RN Clinical Protocol for EC as needed.

2.

Objective: a.

Review blood pressure history within the last 12 months, obtain and document vitals if client onsite.

i.
i.

Recommend client come to clinic for blood pressure if not obtained within the last 12 months.

b. Assess for urgent physical or mental distress.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 12 Division of Public Health 3.

Assessment: a. Protocol applies b. Protocol applies following consultation with MD, APNP, PA c. Protocol does not apply refer to MD, APNP, PA 4.

Plan: a. Prescribe the contraceptive method for up to 3 months b.
Document dispensed contraception as prescribed: i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.

Quantity dispensed v. Name of the delegating prescriber vi.

Date of original prescription vii.

Name of RN dispensing c. Contact the patient for pick up at the clinic or if pharmacy pickup is preferred.

d. Document all patient contact in patient chart.

e. Schedule next appointment for contraception at soonest convenience, within 3 months.
f. Offer the following contraceptive supplies: i.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

5.

Physician, APNP, PA management or consultation required during visit: a.

Use of CHC to manage conditions other than acne, dysmenorrhea, cycle regulation with menses coming at least every 90 days.

b.
b.

Blood pressure >140/90 c. If a provider is unavailable, the RN should make a referral.

6.

Nursing Skills: a.

Skills: i.

Blood pressure ii.

Skill in interviewing and assessment of client reproductive planning goals and priorities iii.

Pregnancy risk assessment and indications for testing b.

Clinical content knowledge: i. Pharmacology of contraceptive options ii.

CDC - Summary - USMEC - Reproductive Health, 2019 iii.
Contraceptive instructions on all methods, transitioning between methods, perfect use instructions, missed pill use recommendations, impact on efficacy and indications for back Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 13 Division of Public Health up methods per CDC - Summary - US SPR - Reproductive Health, 2019 iv.
Insurance impact on method coverage; skills to provide assistance with pharmacy benefits, prior authorization, Family Planning Only Services, 2014. v. ASCCP Management Guidelines Web Application, n.d. for pap screening vi.

Indications for routine Immunization Schedules for Healthcare Professionals, 2019. vii.

CDC, 2021 STI Screening Recommendations and Considerations 7.

Follow up: a.
Follow up: a.

The client should be encouraged to return to the clinic annually for contraceptive follow up and/or at any time to discuss side effects.

b. Pregnancy test per RHFP RN Clinical Pregnancy Testing and Counseling, or home pregnancy test 8.

Referral to provider is required for: a. Pregnancy b.

Urgent physical or mental distress c. Consultation is required but a physician, APNP, or PA is unavailable at the time 9.

Links and resources: a.


Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use.

(n.d.).

https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us- medical-eligibility-criteria_508tagged.pdf b. CDC – Summary – USMEC – Reproductive Health.

(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html c. Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.


https://www.dhs.wisconsin.gov/fpos/index.htm d. ASCCP Management Guidelines Web Application.

(n.d.).

App.asccp.org.

https://app.asccp.org/ e. Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html f. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.


https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm g. Curtis, K.M., Tepper, N.K., Jatlaoui, T.C., Berry-Bibee, E., Horton, L.G., Zapata, L.B., Simmons, K.B., Pagano, H.P., Jamieson, D.J., & Whiteman, M.K.

(2006).

U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.

MMWR.

Recommendations and Reports, 65(3), 1-103. https://www.cdc.gov/mmwr/volumes/65/rr/rr6503a1.htm h. U.S.
Selected Practice Recommendations for Contraceptive Use, 2016 Morbidity and Mortality Weekly Report Recommendations and Reports.

(2016).

https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6504.pdf i. Frieden, T.R., Jaffe, H.W., Iademarco, M.F., Moran, J.S., Leahy, M.A., Martinroe, J.C., Spriggs, S.R., & Starr, T.M.

(2014).
(2014).

Providing Quality Family Planning Services Morbidity and Mortality Weekly Report Centers for Disease Control and Prevention MMWR Editorial and Production Staff (Serials) MMWR Editorial Board.

Recommendations and Reports, 63(4).

https://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf j.

Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/fpos/index.htm k. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.


http://www.myplate.gov Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 14 Division of Public Health Approval– Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: a.
Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: Education is to be documented in the client’s health record.
Method explained by counselor at group or individual education session, includes but not limited to: a. Method-specific instructions, apply selected RHFP RN protocol contraceptive method protocol as applicable b.

Referral education including planned procedure, pregnancy prevention prior to procedure, clinic location, and insurance coverage c. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.


Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking d. Determine appropriateness of quick start, review instructions in contraceptive method RN protocol for quick start and advise on the need for a pregnancy test just before starting second cycle of contraception (regardless of bleeding): i.
Use your first pill, ring, or patch the day of your appointment with your provider; regardless of where you are in your menstrual cycle.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 15 Division of Public Health ii.

Use condoms or another back up method of birth control for seven days after starting.

iii.

Repeat a pregnancy test just before starting the second cycle of contraception (include instructions on how to obtain pregnancy test at the clinic or home).

iv.
iv.

You may experience unexpected bleeding in the first 3 months of hormonal contraceptive use; continue taking your hormonal contraception even if unscheduled bleeding occurs.

Contact your clinician if unscheduled bleeding persists beyond the first 3 months of contraceptive use.

e. If client has simple migraines (without aura), RN should instruct client to monitor and report worsening of headaches (increased frequency or severity) or new onset focal neurologic symptoms and return to clinic if occurs.
i.

Client with new onset or worsening of migraines should be scheduled by the nurse for an appointment with MD, APNP, or PA. 3.

Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Discuss emergency contraception options and availability discussed.
d. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI screening.

e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox f. Provide information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.
g. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 16 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Combined Hormonal Contraception Effective Date: [Add Date] Definition and/or scope: [Clinic name] will provide combined hormonal contraception (CHC) to all clients who desire this method of birth control for their family planning needs.
Procedure: 1.

Subjective: a. Assess if contraceptive option selected by the client is a CHC option.

b. Assess if a starting a method, currently using and continuing a method, or switching a method.

c. Assess client medical history and non-contraceptive needs for CHC that may require provider referral.
d. Assess for contraindications to estrogen or progesterone per Summary Chart U.S. Medical Eligibility for Contraceptive Use, n.d. e. Assess for client preference of daily oral method, patch or monthly vaginal ring using shared decision making, client priorities and preferences.

f. Assess client preference for frequency of withdrawal bleeding/periods (monthly, less often, or never).
g. Assess potential risk of pregnancy and implement the RHFP RN Clinical Protocol for Pregnancy Testing and Counseling as needed.

h. Assess need for emergency contraception and implement the RHFP RN Clinical Protocol for Emergency Contraception (EC) as needed.

i.

Review current medications for interactions with the Classifications for Combined Hormonal Contraceptives | CDC, 2020: i. Rifampin or Rifabutin: Metabolism of some synthetic estrogens and progestins is increased by Rifampin or Rifabutin.
A reduction in contraceptive effectiveness and an increase in menstrual irregularities have been associated with Rifampin.

ii.

Anticonvulsants: Anticonvulsants such as phenobarbital, phenytoin, lamotrigine monotherapy, and carbamazepine have been shown to increase the metabolism of some synthetic estrogens and progestins which could result in a reduction of contraceptive effectiveness.

iii.

Antiretroviral (ARV) therapy: ARV drugs may increase or decrease the bioavailability of steroid hormones in CHCs.
If a client on ARV therapy decides to start or remain on CHCs, the consistent use of condoms is recommended to prevent HIV transmission and unwanted pregnancy.

When a combined oral contraceptive (COC) is chosen, a preparation containing a minimum of 30 mcg of estrogen should be used.

iv.

Antibiotics: Most broad-spectrum antibiotics do not affect the Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 17 Division of Public Health contraceptive effectiveness of COCs.
Pregnancy while taking oral contraceptives has been reported when the oral contraceptives were taken with antimicrobials such as ampicillin or tetracycline, etc.

v. Herbal products: Herbal products containing St. John’s Wort may induce hepatic enzymes and subsequently reduce the effectiveness of contraceptive steroids.

This may also result in breakthrough bleeding.

2.

Objective: a.

Review blood pressure history within the last 12 months, obtain and document vitals if client onsite.

i.
i.

Recommend client come to clinic for blood pressure if not obtained within the last 12 months.

b. Assess for urgent physical or mental distress.

3.

Assessment: a. Protocol applies, no MEC level 3 or 4 contraindications b. Protocol applies following consultation with MD, APNP, PA c. Protocol does not apply, refer to MD, APNP, PA 4.
Plan: a. Prescribe method for 1 year from formulary, attached Oral Contraceptive Pill (OCP), one tablet orally daily Or Vaginal ring, to be inserted into the vagina continuously for 21 days (3 weeks) and removed for 1 week (7 days).
Contraceptive patch, to be replaced weekly for 3 weeks or longer as directed, removed for no longer than 1 week (7 days) Or b. Prescribe or dispense 13 packs for 4 week-cycling, or up to 16 packs for continuous cycling Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 18 Division of Public Health c. Instruct on Quick Start Algorithm, n.d. initiation day of visit.

Quick start: 1.

Initiate birth control method at time of clinic visit 2.
Instruct client to return to clinic for pregnancy test, or complete a home pregnancy test, at the start of new pack or at least 3 weeks after quick start initiation.

a.

Document client education and ensure client verbalizes understanding of instructions b.

Schedule appointment for return visit to check pregnancy test c. If home pregnancy test is positive, instruct client to stop contraception and seek follow-up care at clinic.

3.
3.

Follow up pregnancy test is not needed if they meet any of the following criteria: a.

No unprotected intercourse since last menses b.

Has been using a reliable method consistently and correctly c. Within 7 days of normal menses d. Within 4 weeks postpartum, non-lactating e. Within first 7 days post abortion or miscarriage f. Fully breastfeeding with infant feeding at least once a night 4.
Postpartum clients should not use CHCs during the first 3 weeks after delivery (U.S. MEC 4) because of concerns about increased risk for venous thromboembolism and those who are breastfeeding generally should not use CHCs until after the fourth week postpartum (U.S. MEC 3) because of concerns about potential effects on breastfeeding performance.

Postpartum, breastfeeding clients with other risk factors for venous thromboembolism generally should not use CHCs 4–6 weeks after delivery (U.S. MEC 3).

i.
i.

If pregnancy cannot be reasonably ruled out or if abstinence and/or backup method (BUM) is unlikely to be used in first week following method start, instruct client to return to clinic (RTC) for pregnancy test in placebo week or first week following the start of the second pack.

Provide reassurance that if pregnant there is no health harm to the pregnancy or fetus and the only potential harm is if a pregnancy remains unconfirmed and pregnancy care is not initiated.
d. Document dispensed contraception as prescribed: i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.

Quantity dispensed v. Name of the delegating prescriber vi.

Date of original prescription vii.

Name of RN dispensing e. Instruct on BUM for 7 days for CHC start, switching methods and missed pills.

Refer to CDC - Combined Hormonal Contraceptives - US SPR - Reproductive Health, 2019 for best practice guidelines.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 19 Division of Public Health f. Instruct on continuous cycling option if desired and select monophasic pill, patch, or ring i.

Continuous Cycling: 1.

Oral contraceptives: a.

Any monophasic pill can be used for continuous cycling.

b.

Client will be advised to not use her placebo pills in her pack and to proceed to another pack of pills without a hormone free interval.
Extended cycles of 42, 63, 84 days are well tolerated and acceptable.

c. Advise client of the potential for unscheduled bleeding or spotting.

2.

Vaginal Ring: a.

The client will be instructed to keep the ring in for 4 weeks and then remove and reinsert a new ring on the same day.

Extended ring cycles of 56 or 84 days are well tolerated and acceptable.

b.

Advise client of the potential for unscheduled bleeding or spotting.

3.

Contraceptive Patch: a.

Instruct to use each patch for one week.


May extend cycles for 42, 63 or 84 days.

b.

May not be reimbursed by Medicaid.

c. Advise client of the potential for unscheduled g. Offer the following contraceptive supplies: bleeding or spotting.

iii.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

iv.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

5.
5.

Physician, APNP, PA management or consultation required during visit: a. MEC level 3 or 4 contraindications b.

Use of CHC to manage conditions other than acne, dysmenorrhea, cycle regulation with menses coming at least every 90 days c. Blood pressure >140/90 d. If a provider is unavailable, the RN should make a referral 6.

Nursing skills: a.

Skills: i.

Blood pressure ii.

Shared decision making and client-centered counseling iii.
Skill in interviewing and assessment of client reproductive planning goals and priorities iv.

Pregnancy risk assessment and indications for testing b.

Clinical content knowledge: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 20 Division of Public Health i. Pharmacology of contraceptive options ii.

CDC - Summary - USMEC - Reproductive Health, 2019 iii.
Contraceptive instructions on all methods, transitioning between methods, perfect use instructions, missed pill use recommendations, impact on efficacy and indications for back up methods per CDC - Summary - US SPR - Reproductive Health, 2019 iv.

Insurance impact on method coverage; skills to provide assistance with pharmacy benefits, prior authorization, Family Planning Only Services, 2014. v. ASCCP Management Guidelines Web Application, n.d. pap guidelines vi.
Indications for routine Immunization Schedules for Healthcare Professionals, 2019 vii.

CDC, 2021 STI Screening Recommendations and Considerations 7.

Follow-up: a.

The client should be encouraged to return to the clinic annually for contraceptive follow up and/or at any time to discuss side effects.

b.

At any routine visit, healthcare providers seeing CHC users should do the following: i.

Review the reproductive life plan.

ii.


Assess the client’s satisfaction with contraceptive method and whether the client has any concerns about method use.

iii.

Assess any changes in health status, including medications that would change the appropriateness of CHC for safe and effective continued use based on CDC - Summary - USMEC - Reproductive Health, 2019 (e.g., category 3 and 4 conditions and characteristics).

iv.

Review primary care or medical home status with all clients and refer as necessary.
v. Assess weight changes and counsel clients who are concerned about weight changes perceived to be associated with their contraceptive method.

c. Pregnancy test per RHFP RN Clinical Pregnancy Testing and Counseling, or home pregnancy test, if indicated for Quick Start.

8.

Referral to provider is required for: a.

Positive Pregnancy test with vaginal bleeding or pelvic pain b.
Urgent physical or mental distress c. Client with new onset or worsening of migraines d. Hypertension: After three separate visits blood pressure >140/90 9.

Links and resources: a.

Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use.

(n.d.).

https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us- medical-eligibility-criteria_508tagged.pdf b. Classifications for Combined Hormonal Contraceptives | CDC.

(2020, April 9).

Www.cdc.gov.


Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 21 Division of Public Health https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/appendix d.html c. Quick Start Algorithm.

(n.d.).

Reproductive Health Access Project.

https://www.reproductiveaccess.org/resource/quick-start-algorithm/ d. CDC – Combined Hormonal Contraceptives – US SPR – Reproductive Health.

(2019, October 6).

Www.cdc.gov.


https://cdc.gov/reproductivehealth/contraception/mmwr/spr/combined.html e. CDC – Summary – USMEC – Reproductive Health.

(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html f. CDC – Summary – US SPR – Reproductive Health.

(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html g. Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.


https://www.dhs.wisconsin.gov/fpos/index.htm h. ASCCP Management Guidelines Web Application.

(n.d.).

App.asccp.org.

i. https://app.asccp.org/ Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html j. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.


https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm k. Curtis, K.M., Tepper, N.K., Jatlaoui, T.C., Berry-Bibee, E., Horton, L.G., Zapata, L.B., Simmons, K.B., Pagano, H.P., Jamieson, D.J., & Whiteman, M.K.

(2006).

U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.

MMWR.

Recommendations and Reports, 65(3), 1-103. https://www.cdc.gov/mmwr/volumes/65/rr/rr6503a1.htm l. HPV vaccination recommendations: i.
Human Papillomavirus Vaccination.

(n.d.).

Www.acog.org.

https://www.acog.org/clinical/clinical-guidance/committee- opinion/articles/2020/08/human-papillomavirus-vaccination ii.

HPV Vaccine Recommendations.

(2019).

CDC.

https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html iii.

Final Recommendation Statement: Cervical Cancer: Screening | United States Preventive Services Taskforce.

(n.d.).

Www.uspreventiveservicestaskforce.org.


Retrieved December 14, 2022, from https://www.uspreventiveservicestaskforce.org/Page/Document/Recommenda tionStatementFinal/cervical-cancer-screening m. Be alert to VTE in hormonal contraceptive users | Contraceptive Technology.

(n.d.).

Contraceptivetechnology.org.


Retrieved December 14, 2022, from https://contraceptivetechnology.org/be-alert-to-vte-in-hormonal-contraceptive- users/#:~:text=Clinicians%20would%20be%20well%20advised%20to%20tell%20ne w n. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.


http://www.myplate.gov Approval– Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 22 Family Planning Health Screening and Education Division of Public Health 1.

Periodic Health screening completed annually or as indicated presenting concern: a.
Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: Education is to be documented in the client’s health record.

Method explained by counselor at group or individual education session; includes, but is not limited to: a.
Review method specific instructions and medication package insert and provide copy at client request.

b.

Review and document in encounter note education on BRAIDED: i.

Benefit of the method ii.

Risks of the method (contraceptive options) iii.

Alternatives to the method iv.

Inquiries about the method v. Decision to withdraw from method vi.

Explanation of use of the method vii.


Documentation c. Review and document in encounter note education on ACHES from Be Alert to VTE in Hormonal Contraceptive Users | Contraceptive Technology, n.d.: i. Abdominal pain (severe) ii.

Chest Pain (severe), cough, shortness of breath iii.

Headaches (severe or worsening) iv.


Eye Problems (vision loss or disturbance) v. Severe Leg Pain, swelling, or warmth d. Determine appropriateness of quick start, review instructions in contraceptive method RN protocol for quick start and advise on the need for a pregnancy test just before starting second cycle of contraception (regardless of bleeding): i.

Use your first pill, ring, or patch the day of your appointment with your provider; regardless of where you are in your menstrual cycle.

ii.
ii.

Use condoms or another back up method of birth control for seven days after starting.

iii.

Repeat a pregnancy test just before starting the second cycle of contraception (include instructions on how to obtain pregnancy test at the clinic or home).

iv.
iv.

You may experience unexpected bleeding in the first 3 months of hormonal contraceptive use; continue taking your hormonal Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 23 Division of Public Health contraception even if unscheduled bleeding occurs.

Contact your clinician if unscheduled bleeding persists beyond the first 3 months of contraceptive use.

e. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.
Emergency contraception iii.

Mechanism of action iv.

Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking f. Educate client about preconception health and future fertility.

Counsel on the use of condoms to reduce the risk of STI/HIV.
g. Educate client to return to clinic or visit the closest ER/Urgent Care if client experiences primary side effects or adverse effects h. If client has simple migraines (without aura), RN should instruct client to monitor and report worsening of headaches (increased frequency or severity) or new onset focal neurologic symptoms and return to clinic if occurs.

i.

Client with new onset or worsening of migraines should be scheduled by the nurse for an appointment with MD, APNP, or PA. 3.
Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Discuss emergency contraception options and availability.

d. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI Screening.
e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox f. Provide information and education regarding pregnancies at the request of the recipient, including prenatal counseling and referral.

g. Discuss availability of providers for further questions or problems.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 24 Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Division of Public Health Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 25 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Progestin-Only Pill Effective Date: [Add Date] Definition and/or scope: To provide progestin-only pill (POP), also known as mini pills, to all [clinic name] clients who desire this method of birth control for their family planning needs.
Procedure: 1.

Subjective: a. Assess if contraceptive option selected by the client is a progestin-only option.

b. Assess if starting a method, currently using, and continuing a method or switching a method.

c. Assess client medical history and non-contraceptive needs for hormonal contraception that may require provider referral.
d. Assess for contraindications to progestin-only pill (POP) per Summary Chart U.S. Medical Eligibility for Contraceptive Use, n.d.. e. Assess client preference for frequency of withdrawal bleeding/periods (monthly, less often, or never).

f. Assess potential risk of pregnancy and implement pregnancy testing RHFP RN Clinical Protocol for Pregnancy Testing as needed.

g. Assess need for emergency contraception and implement the RHFP RN Clinical Protocol for Emergency Contraception (EC) as needed.
h. Assess for clients who are breastfeeding; may initiate Progestin-only pill immediately.

i.

Review current medications for interactions with progestin-only pill per the Table C1.

Classifications for Progestin-Only Contraceptives | CDC, 2020.

2.

Objective: a.

Obtain and document vital signs if client is onsite.

i.

Recommend client come to clinic if not obtained within the last 12 months.

b. Assess for urgent physical or mental distress.

3.
3.

Assessment: a. Protocol applies, no MEC level 3 or 4 contraindications b. Protocol applies following consultation with MD, APNP, PA c. Protocol does not apply, refer to MD, APNP, PA Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 26 Division of Public Health 4.

Plan a. Prescribe method for 1 year from formulary, attached Oral Contraceptive progestin-only pill, one tablet orally daily i.

POPs are dispensed in packs of 28 active pills.


Norethindrone POP formulation is taken continuously, no pill free or non- hormonal pill week.

Drospirenone formulation consists of 24 hormonally active tablets followed by 4 inert tablets b.

Instruct on Quick Start Algorithm, n.d. Quick start: 1.

Initiate birth control method at time of clinic visit 2.
Instruct client to return to clinic for pregnancy test, or complete a home pregnancy test, at the start of new pack or at least 3 weeks after quick start initiation.

a.

Document client education and ensure client verbalizes understanding of instructions b.

Schedule appointment for return visit to check pregnancy test c. If home pregnancy test is positive, instruct client to stop contraception and seek follow-up care at clinic.

3.
3.

Follow up Pregnancy test is not needed if they meet any of the following criteria: a.

No unprotected intercourse since last menses b.

Has been using a reliable method consistently and correctly c. Within 7 days of normal menses d. Within 4 weeks postpartum, non-lactating e. Within first 7 days post abortion or miscarriage f. Fully breastfeeding with infant feeding at least once a night 4.
POPs can be started anytime, including immediately postpartum (U.S. MEC 2 if <1 month postpartum and US MEC 1 if > month postpartum) if it is reasonably sure that a client is not pregnant.

c. initiation day of visit.

i.

If pregnancy cannot be reasonably ruled out or if abstinence and/or backup method (BUM) is unlikely to be used in first 48 hours following POP method start, instruct client to return to clinic (RTC) for pregnancy test in first week following the start of the second pack.
Provide reassurance that if pregnant there is no health harm to the pregnancy or fetus and the only potential harm is if a pregnancy remains unconfirmed and pregnancy care is not initiated.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 27 Division of Public Health d. Document dispensed contraception as prescribed: i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.

Quantity dispensed v. Name of the delegating prescriber vi.
Date of original prescription vii.

Name of RN dispensing e. Instruct on BUM for 48 hours for POP start, switching methods and missed pills.

Refer to CDC - Progestin-Only Pills - US SPR - Reproductive Health, 2019 for best practice guidelines.

f. Instruct on the importance that the POP be taken at the same time each day due to the short duration of action and the short half-life.

g. Offer the following contraceptive supplies: i.


Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

5.

Physician, APNP, PA management or consultation required during visit: a. MEC level 3 or 4 contraindications b.

Use of POP when menstrual intervals > 3 months or to manage medical conditions other than dysmenorrhea.
c. If no provider available, RN may prescribe 3 months POP through shared decision-making as long as pregnancy has been reasonably ruled out.

If RN prescribes POP, referral to provider is required.

RN should follow up to ensure referral is completed.

6.

Nursing skills: a.

Skills: i.

Client education ii.

Shared decision making and client-centered counseling iii.

Skill in interviewing and assessment of client reproductive planning goals and priorities iv.
Pregnancy risk assessment and indications for testing b.

Clinical content knowledge: i. Pharmacology of contraceptive options ii.

CDC - Summary - USMEC - Reproductive Health, 2019 iii.

Contraceptive instructions on all methods, transitioning between methods, perfect use instructions, missed pill use recommendations, impact on efficacy and indications for back up methods per CDC - Summary - US SPR - Reproductive Health, 2019 iv.
Insurance impact on method coverage; skills to provide assistance with pharmacy benefits, prior authorization, Wisconsin Family Planning Only Services, 2014.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 28 Division of Public Health v. ASCCP Management Guidelines Web Application, n.d. pap guidelines vi.

Indications for routine Immunization Schedules for Healthcare Professionals, 2019 vii.

CDC, 2021 STI Screening Recommendations and Considerations 7.

Follow-up: a.
Follow-up: a.

The client should be encouraged to return to the clinic annually for contraceptive follow up and/or at any time to discuss side effects.

b.

At any routine visit health-care providers seeing POP users should do the following: i.

Review the reproductive life plan.

Assess the client’s satisfaction with their contraceptive method and whether the client has any concerns about method use.

ii.
ii.

Assess any changes in health status, including medications that would change the appropriateness of POPs for safe and effective continued use based on CDC - Summary - USMEC - Reproductive Health, 2019 (e.g., category 3 and 4 conditions and characteristics).

iii.

Review primary care or medical home status with all clients and refer as necessary.

iv.

Assess weight changes and counsel clients who are concerned about weight changes perceived to be associated with their contraceptive method.
c. If no provider available and RN prescribe 3 months POP through shared decision, referral to provider is required.

RN should follow up to ensure referral is completed by client.

d. Pregnancy test per RHFP RN Clinical Pregnancy Testing and Counseling, or home pregnancy test, if indicated for quick start.

8.

Referral to provider is required for: a.

Positive pregnancy test with vaginal bleeding or pelvic pain b.

Urgent medical or mental distress 9.

Links and resources: a.


Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use.

(n.d.).

https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us- medical-eligibility-criteria_508tagged.pdf b.

Table C1.

Classifications for Progestin-Only Contraceptives | CDC.

(2020, April 9).

Www.cdc.gov.

https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/appexdixc_tableC1 .html#mec_drug_interactions c. CDC – Progestin-Only Pills – US SPR – Reproductive Health.
(2019, October 6).

Www.cdc.gov.

https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/progestin.html d. CDC – Summary – USMEC – Reproductive Health.

(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html e. CDC – Summary – US SPR – Reproductive Health.

(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html f. Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.


https://www.dhs.wisconsin.gov/fpos/index.htm Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 29 Division of Public Health g. ASCCP Management Guidelines Web Application.

(n.d.).

App.asccp.org.

https://app.asccp.org/ h. HPV vaccination recommendations: i.

Human Papillomavirus Vaccination.

(n.d.).

Www.acog.org.

https://www.acog.org/clinical/clinical-guidance/committee- opinion/articles/2020/08/human-papillomavirus-vaccination ii.
HPV Vaccine Recommendations.

(2019).

CDC.

https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html iii.

Final Recommendation Statement: Cervical Cancer: Screening | United States Preventive Services Taskforce.

(n.d.).

Www.uspreventiveservicestaskforce.org.

Retrieved December 14, 2022, from https://www.uspreventiveservicestaskforce.org/Page/Document/Recommenda tionStatementFinal/cervical-cancer-screening i. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.


https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm j.

Quick Start Algorithm.

(n.d.).

Reproductive Health Access Project.

https://www.reproductiveaccess.org/resource/quick-start-algorithm/ k. Be alert to VTE in hormonal contraceptive users | Contraceptive Technology.

(n.d.).

Contraceptivetechnology.org.


Retrieved December 14, 2022, from https://contraceptivetechnology.org/be-alert-to-vte-in-hormonal-contraceptive- users/#:~:text=Clinicians%20would%20be%20well%20advised%20to%20tell%20ne w l. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.


http://www.myplate.gov Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: a.

Intimate partner violence, domestic violence, sexual assault b.
Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: Education is to be documented in the client’s health record.

Method explained by counselor at group or individual education session; includes, but is not limited to: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 30 Division of Public Health a.
Review method specific instructions and package insert and provide copy at client request.

b.

Review and document in encounter note education on BRAIDED: i.

Benefit of the method ii.

Risks of the method (contraceptive options) iii.

Alternatives to the method iv.

Inquiries about the method v. Decision to withdraw from method vi.

Explanation of use of the method vii.


Documentation c. Review and document in encounter note education on ACHES from Be Alert to VTE in Hormonal Contraceptive Users | Contraceptive Technology, n.d.: i. Abdominal pain (severe) ii.

Chest Pain (severe), cough, shortness of breath iii.

Headaches (severe or worsening) iv.

Eye Problems (vision loss or disturbance) v. Severe Leg Pain, swelling, or warmth d. Refer to appropriate client education handout and provide copy to client.
e. Educate clients that hormonal contraception can be continued until the age of menopause in healthy, nonsmoking, normal-weight clients f. Educate client about preconception health and future fertility.

Counsel on the use of condoms to reduce the risk of STI and HIV.

g. Educate client about primary side effects of Minipill-Progestin Only Pills (POP): i. Irregular bleeding ii.
Amenorrhea h. Educate client to return to clinic or visit the closest ER or Urgent Care if they experience primary side effects or adverse effects i.

Instruct on the importance that POP be taken at the same time each day, a dose is considered missed if it has been >3 hours since it should have been taken.

j.

Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.


Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.

Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 31 Division of Public Health b.
Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Emergency contraception options and availability discussed.

d. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI screening.

e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.


Monkeypox f. Information and education regarding pregnancies at the request of the recipient, including prenatal counseling and referral.

g. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 32 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Progestin-Only Injectable Contraceptive Effective Date: [Add Date] Definition and/or scope: To provide progestin-only injectable medroxyprogesterone acetate (MPA), also known as DMPA, to all [clinic name] clients who desire this method of birth control for their family planning needs.
Procedure: 1.

Subjective: a. Assess if contraceptive option selected by the client is a progestin-only option.

b. Assess if a starting a method, currently using, and continuing a method or switching a method.

c. Assess client medical history and non-contraceptive needs for hormonal contraception that may require provider referral.
d. Assess for client preference of progestin-only injection options including intramuscular or subcutaneous route (Curtis et al., 2021) using shared decision making, client priorities and preferences.

e. Assess for contraindications to progestin-only injectable contraception, DMPA per Summary Chart U.S. Medical Eligibility for Contraceptive Use, n.d. f. Assess client preference for frequency of withdrawal bleeding and/or periods (monthly, less often, or never).
g. Assess potential risk of pregnancy and implement the RHFP RN Clinical Protocol for Pregnancy Testing and Counseling as needed.

h. Assess need for emergency contraception and implement the RHFP RN Clinical Protocol for Emergency Contraception (EC) as needed.

i.

Review current medications for interactions with progestin-only injection per the Table C1.

Classifications for Progestin-Only Contraceptives | CDC, 2020 2.

Objective: a.
Objective: a.

Review blood pressure history within the last 12 months, obtain and document blood pressure if client onsite.

i.

Recommend client come to clinic for blood pressure if not obtained within the last 12 months.

b. Assess for urgent physical or mental distress.

3.
3.

Assessment: a. Protocol applies, no MEC level 3 or 4 contraindications b. Protocol applies following consultation with MD, APNP, PA c. Protocol does not apply, refer to MD, APNP, PA Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 33 4.
Plan: a. Prescribe method for 1 year from formulary, attached Division of Public Health Intramuscular (IM) route: DMPA 150mg intramuscular (IM) every 3 months (13 weeks) Or Subcutaneous (SC) route: DMPA 104mg subcutaneous (SC) every 3 months (13 weeks) b.

Timing of Initiation Injectable i.

The first DMPA injection can be given at any time if it is reasonably certain that the person is not pregnant.

ii.

Need for Back-Up Contraception b.


If DMPA is started within the first 7 days since menstrual bleeding started, no additional contraceptive protection is needed.

b.

If DMPA is started >7 days since menstrual bleeding started, the person needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days.

iii.

Reference CDC - Injectables - US SPR - Reproductive Health, 2021 for additional initiation timing.
c. Timing of Repeat Injections i. Reinjection Interval - Provide repeat DMPA injections every 3 months (13 weeks).

ii.

Special Considerations iii.

Early Injection - The repeat DMPA injection can be given early when necessary.

iv.

Late Injection c. The repeat DMPA injection can be given up to 2 weeks late (15 weeks from the last injection) without requiring additional contraceptive protection.
c. If the person is >2 weeks late (>15 weeks from the last injection) for a repeat DMPA injection, they can have the injection if it is reasonably certain that she is not pregnant.

They need to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days.

They might consider the use of emergency contraception (with the exception of UPA) if appropriate.

d. Instruct on Quick Start Algorithm, n.d. initiation day of visit.

i.
i.

If pregnancy cannot be reasonably ruled out or if abstinence and/or backup method (BUM) is unlikely to be used in first week following method start, instruct client to RTC for pregnancy test in 2-4 weeks following the initial injection.

Provide reassurance that if pregnant there is no health harm to the pregnancy or fetus and the only potential harm is if a pregnancy remains unconfirmed and pregnancy care is not initiated.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 34 Division of Public Health Quick start: 1.

Initiate birth control method at time of clinic visit 2.

Instruct client to return to clinic for pregnancy test, or complete a home pregnancy test, at the start of new pack or at least 3 weeks after quick start initiation.

a.

Document client education and ensure client verbalizes understanding of instructions b.
Schedule appointment for return visit to check pregnancy test c. If home pregnancy test is positive, instruct client to stop contraception and seek follow-up care at clinic.

3.

Follow up Pregnancy test is not needed if they meet any of the following criteria: a.

No unprotected intercourse since last menses b.


Has been using a reliable method consistently and correctly c. Within 7 days of normal menses d. Within 4 weeks postpartum, non-lactating e. Within first 7 days post abortion or miscarriage f. Fully breastfeeding with infant feeding at least once a night 4.

Postpartum clients can be given DMPA injection at any time, including immediately postpartum (US MEC 2 if <1 month postpartum and US MEC 1 if > 1 month postpartum).
e. Document injection site and rotate site.

f. Document dispensed medication as prescribed by the licensed provider.

i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.

Quantity dispensed v. Name of the delegating prescriber vi.

Date of original prescription vii.

Name of RN dispensing g. Instruct on BUM for 7 days for DMPA start, switching methods and late injections.

Refer to CDC - Injectables - US SPR - Reproductive Health, 2019, for best practice guidelines.
h. Instruct on the reinjection interval with education on late injection (15 weeks from the last injection), schedule appointment for return visit for re-injection or refer to RHFP RN Protocol for Medication Pickup for self-administered DMPA-SC method.

i.

Instruct on self-administration, proper disposal of needles and re- injection time frame if client will be prescribed subcutaneous DMPA.

j. Instruction and counseling on potential menstrual changes including unpredictable bleeding and spotting.
The frequency and duration of unscheduled bleeding may decrease over time.

Amenorrhea becomes increasing prevalent with longer use of progestin-only injectable contraception.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 35 Division of Public Health i. Amenorrhea does not require any medical treatment.

If bleeding pattern is unacceptable, counsel on alternative methods of contraception.

k. Offer the following contraceptive supplies: i.


Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

7.

Physician, APNP, PA management or consultation required during visit: a. MEC level 3 or 4 contraindications b.
Client request for management options of unscheduled bleeding pattern c. Unable to rule out pregnancy d. Client presents for re-injection earlier than 11 weeks or greater than 15 weeks after last injection e. If client has been on DMPA > 2 years, consult for conversation regarding bone density f. If clinically indicated, consider referral for underlying gynecologic problem such as medication interactions, an STI, pregnancy, or new pathologic uterine conditions.
Note: If a provider is unavailable, the RN should make a referral.

8.

Nursing skills: a.

Skills: i.

Blood pressure ii.

Client education iii.

Shared decision-making and client-centered counseling iv.

Skill in interviewing and assessment of client reproductive planning goals and priorities v. Pregnancy risk assessment and indications for testing b.

Clinical content knowledge: i. Pharmacology of contraceptive options ii.

CDC - Summary - USMEC - Reproductive Health, 2019 iii.
Contraceptive instructions on all methods, transitioning between methods, perfect use instructions, timing of subsequent injection, impact on efficacy and indications for back up methods per CDC - Summary - US SPR - Reproductive Health, 2019 iv.

Insurance impact on method coverage; skills to provide assistance with pharmacy benefits, prior authorization, Wisconsin Family Planning Only Services, 2014. v. ASCCP Management Guidelines Web Application, n.d. pap guidelines vi.
Indications for routine Immunization Schedules for Healthcare Professionals, 2019 Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 36 vii.

CDC, 2021 STI Screening Recommendations and Considerations Division of Public Health 10.

Follow-up: a.

The client should be encouraged to return to the clinic annually for contraceptive follow up and/or at any time to discuss side effects.

b.

At any routine visit health care providers seeing DMPA users should do the following: i.
Review the reproductive life plan.

Assess the client’s satisfaction with their contraceptive method and whether the client has any concerns about method use.

ii.

Assess any changes in health status, including medications that would change the appropriateness of DMPA for safe and effective continued use based on CDC - Summary - USMEC - Reproductive Health, 2019 (e.g., category 3 and 4 conditions and characteristics).

iii.
iii.

Review primary care or medical home status with all clients and refer as necessary.

iv.

Assess weight changes and counsel clients who are concerned about weight changes perceived to be associated with their contraceptive method.

c. Return to clinic for next injection and at any time to discuss side effects or other problems, and if they want to change the method being used.

d. Pregnancy test per RHFP RN Clinical Pregnancy Testing and Counseling if indicated for Quick Start.

11.
11.

Referral to provider is required for: a.

Positive Pregnancy test with vaginal bleeding or pelvic pain b.

Urgent mental or physical distress c. Hypertension: After three separate visits blood pressure >140/90 12.

Links and resources: a. Curtis, K.M., Nguyen, A., Reeves, J.A., Clark, E.A., Folger, S.G., & Whiteman, M.K.

(2021).

Update to U.S.

Selected Practice Recommendations for Contraceptive Use: Self-Administration of Subcutaneous Depot Medroxyprogesterone Acetat.

MMWR.
MMWR.

Morbidity and Mortality Weekly Report, 70(20), 739-743. https://doi.org/10.15585/mmwr.mm7020a2 b.

Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use.

(n.d.).

https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us- medical-eligibility-criteria_508tagged.pdf c. CDC – Progestin-Only Pills – US SPR – Reproductive Health.

(2019, October 6).

Www.cdc.gov.


https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/progestin.html d. CDC – Injectables – US SPR – Reproductive Health.

(2021, May 20).

Www.cdc.gov.

https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/injectables.html#ini t e. Quick Start Algorithm.

(n.d.).

Reproductive Health Access Project.

https://www.reproductiveaccess.org/resource/quick-start-algorithm/ f. CDC – Summary – USMEC – Reproductive Health.

(2019).
(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 37 Division of Public Health g. CDC – Summary – US SPR – Reproductive Health.

(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html h. Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/fpos/index.htm i. ASCCP Management Guidelines Web Application.
(n.d.).

App.asccp.org.

j. https://app.asccp.org/ Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html k. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm l. Curtis, K.M., Nguyen, A., Reeves, J.A., Clark, E.A., Folger, S.G., & Whiteman, M.K.

(2021).

Update to U.S.


Selected Practice Recommendations for Contraceptive Use: Self-Administration of Subcutaneous Depot Medroxyprogesterone Acetate.

MMWR.

Morbidity and Mortality Weekly Report, 70(20), 739-743. https://doi.org/10.15585/mmwr.mm7020a2 m. HPV vaccination recommendations: i.

Human Papillomavirus Vaccination.

(n.d.).

Www.acog.org.

https://www.acog.org/clinical/clinical-guidance/committee- opinion/articles/2020/08/human-papillomavirus-vaccination ii.

HPV Vaccine Recommendations.


(2019).

CDC.

https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html iii.

Final Recommendation Statement: Cervical Cancer: Screening | United States Preventive Services Taskforce.

(n.d.).

Www.uspreventiveservicestaskforce.org.


Retrieved December 14, 2022, from https://www.uspreventiveservicestaskforce.org/Page/Document/Recommenda tionStatementFinal/cervical-cancer-screening n. Final Recommendation Statement: Cervical Cancer: Screening | United States Preventive Services Taskforce.

(n.d.).

Www.uspreventiveservicestaskforce.org.

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStat ementFinal/cervical-cancer-screening o.
Be alert to VTE in hormonal contraceptive users | Contraceptive Technology.

(n.d.).

Contraceptivetechnology.org.

Retrieved December 14, 2022, from https://contraceptivetechnology.org/be-alert-to-vte-in-hormonal-contraceptive- users/#:~:text=Clinicians%20would%20be%20well%20advised%20to%20tell%20ne w p. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.


http://www.myplate.gov Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: a.

Intimate partner violence, domestic violence, sexual assault b.
Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 38 Division of Public Health d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: Education is to be documented in the client’s health record.

Method explained by counselor at group or individual education session; includes, but is not limited to: a.
Review method-specific instructions and package insert and provide copy at client request b.

Review and document in encounter note education on BRAIDED: i.

Benefit of the method ii.

Risks of the method (contraceptive options) iii.

Alternatives to the method iv.

Inquiries about the method v. Decision to withdraw from method vi.

Explanation of use of the method vii.


Documentation c. Review and document in encounter note education on ACHES from Be Alert to VTE in Hormonal Contraceptive Users | Contraceptive Technology, n.d.: i. Abdominal pain (severe) ii.

Chest Pain (severe), cough, shortness of breath iii.

Headaches (severe or worsening) iv.


Eye Problems (vision loss or disturbance) v. Severe Leg Pain, swelling, or warmth d. Educate client on adequate calcium intake from foods or a calcium and/or vitamin D supplement daily, regular exercise, avoiding alcohol, and excessive intake of sodas and caffeine.

e. Educate clients that hormonal contraception can be continued until the age of menopause in nonsmoking, healthy-weight clients with no contraindications.
f. Educate client about preconception health and future fertility.

Counsel on the use of condoms to reduce the risk of STI and HIV.

g. Return of fertility: Generally, fertility returns 4 months to 10 months from the last injection but may take as long as 18 months.

If pregnancy is desired in the next one to two years, have a discussion with about prolonged return to fertility and alternative contraceptive options, if necessary.
h. Educate client about primary side effects of DMPA: i. Irregular bleeding ii.

Amenorrhea h. Educate client to return to clinic or visit the closest ER or Urgent Care if they experience primary side effects or adverse effects i.

Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 39 Division of Public Health iii.

Mechanism of action iv.


Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.

Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Emergency contraception options and availability discussed.
d. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI Screening.

e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox f. Information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.
g. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 40 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Internal Condom Effective Date: [Add Date] Definition and/or scope: Clients seeking medical care at, [clinic name] will be given internal (receptive) condoms at their request.
Procedure: 1.

Subjective: a. Assess for history of allergy to any component of the condom in client or partner.

2.

Objective: a. Assess for vaginal abnormalities which preclude use of condom (vaginal septum, cervical anomalies) and refer as appropriate.

b.

Review blood pressure history within the last 12 months and obtain and document vitals if client onsite.

i.

Recommend client come to clinic for blood pressure if not obtained with the last 12 months.
c. Assess for urgent physical and mental distress.

3.

Assessment: a. Protocol applies b. Protocol applies following consultation with MD, APNP, PA c. Protocol does not apply, refer to MD, APNP, PA 4.

Plan: a. Prescribe internal condoms as needed for 1 year.

b.

Document dispensed contraception as prescribed: i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.

Quantity dispensed v. Name of the delegating prescriber vi.

Date of original prescription vii.


Name of RN dispensing c. Provide client with condoms and education on correct use according to manufacturer’s instructions.

d. Offer emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 41 Division of Public Health 5.

Physician, APNP, PA management or consultation required during visit: a.

Signs or symptoms of STI that require further assessment b. Pregnancy 6.
Nursing skills: a.

Skills: i.

Client interviewing ii.

Client education b.

Clinical contact knowledge: i.

Condom Effectiveness, 2019 ii.

Contraceptive instructions on all methods, transitioning between methods, perfect use instructions, missed pill use recommendations, impact on efficacy and indications for back up methods per CDC - Summary - US SPR - Reproductive Health, 2019 iii.
Insurance impact on method coverage; skills to provide assistance with pharmacy benefits, prior authorization, Wisconsin Family Planning Only Services, 2014. iv.

Risk based STI screening recommendations outlined by the CDC, 2021 7.

Follow-up: a.

Encourage client to schedule routine annual wellness visit 8.

Referral to provider is required for: a. Pregnancy b.

Urgent physical or mental distress 9.

Links and resources: a.

Condom Effectiveness.

(2019).


https://www.cdc.gov/condomeffectiveness/index.html b. Hatcher, R.A. (2018).

Contraceptive technology.

Ayer Company Publishers, Inc. c. CDC – Summary – US SPR – Reproductive Health.

(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html d. Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/fpos/index.htm e. CDC.

(2021, August 12).

STI Screening Recommendations.


Www.cdc.gov.

f. https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html g. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.


http://www.myplate.gov Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 42 Division of Public Health Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: a.
Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: a.

Review correct use of condoms.

Review efficacy rates (typical use has 21% failure rate in first year).

b.

Stress that internal condom cannot be used with external latex condom, and internal condoms are not reusable.
c. Educate client to check the condom for visible damage, such as holes, before and after intercourse.

Condoms in damaged packages or that show obvious signs of deterioration (e.g., brittleness, stickiness or discoloration) should never be used.

d. Educate client if they do not use a condom or if the condom tears, leaks, breaks, or falls out: i.

Do not douche.

ii.

Wash genitals with soap and water immediately after intercourse to reduce the risk of acquiring a sexually transmitted infection (STI).
iii.

Insert an applicator full of spermicide into the vagina as soon as possible.

iv.

Emergency contraception may be used to prevent pregnancy if started up to 120 hours (5 days) after having unprotected intercourse but works best the sooner it is started.

v. Contact your health care provider as soon as you can.
e. Educate client that natural membrane condoms (or “lambskin” condoms) may permit the passage of viruses, including hepatitis B virus, herpes simplex virus, and HIV and many not provide the same level of protection against STIs.

f. Educate client that latex and synthetic condoms can also be used during anogenital and orogenital intercourse to reduce the risk of STIs, including HIV (though, to date, the FDA has not officially cleared any condoms for such use).
g. Encourage clients to use condoms consistently and correctly with every act of anal, vaginal, and oral intercourse.

h. Review safer sex education, as appropriate.

i.

Review STI risk reduction plan, as appropriate.

j.

Other instruction: i. Dual protection (benefits of using condoms with other preventative method) Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 43 Division of Public Health ii.

Emergency contraception iii.

Mechanism of action iv.


Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.

Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Discuss emergency contraception options and availability discussed.
d. Assess STI screening needs and offer screening following RHFP RN Clinical Protocol for Asymptomatic STI Screening.

e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox f. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 44 Division of Public Health [Clinic Name] Reproductive Health RN Protocol External Condom Effective Date: [Add Date] Definition and/or scope: Clients seeking medical care at, [clinic name] will be given external (receptive) condoms at their request.
Procedure: 1.

Subjective: a. Assess for history of allergy to any component of the condom in client or partner.

2.

Objective: a. Assess for penile abnormalities which preclude use of condom (erectile dysfunction) and refer as appropriate.

b.

Review blood pressure history within the last 12 months and obtain and document vitals if client onsite.

i.

Recommend client come to clinic for blood pressure if not obtained with the last 12 months.

c. Assess for urgent physical and mental distress.

3.
3.

Assessment: a. Protocol applies b. Protocol applies following consultation with MD, APNP, PA c. Protocol does not apply, refer to MD, APNP, PA 4.

Plan: a. Prescribe external condoms as needed for 1 year.

b.

Document dispensed contraception as prescribed: i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.

Quantity dispensed v. Name of the delegating prescriber vi.

Date of original prescription vii.


Name of RN dispensing c. Provide client with condoms and education on correct use according to manufacturer’s instructions.

d. Offer emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

5.

Physician, APNP, PA management or consultation required during visit: a.

Signs or symptoms of STI that require further assessment.

b. Pregnancy Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 45 Division of Public Health 6.
Nursing skills: a.

Skills: i.

Client interviewing ii.

Client education b.

Clinical contact knowledge: i.

Condom Effectiveness, 2019 ii.

Contraceptive instructions on all methods, transitioning between methods, perfect use instructions, missed pill use recommendations, impact on efficacy and indications for back up methods per CDC - Summary - US SPR - Reproductive Health, 2019 iii.
Insurance impact on method coverage; skills to provide assistance with pharmacy benefits, prior authorization, Wisconsin Family Planning Only Services, 2014. iv.

Risk based STI screening recommendations outlined by the CDC, 2021 7.

Follow-up: a.

Encourage client to schedule routine annual wellness visit.

8.

Referral to provider is required for: a. Pregnancy b.

Urgent physical or mental distress 9.

Links and resources: a.

Condom Effectiveness.

(2019).


https://www.cdc.gov/condomeffectiveness/index.html b. Hatcher, R.A. (2018).

Contraceptive technology.

Ayer Company Publishers, Inc. c. CDC – Summary – US SPR – Reproductive Health.

(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html d. Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/fpos/index.htm e. CDC.

(2021, August 12).

STI Screening Recommendations.


Www.cdc.gov.

f. https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html g. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.


http://www.myplate.gov Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 46 Division of Public Health Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: a.
Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: a.

Review correct use of condoms.

Review efficacy rates (about 13 of every 100 couples using condoms for contraception will become pregnant during the first year of typical use).

b.
b.

Stress that external condom cannot be used with another external latex condom or internal condom.

External condoms are not reusable.

c. Educate client not to use Vaseline or any oil-based lubricants with latex condoms, as these products may weaken the condoms and lead to breakage.

Client may want to use contraceptive spermicide if additional lubrication is needed.

d. Educate client to check the condom for visible damage, such as holes, before and after intercourse.
Condoms in damaged packages or that show obvious signs of deterioration (e.g., brittleness, stickiness or discoloration) should never be used.

e. Educate client if they do not use a condom or if the condom tears, leaks, breaks, or falls off: i.

Do not douche.

ii.

Wash genitals with soap and water immediately after intercourse to reduce the risk of acquiring a sexually transmitted infection (STI).

iii.

Insert an applicator full of spermicide into the vagina as soon as possible.

iv.
iv.

Emergency contraception may be used to prevent pregnancy if started up to 120 hours (5 days) after having unprotected intercourse but works best the sooner it is started.

v. Contact your health care provider as soon as you can.

f. Educate client that unlike latex condoms, natural membrane condoms (or “lambskin” condoms) may permit the passage of viruses, including hepatitis B virus, herpes simplex virus, and HIV and many not provide the same level of protection against STIs as latex condoms.
g. Educate client that latex and synthetic condoms can also be used during anogenital and orogenital intercourse to reduce the risk of STIs, including HIV (though, to date, the FDA has not officially cleared any condoms for such use).

h. Encourage clients to use condoms consistently and correctly with every act of anal, vaginal, and oral intercourse.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 47 Division of Public Health i.

Review safer sex education, as appropriate.

j.


Review STI risk reduction plan, as appropriate.

k. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.

Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.


Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Discuss emergency contraception options and availability discussed.

d. Assess STI screening needs and offer screening following RHFP RN Clinical Protocol for Asymptomatic STI Screening.
e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox f. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 48 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Fertility Awareness Based Method Effective Date: [Add Date] Definition and/or scope: Fertility Awareness Based Methods (FABM) are methods for avoiding or achieving pregnancy that require clients to monitor their fertility indicators and identify the fertile days of the menstrual cycle.
FABMs should be used in conjunction with abstinence or barrier methods during the fertile days.

Procedure: 1.

Subjective: a. Assess client’s goals for contraception start or continuation using client-centered counseling and shared decision-making.

b.

Completion of a comprehensive health history and assessment including: i.

Reproductive life plan (PATH model) or other client-centered counseling technique ii.

Contraceptive history iii.

Sexual history c. Assess for client readiness for FABM: i.
Strength of desire to prevent or achieve pregnancy (PATH model).

If client reports strong desire to prevent pregnancy, counsel appropriately on risks and benefits of FABM.

ii.

Ability and willingness to track detailed, sometimes complex information consistently and reliably over time iii.
Relationship and/or sexual partner(s) that empowers client to abstain from intercourse during periods of fertility or to use backup method during fertile window d. Assess current medications e. Assess for special health considerations that necessitate follow-up and/or counseling on alternative method: i. Amenorrhea ii.

Irregular menstrual cycles e. Menstrual irregularities are common during the post menarche and perimenopausal periods iii.

Unexplained vaginal bleeding iv.


<6 months postpartum v. Post abortion without the return of menses vi.

Menstrual cycle less than 22 days or greater than 42 days in length vii.

Strong desire for pregnancy prevention viii.

Diseases that place client at very high risk for adverse health outcomes for pregnant person and/or fetus if unplanned pregnancy were to occur ix.

Sexual coercion or IPV Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 49 Division of Public Health x.
Current untreated chlamydia, gonorrhea, mucopurulent cervicitis, or pelvic inflammatory disease (PID) xi.

Use of drugs that affect cycle regularity, hormones, and/or fertility signs xii.

Diseases that elevate body temperature 2.

Objective: a.

Obtain and document vital signs if client on site.

i.

Recommend client come to clinic if not obtained within the last 12 months.

b. Assess for urgent physical or mental distress.

3.
3.

Assessment: a. Protocol applies b. Protocol applies following consultation with MD, APNP, PA c. Protocol does not apply, refer to MD, APNP, PA 4.

Plan: a.

Educate client on menstrual cycle and hormonal changes, including difference between fertile and non-fertile window (See Fertility Awareness-Based Methods Fertility Indicator Concepts and Counseling Points, n.d. Job Aid) b.
Ensure client understands that, if pregnancy prevention is desired, they must either: i. Abstain from intercourse on fertile days ii.

Use barrier or other method on fertile days c. Educate client on observable fertility signs (“biomarkers”) i. Cervical fluid ii.

Basal body temperature iii.

Day of menstrual cycle iv.

Urinary hormone detection v. Cervical Position d. Review categories and methods for FABM with client.
Using shared decision making, assist client in selecting method that works best for them.

(For information on methods for FABM, see Addendum A - Considerations for Selecting FABM).

e. Provide education on selected method f. Review benefits of daily supplementation with 400 mcg to 800 mcg folic acid to prevent neural tube defects if pregnancy occurs.

i.
i.

Encourage daily supplementation with folic acid 400 mcg to 800mcg or prenatal vitamin, the later preferred if planning pregnancy in next 3 months or breastfeeding.

g. Prescribe, if applicable, for 1 year Folic Acid 400 mcg orally daily Quantity: 90 Refill: 3 Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 50 Division of Public Health h. Document medication as prescribed i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.


Quantity dispensed v. Name of the delegating prescriber vi.

Date of original prescription vii.

Name of RN dispensing i.

Offer the following contraceptive supplies: i.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

5.
Physician, APNP, PA management or consultation required during visit: a. Amenorrhea or oligomenorrhea for medical workup to rule out underlying cause b. Unexplained vaginal bleeding c. Diseases that place client at very high risk for adverse health outcomes for pregnant person and/or fetus if unplanned pregnancy were to occur d. Current untreated mucopurulent cervicitis or PID (pelvic inflammatory disease) (For chlamydia and/or gonorrhea, RN may reference relevant protocol) Note: If a provider is unavailable, the RN should make a referral.
6.

Nursing skills: a.

Skills: i.

Interviewing and physical exam ii.

Client education and teaching b.

Knowledge: i.

Fertility Based Awareness Methods ii.

There is quite a bit of information to learn for each method of FABM.

Nurses teaching FABM should have a solid overarching understanding of the differences between the methods and familiarize themselves with more in-depth information as appropriate and needed for their client population.

7.

Follow-up: a.
7.

Follow-up: a.

Client should return in 1-3 months to assess FABM tracking b. Assess any difficulties with the FABM method and/or charting c. Assess need for backup method, and provide if necessary 8.

Referral to provider is required for: a. Pregnancy b.

Urgent mental or physical distress Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 51 9.

Links and resources: Division of Public Health a.

Fertility Awareness-Based Methods Fertility Indicator Concepts and Counseling Points.
(n.d.).

Retrieved December 14, 2022, from https://rhntc.org/sites/default/files/resources/RHNTC_FABM_JobAid_2021-03- 31.pdf?_sm_au_=iVVVRsk3b2SRnvqQBLQtvK7BJGKjp b. CDC – Fertility Awareness-Based Methods – USMEC – Reproductive Health.

(2019, June 20).

Www.cdc.gov.

https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/appendixf.html c. CDC – Standard Days Method – US SPR – Reproductive Health.

(2019, January 16).

Www.cdc.gov.


https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/days.html d. Appendix H. (n.d.).

Www.cdc.gov.

Retrieved December 14, 2022, from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr59e0528a9.htm e. Information for Healthcare Professionals.

(2020, September 1).

Natural Cycles.

https://www.naturalcycles.com/hcp?_sm_au_=iVVvvQLQZ212Sv3HBLQtvK7BJGKjp f. Clue: Period and Ovulation Tracker for iPhone and Android.

(n.d.).

Helloclue.com.


Retrieved December 14, 2022, from https://helloclue.com/?_sm_au_=iVVvvQLQZ212Sv3HBLQtvK7BJGKjp g. Natural Family Planning and Birth Control | CycleBeads.

(n.d.).

Cyclebeads_NEW.

Retrieved December 14, 2022, from https://www.cyclebeads.com/?_sm_au_=iVVvvQLQZ212Sv3HBLQtvK7BJGKjp h. TwoDay Method – Institute for Reproductive Health.

(2022, April 27).

Institute for Reproductive Health.


https://irh.org/twoday- method/?_sm_au_=iVVvvQLQZ212Sv3HBLQtvK7BJGKjp i. Coding with Ann: Coding for Fertility Awareness-Based Methods – Episode 10 | Reproductive Health National Training Center.

(n.d.) Rhntc.org.

Retrieved December 14, 2022, from https://rhntc.org/resources/coding-ann-coding-fertility-awareness- based-methods-episode-10 j.

Fertility Awareness Methods Webinar.

(n.d.).

Hcet.org.
(n.d.).

Hcet.org.

Retrieved December 14, 2022, from https://www.youtube.com/watch?v=AhEWxaJZWA0&feature=youtu.be k. Understanding and Counseling Potential Users on Fertility Awareness-Based Methods for Pregnancy Prevention Webinar | Reproductive Health National Training Center.

(n.d.).

Rhntc.org.
(n.d.).

Rhntc.org.

Retrieved December 14, 2022, from https://rhntc.org/resources/understanding-and-counseling-potential-users-fertility- awareness-based-methods-pregnancy l. Effectiveness of FABMs for Pregnancy Prevention Webinar | Reproductive Health National Training Center.

(n.d.).

Rhntc.org.

Retrieved December 14, 2022, from https://rhntc.org/resources/effectiveness-fabms-pregnancy-prevention-webinar m. Fertility Apps: A New Approach to FABMs Webinar | Reproductive Health National Training Center.
(n.d.).

Rhntc.org.

Retrieved December 14, 2022, from https://rhntc.org/resources/fertility-apps-new-approach-fabms-webinar n. Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html o. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.


http://www.myplate.gov Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 52 Division of Public Health Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: a.
Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: Education is to be documented in the client’s health record.

Method explained by counselor at group or individual education session, includes, but is not limited to: a.

If a client screens positive for contraindications: i.
Explanation that method use poses risk for failure and unintended pregnancy ii.

Facilitate discussion related to alternate contraceptive method b.

Educate on failure rates of FABMs, and counsel about perfect vs. imperfect use of FABMs c. Encourage development of a support system i.

Partner(s) ii.

Clinical provider iii.

Educator iv.

Community resources d. Encourage patience, practice, and persistence e. Review BRAIDED: i.

Benefit of the method ii.

Risks of the method (contraceptive options) iii.


Alternatives to the method iv.

Inquiries about the method v. Decision to withdraw from method vi.

Explanation of use of the method vii.

Documentation f. Educate client about preconception health and future fertility.

Counsel on the use of condoms to reduce the risk of STI and HIV.

g. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.


Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 53 Division of Public Health 3.

Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.
b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Emergency contraception options and availability discussed.

d. Assess STI screening needs and offer screening following asymptomatic STI Screening RN Protocol guidelines.

e. Review Immunization Schedules for Healthcare Professionals, 2019 but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox f. Discuss availability of providers for further questions or problems.
g. Information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 54 Please see Fertility Awareness-Based Methods: Fertility Indicator Concepts and Counseling Points Job Aid, n.d. for the most up to date resource.
Division of Public Health Last updated 12/2022 Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 55 Division of Public Health Potential questions to ask client when counseling on choice of FABM: 1) Are you able negotiate with and communicate with your partner(s) and avoid unprotected intercourse on certain days?

a) If no, recommend against FABM for avoiding pregnancy until this improves.

2) How long do you plan to avoid pregnancy?


a) If <6 months, may be interested in a method that is quick to learn, less costly (though possibly less effective or versatile) like standard days, Two Day method, Clue Birth Control.

3) Do you want a method that will help you conceive eventually?

a) Consider a method that helps pinpoint the days of highest fertility like Billings Ovulation, symptothermal, or symptohormonal.

4) Are you breastfeeding or postpartum without the return of normal cycles?
a) Billings, Sensiplan, and Marquette can be used.

Should consult with an experienced teacher.

b) Caution: very little effectiveness data for this group 5) Do you have an irregular sleep/work/travel schedule?

a) Basal body temperature method and symptothermal may be difficult to use.

b) Cervical mucus methods may work better (Billings Ovulation, Two Day Method) 6) Do you have physical or learning limitations?

a) Billings Ovulation has been used by visually impaired and low literacy populations.
b) Standard Days and Two-Day Methods have been used successfully in very low literacy populations.

c) For learning limitations, avoid symptothermal methods.

7) Do you have time or cost considerations?

a) Time: Natural cycles, Standard Days, Clue Birth Control and Two-Day methods involve the least amount of time to learn.

b) Cost: i) Method related costs such as equipment or monitors ii) App related purchases or on-going subscriptions 8) Do you have any religious considerations?
a) All FABMs can be used in a way that is compatible with major religious beliefs.

b) For example, the US Conference of Catholic Bishops explicitly promotes specific methods (Billings and Marquette) 9) Do you have long or irregular cycles?

a) Calendar methods cannot be used.

b) Mucus-based methods might be the best option.


Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 56 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Periodic Medication Pick up Effective Date: [Add Date] Definition and/or scope: [Clinic name] will provide refill of prescription contraceptive method to clients who return to clinic for pickup.
Clients who report no significant change in physical or mental health status since last visit with a licensed independent provider.

Procedure: 1.

Subjective: a. RN to assess for the following: i.

Potential side effects.

ii.

Change in physical or mental health status since last visit.

iii.

Compliance with medication regimen.

iv.


Sexually transmitted infection (STI) exposure and/or risk per RN Clinical Protocol for Asymptomatic STI Screening v. ACHES from Be Alert to VTE in Hormonal Contraceptive Users | Contraceptive Technology, n.d. to review danger signs.

a. Abdominal pain (severe) a.

Chest Pain (severe), cough, shortness of breath a.

Headaches (severe or worsening) a.

Eye Problems (vision loss or disturbance) a.

Severe Leg Pain, swelling, or warmth 2.

Objective: a.
Objective: a.

Obtain and document vital signs if client is onsite.

i.

Recommend client come to clinic if not obtained within the last 12 months.

b. Assess for urgent physical or mental distress.

3.

Assessment: a. Protocol applies b. Protocol applies following consultation with MD, APNP, PA c. Protocol does not apply, refer to MD, APNP, PA 4.

Plan: a.

Answer all questions, including but not limited to: i.

Methods of contraception, including how they work, side effects and effectiveness ii.
Any additional concerns Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 57 Division of Public Health b. Elicit from the client evidence of a complete understanding of the use of family planning method c. Dispense and document contraception as prescribed by the licensed provider.

i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.

Quantity dispensed v. Name of the delegating prescriber vi.

Date of original prescription vii.


Name of RN dispensing c. Offer the following contraceptive supplies: i.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

5.

Physician, APNP, PA management or consultation required during visit: a.

Consult provider if client verbalizes any change in physical or mental health status.
b. Pregnancy c. If a provider is unavailable, RN should make a referral.

6.

Nursing skills: a.

Skills: i.

Client education ii.

Shared decision-making and client-centered counseling b.

Clinical content knowledge: i. Pharmacology of contraceptive options ii.

CDC - Summary - USMEC - Reproductive Health, 2019 iii.
Contraceptive instructions on all methods, transitioning between methods, perfect use instructions, missed pill use recommendations, impact on efficacy and indications for back up methods per CDC - Summary - US SPR - Reproductive Health, 2019 iv.

Insurance impact on method coverage; skills to provide assistance with pharmacy benefits, prior authorization, Family Planning Only Services, 2014. v. ASCCP Management Guidelines Web Application, n.d. pap guidelines vi.
Indications for routine Immunization Schedules for Healthcare Professionals, 2019 vii.

CDC, 2021 STI Screening Recommendations and Considerations Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 58 Division of Public Health 7.

Follow-up: a.

Schedule next appointment for refill of contraception or visit with provider b.

Method must be prescribed every 12 months and can be obtained at an annual visit or contraception in advance of exam visit per RN clinical protocol.

8.
8.

Referral to provider is required for: a. Pregnancy b.

Urgent mental or physical distress c. Client request for pelvic or breast examination d. Hypertension: After three separate visits blood pressure >140/90 9.

Links and resources: a.

Be alert to VTE in hormonal contraceptive users | Contraceptive Technology.

(n.d.).

Contraceptivetechnology.org.


Retrieved December 14, 2022, from https://contraceptivetechnology.org/be-alert-to-vte-in-hormonal-contraceptive- users/#:~:text=Clinicians%20would%20be%20well%20advised%20to%20tell%20new b. CDC – Summary – USMEC – Reproductive Health.

(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html c. CDC – Summary – US SPR – Reproductive Health.

(2019).
(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html d. Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/fpos/index.htm e. ASCCP Management Guidelines Web Application.

(n.d.).

App.asccp.org.

f. https://app.asccp.org/ Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html g. CDC.

(2021, August 12).

STI Screening Recommendations.


Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm h. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.

http://www.myplate.gov i. U.S.

Selected Practice Recommendations for Contraceptive Use, 2016 Morbidity and Mortality Weekly Report Recommendations and Reports.

(2016).
(2016).

https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6504.pdf Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 59 Family Planning Health Screening and Education Division of Public Health 1.

Periodic Health screening completed annually or as indicated presenting concern: a.
Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: Education is to be documented in the client’s health record.
Method explained by counselor at group or individual education session, includes but not limited to: a. Method-specific instructions, apply selected RHFP RN protocol contraceptive method protocol as applicable b.

Referral education including planned procedure, pregnancy prevention prior to procedure, clinic location, and insurance coverage c. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.


Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking d. Determine appropriateness of quick start, review instructions in contraceptive method RN protocol for quick start and advise on the need for a pregnancy test just before starting second cycle of contraception (regardless of bleeding): i.
Use your first pill, ring, or patch the day of your appointment with your provider; regardless of where you are in your menstrual cycle.

ii.

Use condoms or another back up method of birth control for seven days after starting.

iii.

Repeat a pregnancy test just before starting the second cycle of contraception (include instructions on how to obtain pregnancy test at the clinic or home).

iv.
iv.

You may experience unexpected bleeding in the first 3 months of hormonal contraceptive use; continue taking your hormonal contraception even if unscheduled bleeding occurs.

Contact your clinician if unscheduled bleeding persists beyond the first 3 months of contraceptive use.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 60 Division of Public Health e. If client has simple migraines (without aura), RN should instruct client to monitor and report worsening of headaches (increased frequency or severity) or new onset focal neurologic symptoms and return to clinic if occurs.

i.

Client with new onset or worsening of migraines should be scheduled by the nurse for an appointment with MD, APNP, or PA. 3.
Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Discuss emergency contraception options and availability discussed.

d. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI screening.
e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to v. Hepatitis A vi.

Hepatitis B vii.

HPV viii.

Monkeypox f. Provide information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.

g. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 61 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Emergency Contraception Effective Date: [Add Date] Definition and/or scope: Clients seeking medical care at, [Clinic Name] will have access to emergency contraception (EC) to decrease their risk of unintended pregnancy.
EC is intended to reduce the risk of pregnancy following unprotected intercourse.

Emergency contraceptive pills (ECPs) should be taken as soon as possible within 5 days of unprotected sexual intercourse.

Ulipristal acetate (UPA) and levonorgestrel ECPs have similar effectiveness when taken within 3 days after unprotected sexual intercourse; however, UPA has been shown to be more effective than the levonorgestrel formulation 3–5 days after unprotected sexual intercourse.
The copper intrauterine device (IUD) can be inserted within 5 days of the first act of unprotected sexual intercourse as an emergency contraceptive.

If taken within the first 24 hours after an episode of unprotected sexual intercourse, ECP can reduce the risk of pregnancy by 95%.

EC should not be prescribed when suspicion or evidence of an already established pregnancy exists; however, there do not appear to be harmful effects to the fetus or the individual if EC is used during a pregnancy.
Victims of sexual assault at risk for becoming pregnant should be offered EC to reduce the chance of unwanted pregnancy.

Procedure: 1.

Subjective: a.

Obtain history: i.

Date of last menstrual period (LMP), typical flow and timing.

ii.

Assess for all unprotected intercourse since last menses, especially within the last 120 hours.

iii.

Assess for symptoms of pregnancy.

b.

Review current medications.

c. Review allergies to medications.

d. Assess client if sexual contact was consensual.


If not, refer for sexual assault, assess and refer for human trafficking, sexual coercion, child abuse, IPV.

Refer to periodic health screenings for screening and referral resources.

e. Assess sexually transmitted infection (STI) screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI Screening or the Symptomatic STI Screening.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 62 Division of Public Health 2.

Objective: a.

Obtain and document vital signs if client is onsite.

i.

Recommend client come to clinic if not obtained within the last 12 months.

ii.

Determine body mass index (BMI) by most recent weight in chart or client reported weight.

b. Assess for urgent physical and mental distress.

c. Perform urine pregnancy test per RHFP RN Clinical Protocol for Pregnancy Testing and Counseling if: i.
Multiple incidences of unprotected sexual intercourse since LMP especially if >120 hours ago ii.

LMP was not typical in amount or duration or bleeding iii.

LMP > 28 days ago iv.

Symptoms of pregnancy v. Client request vi.

Uncertain history of LMP, contraception use, unprotected sexual activity d. Pregnancy test results: i.

If negative, EC indicated.

ii.

If positive, counsel on options per RFHP RN Clinical Protocol for Pregnancy Testing and Counseling.

3.
3.

Assessment: a. Protocol applies b. Protocol applies following consultation with MD, APNP, PA c. Protocol does not apply, refer to MD, APNP, PA 4.

Plan: a.

Review efficacy of methods, including the IUD (most effective) and UPA more effective than levonorgestrel 1.5mg (plan B) if unprotected sexual contact occurred 72-120 hours ago.

Efficacy is greatest in first 24 hours at up to 95% decreasing to 89% at 72 hours and persists at this level with UPA for 120 hours (Emergency Contraception, n.d.).

b.
b.

If BMI is >25 kg/m2, discuss levonorgestrel EC may be less effective.

If BMI > 35 kg/m2, UPA may be less effective.

c. Review side effects of methods.

d. Prescribe method chosen through shared decision making.

Refer for IUD if services not available on site.


OR Ulipristal Acetate (UPA) 30 mg tablet orally now OR Levonorgestrel 1.5 mg tablet orally now or 0.75 mg tablets, 2 tablets orally now Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 63 e. Document dispensed contraception as prescribed by the licensed Division of Public Health provider.

i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.


Quantity dispensed v. Name of the delegating prescriber vi.

Date of original prescription vii.

Name of RN dispensing f. Advise of the need to avoid hormonal method start or restart for 5 days after UPA use.

g. Advise to take the medication as soon as client receives it.

h. If emesis within 3 hours of taking EC, repeat dose is indicated U.S.

Selective Practice Guidelines for CDC - Emergency Contraception - US SPR - Reproductive Health, 2019. i.
If referring for IUD, consider providing Plan B if unable to get in for same day appointment for IUD placement.

j.

Offer the following contraceptive supplies: i.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

5.
5.

Physician, APNP, PA management or consultation required during visit: a. IUD Insertion b. Abnormal findings or symptoms c. Indications for lab testing identified d. Request for physical exam e. If provider management and/or consultation not available, RN should provide referral.

6.

Nursing skills: a.

Skills: i.

Client education ii.

Shared decision-making and client-centered counseling iii.

Skill in interviewing and assessment of client reproductive planning goals and priorities iv.
Pregnancy risk assessment and indications for testing b.

Clinical content knowledge: i. Pharmacology of contraceptive options ii.

CDC - Summary - USMEC - Reproductive Health, 2019 iii.
Contraceptive instructions on all methods, transitioning between methods, perfect use instructions, missed pill use recommendations, impact on efficacy and indications for back up methods per CDC - Summary - US SPR - Reproductive Health, 2019 Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 64 Division of Public Health iv.
Insurance impact on method coverage; skills to provide assistance with pharmacy benefits, prior authorization, Family Planning Only Services, 2014. v. ASCCP Management Guidelines Web Application, n.d. pap guidelines vi.

Indications for routine Immunization Schedules for Healthcare Professionals, 2019 vii.

CDC, 2021 STI Screening Recommendations and Considerations 7.

Follow-up: a. Pregnancy test per RHFP RN Clinical Pregnancy Testing and Counseling if: i.

No normal menses in 3 weeks.

ii.


2 weeks from unprotected intercourse, if desired.

8.

Referral to provider is required for: a.

Positive pregnancy test with vaginal bleeding or pelvic pain.

b. STI symptoms needing physical exam assessment.

c. Client selects IUD method.

d. Urgent physical or mental distress.

9.

Links and resources: a. CDC – Emergency Contraception – US SPR – Reproductive Health.

(2019, October 6).

Www.cdc.gov.


https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/emergency.html b. CDC – Summary – USMEC – Reproductive Health.

(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html c. CDC – Summary – US SPR – Reproductive Health.

(2019).

https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html d. Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.


https://www.dhs.wisconsin.gov/fpos/index.htm e. ASCCP Management Guidelines Web Application.

(n.d.).

App.asccp.org.

f. https://app.asccp.org/ Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html g. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm h. MyPlate | U.S. Department of Agriculture.

(n.d.).
(n.d.).

Www.myplate.gov.

http://www.myplate.gov i.

Emergency Contraception.

(n.d.).

Www.acog.org.

https://www.acog.org/clinical/clinical-guidance/practice- bulletin/articles/2015/09/emergency-contraception j. HPV vaccination recommendations: i.

Human Papillomavirus Vaccination.

(n.d.).

Www.acog.org.

https://www.acog.org/clinical/clinical-guidance/committee- opinion/articles/2020/08/human-papillomavirus-vaccination ii.

HPV Vaccine Recommendations.

(2019).

CDC.


https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html iii.

Final Recommendation Statement: Cervical Cancer: Screening | United States Preventive Services Taskforce.

(n.d.).

Www.uspreventiveservicestaskforce.org.
Retrieved December 14, 2022, from https://www.uspreventiveservicestaskforce.org/Page/Document/Recommendati onStatementFinal/cervical-cancer-screening Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 65 Division of Public Health Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.
Periodic Health screening completed annually or as indicated presenting concern: a.

Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: Education is to be documented in the client’s health record.
Method selected explained by counselor at group or individual education session; includes, but is not limited to: a.

Review method specific instructions and medication package insert and provide copy at client request.

b.

Review and document in encounter note education on BRAIDED: i.

Benefit of the method ii.

Risks of the method (contraceptive options) iii.

Alternatives to the method iv.

Inquiries about the method v. Decision to withdraw from method vi.

Explanation of use of the method vii.


Documentation c. Review unpredictable bleeding pattern is common.

d. Review side effects of selected method.

e. Review when to return for a pregnancy test and how to schedule (see follow-up section above) f. Review reproductive life plan and if contraceptive needed, offer to initiate today using RN Clinical Protocol for Contraception in Advance of Exam.

g. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.
Emergency contraception iii.

Mechanism of action iv.

Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 66 Division of Public Health vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.

Health screening education and/or anticipatory guidance to consider at every visit: a.
Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Assess asymptomatic STI screening needs and offer screening following RHFP RN Clinical Protocol for Asymptomatic STI Screening.

d. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.


Monkeypox e. Information and education regarding pregnancies at the request of the recipient, including prenatal counseling and referral.

f. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 67 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Asymptomatic Sexually Transmitted Infection (STI) Screening Visit Effective Date: [Add Date] Definition and/or scope: Asymptomatic clients seeking medical care at, [Clinic Name] will be assessed and screened using best practice guidelines.
Procedure: 1.

Subjective: a.

Sexual Health History – for items with an asterisk that screen positive complete the Supplemental STI Screen in section 4.

Plan item e. below.

i.

Number of partners in the past 90 days ii.

Sex (assigned male or female at birth) and gender identity of recent sexual partners iii.

For men with male partners (MSM) or women with bisexual male partners, evaluate sites of exposure* iv.

Frequency of condom use v. Prior sexually transmitted infection (STI) testing vi.
Prior history of STI (diagnosis, date and treatment) * vii.

Known or suspected exposure to STI in the past 90 days 1.

Date and type of STI exposure 2.

Treatment of the STI exposure viii.

History of IV drug use* ix.

Partners from urban or > 2% prevalence areas* x. Nonconsensual sexual contact b.

Symptoms, if present, use symptomatic STI RN protocol.

Will need consultation with provider: i. Urethral discharge ii.

Bothersome vaginal discharge and/or odor iii.


Dysuria in client assigned female at birth iv.

Genital rash, sores, or lesions v. Genital itching or pain vi.

Pelvic pain vii.

Pain with intercourse viii.

Testicular pain ix.

Anal itching, pain, bleeding, discharge x.

Acute HIV symptoms (fever, chills, sweats, lymph node swelling and/or pain) xi.

Pharyngitis xii.

Reactive arthritis triad (arthritis, conjunctivitis or uveitis, and urethritis or cervicitis) xiii.
Postcoital bleeding c. General health history review i.

Current medications ii.

Medication allergies or adverse reactions Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 68 Division of Public Health iii.

Substance use impacting recall and/or risks iv.

Contraception v. Date of last Pap test if applicable vi.

Date of last menstrual period vii.

HPV Immunization status viii.

Hep B immunization status 2.

Objective: a.

No symptoms reported b.


Obtain and document vital signs if client is onsite.

i.

Recommend client come to clinic if not obtained within the last 12 months.

c. Assess for urgent mental and physical distress.

3.

Assessment: a. Protocol applies b. Protocol applies following consultation with MD, APNP, PA c. Protocol does not apply, refer to MD, APNP, PA 4.

Plan: a.

If symptoms are reported use Symptomatic STI protocol b.
Recommend testing based on the STI guidelines from the CDC, 2021 c. Document screening consistent with CDC and Wisconsin State Laboratory of Hygiene (WSLH) selective screening criteria (SSC).

d. Standard screening tests offered to all clients: i. Pregnancy tests, refer to RFHP RN Clinical Protocols for Pregnancy Testing and Counseling.

ii.

Chlamydia 1.

Clients with penises – Obtain a first catch (20mL) urine specimen (if has not urinated in the past hour).

2.
2.

Clients with vaginas – Self collected vaginal swab or first catch urine specimen (if has not urinated in the past hour).

iii.

HIV 1/2 Antibody screen e. Offer supplemental STI screening to people identified at risk per sexual history, or summarized below: i. Chlamydia 1.

Pharynx – not indicated for any population 2.

Rectal – MSM with history of recent receptive anal intercourse ii.

Gonorrhea 1.

Any new sexual partners in the past 3 months or since last STI screening 2.
MSM – Collect pharyngeal specimen on clients with history of oral intercourse.

Collect rectal specimens if history of receptive anal intercourse in the past 6 months.

3.

Client or partner is from community and/or sexual network with high prevalence Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 69 Division of Public Health 4.

High risk sexual behavior 5.

Diagnosis of other STIs in client or partner iii.

Syphilis 1.

Client requests test 2.


Sexual contact with person known or suspected to have syphilis 3.

Men that have sex with other men (MSM) 4.

Anyone with a positive test for gonorrhea, chlamydia, or HIV, if there is a high-risk history 5.

Any physical signs consistent with syphilis, especially suspicious ulcer (repeat 7-14 days after appearance), a highly variable skin rash, unusual condyloma, papule, mucocutaneous patch 6.
History of syphilis with or without incomplete or unknown post-treatment follow-up 7.

Consider testing with presence of trichomonas or HSV (consult to provider) 8.

HIV testing should be done with individuals at risk for syphilis.

9.

Additional notes on Syphilis testing: a.

When indicated, RN should send a venous blood draw for syphilis diagnostic algorithm through the WSLH according to clinic and WSLH protocol (see plan section below for more information on testing and treatment) b.
If a client has been previously treated for syphilis, order a Syphilis VDRL (Post-Treatment) test.

iv.

Mycoplasma Genitalium: known exposure to partner who tested positive for mycoplasma genitalium v. Herpes: not indicated for routine screening.

vi.

HPV: not indicated for routine screening.

Refer to cervical cancer screening guidelines.

vii.

Hepatitis B serology (HbsAg) 1.

Sexual partner with recent or chronic Hep B infection 2.

MSM not immunized prior to sexual debut 3.


Born in country with >2% prevalence viii.

Hepatitis C serology 1.

History of injection drug use 2.

Known exposure to Hepatitis C f. Obtain laboratory test(s) using the Wisconsin State Lab of Hygiene (WSLH) or other lab partner specimen collection, handling, and shipping instructions.

Utilize appropriate test requisition.

Instruct client on appropriate laboratory testing and collecting technique: i.

Vaginal swab ii.

Urine test iii.

Rectal swab iv.


Pharyngeal swab Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 70 Division of Public Health g. Offer routine immunizations as indicated i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox h. Clients who are sexual partners of person recently diagnosed (time frames listed below) with a known STI should be treated empirically, regardless of the client’s test results.

Refer to RHFP RN Clinical Protocols for STI Treatment.

i.
i.

Sexual contact within the past 3 months 1.

Chlamydia 2.

Gonorrhea 3.

Trichomoniasis ii.

Sexual contact within the past 6 months 1.

Syphilis i.

Offer the following contraceptive supplies: i.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

5.

Physician, APNP, PA management or consultation required during visit for: a.
Symptoms of STI (follow Symptomatic STI RN Protocol) b.

Client has a contraindication and/or allergy to the medications in the treatment protocol.

c. Client has positive HIV test results referral to Vivent Health.

d. Client has positive Hepatitis B or C results.

e. Clients who are pregnant or breastfeeding without established care.

f. Clients are already immunocompromised or have significant, chronic medical conditions.
g. Client needs further examination or suspected diagnosis falls outside the protocol.

h. If a provider is unavailable for consultation, the RN should make a referral.

6.

Nursing skills: a.

Skills i.

Client interviewing ii.

Physical exam skills iii.

Client education and counseling b.

Clinical content knowledge: i. STIs and their common signs and symptoms per Centers for Disease Control and Prevention, 2019 ii.
Risk based screening recommendations outlined by the STI Screening recommendations from the CDC, 2021 Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 71 Division of Public Health iii.

Process for obtaining and sending specimens to appropriate lab using agency workflow iv.

Indications for routine Immunization Schedules for Healthcare Professionals, 2019 7.

Follow-up: a.

Contact client with results b.


Treat per RHFP RN Clinical Protocol for Asymptomatic STI Screening if client remains asymptomatic c. Reporting procedures: i.

State law requires that positive reportable Sexually Transmitted Diseases, 2019 or other related Disease Reporting, 2021 be reported by the provider to Wisconsin DHS.
Clinic staff members are responsible for completing the DHS, 2022 state form, including treatment information and reporting it to the county health department in which the client resides.

8.

Referral to provider is required for: a. Pregnancy.

b.

Urgent physical or mental distress.

c. STI symptoms consistent with pelvic inflammatory disease (PID), vaginitis, prostatitis, orchitis, or otherwise requiring physical exam assessment.

9.

Links and resources: a. CDC.

(2021, August 12).


STI Screening Recommendations.

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm a. Wisconsin State Laboratory of Hygiene | Wisconsin’s Public Health and Environmental Laboratory Since 1903.

(n.d.).

Retrieved December 14, 2022, from https://www.slh.wisc.edu b. Vivent Health | Excellence in Health Care.

(n.d.).

Viventhealth.org.

https://viventhealth.org c. Centers for Disease Control and Prevention.

(2019).
(2019).

CDC – STD diseases & related conditions.

CDC.

https://www.cdc.gov/std/general/default.htm a. Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html d. STD: Information for Health Care Professionals.

(2019, September 11).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/std/health-pros.htm e. Sexually Transmitted Diseases (STD).

(2019, April 15).

Wisconsin Department of Health Services.


https://www.dhs.wisconsin.gov/std/index.htm#:~:text=Chlamydia%20is%20a%20sex ually%20transmitted%20disease%20%28STD%29%20caused,second%20most%20co mmonly%20reported%20STD%20in%20the%20state.

f. Disease Reporting.

(2021, October 7).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/disease/reporting.htm g. Department of Health Services.

(2022, May).

Sexually Transmitted Infection Laboratory and Morbidity Case Report.
https://www.dhs.wisconsin.gov/forms/f4/f44243.pdf a. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.

http://www.myplate.gov Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 72 Division of Public Health Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.
Periodic Health screening completed annually or as indicated presenting concern: a.

Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: Education is to be documented in the client’s health record.
Method explained by counselor at group or individual education session, includes but not limited to: a. Method-specific instructions, apply selected RHFP RN protocol contraceptive method protocol as applicable b.

Referral education including planned procedure, pregnancy prevention prior to procedure, clinic location, and insurance coverage c. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.


Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking d. Determine appropriateness of quick start, review instructions in contraceptive method RN protocol for quick start and advise on the need for a pregnancy test just before starting second cycle of contraception (regardless of bleeding): i.
Use your first pill, ring, or patch the day of your appointment with your provider; regardless of where you are in your menstrual cycle.

ii.

Use condoms or another back up method of birth control for seven days after starting.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 73 Division of Public Health iii.

Repeat a pregnancy test just before starting the second cycle of contraception (include instructions on how to obtain pregnancy test at the clinic or home).

iv.
iv.

You may experience unexpected bleeding in the first 3 months of hormonal contraceptive use; continue taking your hormonal contraception even if unscheduled bleeding occurs.

Contact your clinician if unscheduled bleeding persists beyond the first 3 months of contraceptive use.

e. If client has simple migraines (without aura), RN should instruct client to monitor and report worsening of headaches (increased frequency or severity) or new onset focal neurologic symptoms and return to clinic if occurs.
i.

Client with new onset or worsening of migraines should be scheduled by the nurse for an appointment with MD, APNP, or PA. 3.

Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation.

c. Emergency contraception options and availability discussed d. Assess STI screening needs and offer screening following Asymptomatic STI RN Protocol guidelines.
e. Review HPV vaccine status and make recommendations f. Information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.

g. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 74 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Symptomatic Sexually Transmitted Infection (STI) Visit Effective Date: [Add Date] Definition and/or scope: Clients with symptoms of a STI seeking medical care at, [Clinic Name] will be assessed and managed using best practice guidelines.
Procedure: 1.

Subjective: a.

Sexual Health History – for items with an asterisk that screen positive complete the Supplemental STI Screen in section 4.

Plan item d. below.

i.

Number of partners in the past 90 days ii.

Sex (assigned male or female at birth) and gender identity of recent sexual partners iii.

For men with male partners (MSM) or women with bisexual male partners, evaluate sites of exposure* iv.

Frequency of condom use v. Prior sexually transmitted infection (STI) testing vi.
Prior history of STI (diagnosis, date, and treatment) * vii.

Known or suspected exposure to STI in the past 90 days 1.

Date and type of STI exposure 2.

Treatment of the STI exposure viii.

History of IV drug use* ix.

Partners from urban or > 2% prevalence areas* x. Nonconsensual sexual contact b.

Symptoms, if present, will need consultation with provider or referral: i. Urethral discharge ii.

Bothersome vaginal discharge and/or odor iii.

Dysuria in client assigned female at birth iv.


Genital rash, sores, or lesions v. Genital itching or pain vi.

Pelvic pain vii.

Pain with intercourse viii.

Testicular pain ix.

Anal itching, pain, bleeding, discharge x.

Acute HIV symptoms (fever, chills, sweats, lymph node swelling and/or pain) xi.

Pharyngitis xii.

Reactive arthritis triad (arthritis, conjunctivitis or uveitis, and urethritis or cervicitis) xiii.

Postcoital bleeding c. General health history review i.

Current medications ii.


Medication allergies or adverse reactions iii.

Substance use impacting recall and/or risks Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 75 Division of Public Health iv.

Contraception v. Date of last Pap test if applicable vi.

Date of last menstrual period vii.

HPV Immunization status viii.

Hep B immunization status 2.

Objective: a.


Symptoms reported (vulvar, vaginal, abnormal bleeding, pelvic pain, pain with intercourse, penile discharge, dysuria, etc.)

b.

Obtain and document vital signs if client is onsite.

i.

Recommend client come to clinic if not obtained within the last 12 months.

c. Assess for urgent mental and physical distress.

3.

Assessment: a. Protocol applies b. Protocol applies following consultation with MD, APNP, PA c. Protocol does not apply, refer to MD, APNP, PA 4.
Plan: a.

Consult with provider required to include description and time frame of symptoms for recommendations regarding additional testing, exam, and if referral is advised.

i. Pelvic pain (differential includes PID, ectopic, ovarian cyst, appendicitis, pelvic floor dysfunction, constipation, inflammatory bowel disease) ii.

Change in vaginal discharge (differential includes yeast, BV, trichomoniasis, mycoplasma genitalium, contact dermatitis, foreign body) iii.
Vulvar/Vaginal itching (differential includes yeast, BV, trichomoniasis, contact dermatitis, vulvar dermatoses) iv.

Vulvar/Vaginal irritation/pain (differential includes yeast, BV, trichomoniasis, contact dermatitis, vulvar dermatoses, trauma, HSV, foreign body) v. Vulvar/Genital lesions/sores (differential includes yeast, vulvar dermatoses, contact dermatitis, trauma, HSV, HPV, Syphilis, LVG, Granuloma Inguinale, Chancroid, Behcet’s disease, Chron’s, apthous ulcers, carcinoma, melanoma) vi.
Abnormal vaginal bleeding including post coital bleeding (differential includes cervicitis, PID, ectopic or intrauterine pregnancy, cervical polyp, fibroids, trauma, contraceptive side effect, carcinoma of vagina, cervix, uterus, ovary vii.

Pain with intercourse (Vulvar sores, vaginal infection, trauma, pelvic floor dysfunction, ovarian cyst, PID, IBD, pregnancy, penile infection, penile contact dermatitis) viii.

Penile/urethral discharge/dysuria (urethritis, epididymitis, prostatitis) ix.
Testicular pain Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 76 Division of Public Health x. Anal pain, bleeding, lesion b.

Review indications for chlamydia and gonorrhea testing, educate, and offer testing using shared decision making with patient at time of visit.

c. Screen for STI and pregnancy i.

Recommend STI testing based on screening guidelines from the CDC, 2021 ii.
Document screening consistent with CDC and Wisconsin State Laboratory of Hygiene (WSLH) selective screening criteria (SSC).

iii.

Standard screening tests offered to all clients: 1.

Pregnancy tests, refer to RFHP RN Clinical Protocols for Pregnancy Testing and Counseling.

2.

Chlamydia a.

Clients with penises – Obtain a first catch (20mL) urine specimen (if has not urinated in the past hour).

b.
b.

Clients with vaginas – Self collected vaginal swab or first catch urine specimen (if has not urinated in the past hour).

3.

HIV 1/2 Antibody screen d. Required if any items above in the subjective section with an * were screened as positive *Supplemental STI screening offered to people at high risk* as outlined below: i. Chlamydia 1.

Pharynx – not indicated for any population 2.

Rectal – MSM with history of recent receptive anal intercourse ii.

Gonorrhea 1.
Gonorrhea 1.

Any new sexual partners in the past 3 months or since last STI screening 2.

MSM – Collect pharyngeal specimen on clients with history of oral intercourse.

Collect rectal specimens if history of receptive anal intercourse in the past 6 months.

3.

Client or partner is from community and/or sexual network with high prevalence 4.

High risk sexual behavior 5.

Diagnosis of other STIs in client or partner iii.

Syphilis 1.

Client requests test 2.


Sexual contact with person known or suspected to have syphilis 3.

Men that have sex with other men (MSM) 4.

Anyone with a positive test for gonorrhea, chlamydia, or HIV, if there is a high-risk history 5.
Any physical signs consistent with syphilis, especially suspicious ulcer (repeat 7-14 days after appearance), a highly variable skin rash, unusual condyloma, papule, mucocutaneous patch Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 77 Division of Public Health 6.

History of syphilis with or without incomplete or unknown post-treatment follow-up 7.

Consider testing with presence of trichomonas or HSV (consult to provider) 8.
HIV testing should be done with individuals at risk for syphilis.

9.

Additional notes on Syphilis testing: a.

When indicated, RN should send a venous blood draw for syphilis diagnostic algorithm through the WSLH according to clinic and WSLH protocol (see plan section below for more information on testing and treatment) b.

If a client has been previously treated for syphilis, order a Syphilis VDRL (Post-Treatment) test.

iv.
iv.

Mycoplasma Genitalium: known exposure to partner who tested positive for mycoplasma genitalium v. Herpes: not indicated for routine screening.

vi.

HPV: not indicated for routine screening.

Refer to cervical cancer screening guidelines.

vii.

Hepatitis B serology (HbsAg) 1.

Sexual partner with recent or chronic Hep B infection 2.

MSM not immunized prior to sexual debut 3.

Born in country with >2% prevalence viii.

Hepatitis C serology 1.

History of injection drug use 2.


Known exposure to Hepatitis C e. Obtain laboratory test(s) using WSLH or other lab partner specimen collection, handling and shipping instructions or other testing labs used.

Utilize appropriate test requisition.

Instruct client on appropriate laboratory testing and collecting technique: i.

Vaginal swab ii.

Urine test iii.

Rectal swab iv.


Pharyngeal swab f. Known positive contact or positive laboratory results treat per appropriate protocol along with consultation or referral for symptom evaluation.

g. Offer the following contraceptive supplies: i.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

5.
5.

Physician, APNP, PA management or consultation required: a.

Symptoms of STI b.

Client has a contraindication and/or allergy to the medications in the treatment protocol.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 78 Division of Public Health c. Client has positive HIV test results refer to Vivent Health.

d. Client has positive Hepatitis B or C results.

e. Clients who are pregnant, planning to become pregnant or breastfeeding.
f. Clients are already immunocompromised or have significant, chronic medical conditions.

g. Client needs further examination or suspected diagnosis falls outside the protocol.

h. If a provider is unavailable for consultation, the RN is required to make a referral.

6.

Nursing skills: a.

Skills i.

Client interviewing ii.

Physical exam skills iii.

Client education and counseling b.


Clinical content knowledge: i. STIs and their common signs and symptoms per the Centers for Disease Control and Prevention, 2019 ii.

Risk based STI screening recommendations outlined by the CDC, 2021 iii.

Process for obtaining and sending specimens to appropriate lab using agency workflow iv.

Indications for routine Immunization Schedules for Healthcare Professionals, 2019.

7.

Follow-up: a.

Contact client with results b.


Contact patient to confirm referral appointment made and reinforce need for appointment if continued symptoms, new symptoms, pregnancy.

c. Reporting procedures: i.

State law requires that positive reportable STD, 2019 or other related Disease Reporting, 2021 be reported by the provider to Wisconsin DHS.
Clinic staff members are responsible for completing the DHS, 2022 reporting form, including treatment information and reporting it to the county health department in which the client resides.

8.

Referral to provider is required for: a. Pregnancy.

b.

Urgent physical or mental distress.


c. STI symptoms consistent with conditions (above differentials) including but not limited to pelvic inflammatory disease (PID), vulvar conditions, vaginitis, cervicitis, cervical mass, uterine mass, ovarian mass, prostatitis, orchitis, or otherwise requiring physical exam assessment.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 79 Division of Public Health 9.

Links and resources: a. CDC.

(2021, August 12).


STI Screening Recommendations.

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm b. Wisconsin State Laboratory of Hygiene | Wisconsin’s Public Health and Environmental Laboratory Since 1903.

(n.d.).

Retrieved December 14, 2022, from https://www.slh.wisc.edu c. Vivent Health | Excellence in Health Care.

(n.d.).

Viventhealth.org.

https://viventhealth.org d. Centers for Disease Control and Prevention.

(2019).
(2019).

CDC – STD diseases & related conditions.

CDC.

https://www.cdc.gov/std/general/default.htm e. Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html f. STD: Information for Health Care Professionals.

(2019, September 11).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/std/health-pros.htm g. Sexually Transmitted Diseases (STD).

(2019, April 15).

Wisconsin Department of Health Services.


https://www.dhs.wisconsin.gov/std/index.htm#:~:text=Chlamydia%20is%20a%20sex ually%20transmitted%20disease%20%28STD%29%20caused,second%20most%20co mmonly%20reported%20STD%20in%20the%20state.

h. Disease Reporting.

(2021, October 7).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/disease/reporting.htm i.

Department of Health Services.

(2022, May).

Sexually Transmitted Infection Laboratory and Morbidity Case Report.
https://www.dhs.wisconsin.gov/forms/f4/f44243.pdf j. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.

http://www.myplate.gov APPROVAL – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: a.
Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: Education is to be documented in the client’s health record.
Method explained by counselor at group or individual education session, includes but not limited to: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 80 Division of Public Health a. Method-specific instructions, apply selected RHFP RN protocol contraceptive method protocol as applicable b.
Referral education including planned procedure, pregnancy prevention prior to procedure, clinic location, and insurance coverage c. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.

Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.


Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Discuss emergency contraception options and availability discussed.

d. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI screening.
e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox f. Provide information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.

g. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 81 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Chlamydia Treatment Effective Date: [Add Date] Definition and/or scope: Clients seeking medical care at, [clinic name] will be treated for chlamydia (Chlamydia trachomotis) using best practice guidelines.
Procedure: 1.

Subjective: a. Assess reason for treatment: i.

Does client present with a known exposure to chlamydia?

ii.

Does client present with positive chlamydia test?

iii.

Does client present with signs and/or symptoms?

b.

Review current medications c. Review allergies d. Review and update sexual history e. Assess for pregnancy or breastfeeding f. Assess for indicated sexually transmitted infections (STI) screenings using RHFP RN Clinical Protocol for Asymptomatic STI Screening.
g. Assess for signs and symptoms of infection reported by client including pelvic inflammatory disease (PID*) that will require consultation and/or referral to MD, APNP, or PA.

Note: most frequent presentation is asymptomatic.

iii.

Abnormal symptoms: 1.

*Abnormal discharge from vagina 2.

*Intermenstrual or bleeding after intercourse (postcoital) 3.

Vulvar or vaginal itching 4.

*Pelvic pain 5.

*Pain with sexual activity 6.

Mucoid or watery urethral discharge 7.

Itching of the urethral meatus 8.


Dysuria, pyuria, urinary frequency 9.

Pain or swelling of the testicles iv.

Anal symptoms: 10.

Rectal pain 11.

Discharge or bleeding 12.

Rectal itching v. Other clinical syndromes: 13.

Pharyngitis 14.

Reactive arthritis triad (arthritis, conjunctivitis, or uveitis and urethritis or cervicitis) Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 82 Division of Public Health 2.

Objective: a.

Obtain and document vital signs if client is onsite.
i.

Recommend client come to clinic if not obtained within the last 12 months.

b. Assess for urgent physical and/or mental distress.

c. Positive test (amplification, culture, DNA probe) for Chlamydia trachomotis.

3.

Assessment: a. Protocol applies: i.

As a result of a positive laboratory result.

ii.

To treat presumptively based on asymptomatic presentation with exposure history.

b. Protocol applies following consultation with MD, APNP, or PA. c. Protocol does not apply, refer to MD, APNP, or PA. 4.
Plan: a.

Recommend laboratory tests for other sexually transmitted infections (STI) as appropriate using RHFP RN Clinical Protocol for Asymptomatic STI Screening.

b.

Treat chlamydia infection according to regimens recommended by the current CDC, 2021 guidelines.

Doxycycline 100mg orally every 12 hours for 7 days (Recommended Treatment per CDC Guidelines) OR Azithromycin 1g orally in a single dose (Alternative Treatment per CDC Guidelines) i.

For Consideration: 1.


Do not give doxycycline to pregnant clients or lactating client(s).

Client(s) must be advised to discontinue breastfeeding or receive alternative regimen.

2.

Doxycycline is the recommended treatment regimen; however, it is essential to use shared decision making to determine if alternative regimen is likely to yield compliance and preferred by client.

3.

If vomiting occurs within 1 hour of taking azithromycin, client should contact the clinic.
Dose should be repeated with ondansetron 30 minutes before repeat azithromycin dose.

Ondansetron 8mg orally single dose 30 minutes before repeat dose and Azithromycin 1g orally in a single dose Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 83 Division of Public Health 4.

If vomiting occurs with doxycycline within 1 hour, RN needs to contact prescribing provider for decision to continue doxycycline with ondansetron or use alternative regimen.

b.
b.

Document dispensed medication as prescribed by the licensed provider.

i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.

Quantity dispensed v. Name of the delegating prescriber vi.

Date of original prescription vii.

Name of RN dispensing d. Offer the following contraceptive supplies: i.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.
ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

e. Report all positive test results within 72 hours.

RN should consult clinic policy to understand procedure for disease reporting.

See STD: Information for Health Care Professionals, 2019 for more information.

f. Management of sex partners: i.

Educate on abstaining from intercourse until 7 days following the start of the treatment regimen and resolution of symptoms.
Abstain from sex until sex partner(s) have been adequately treated (for 7 days following the start of treatment and resolution of symptoms).

ii.

Counsel on the importance of evaluation and treatment for the most recent sexual partner(s) per the CDC, 2021.

1.

Recent sex partners (i.e., persons having sexual contact with the infected client within the 60 days preceding onset of symptoms or chlamydia diagnosis) should be referred for evaluation, testing, and presumptive treatment.

2.
2.

Provide clients with written educational materials to give to their partner(s), to include notification that partner(s) have been exposed and information about the importance of treatment.

3.

Legal status of EPT - Wisconsin, 2020 for treatment of sex partners.

Refer to Expedited Partner Therapy Protocol.

5.

Physician, APNP, PA management or consultation required during the visit: b.
When further medical guidance is needed, and standard protocol is not applicable for therapeutic treatment of client.

c. If client presents with signs and symptoms of infection.

Note: Most frequent presentation is asymptomatic.

i. Abnormal symptoms: 1.

Abnormal discharge from vagina Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 84 Division of Public Health 2.

Intermenstrual or bleeding after intercourse (postcoital) 3.

Dysuria, pyuria, urinary frequency 4.


Vulvar or vaginal itching 5.

Pelvic pain 6.

Pain with sexual activity 7.

Mucoid or watery urethral discharge 8.

Itching of the urethral meatus 9.

Dysuria, pyuria, urinary frequency 10.

Pain or swelling of the testicles i. Anal symptoms: 1.

Rectal pain 2.

Discharge or bleeding 3.

Rectal itching ii.

Other clinical syndromes: 1.

Pharyngitis 2.


Reactive arthritis triad (arthritis, conjunctivitis, or uveitis and urethritis or cervicitis) c. If vomiting occurs with doxycycline within 1 hour, RN must contact prescribing provider for decision to continue doxycycline with ondansetron or use alternative regimen.

d. If client presents with allergies or intolerance to all treatment options.

e. If client is pregnant.

f. If client is breastfeeding.


g. If provider management and/or consultation not available, RN should provide referral.

6.

Nursing skills: b.

Skills: iii.

Client interviewing iv.

Client education v. Shared decision making and client-centered counseling vi.

Proper collection, handling, shipping of biological specimens b.

Clinical content knowledge: i.

Infection basics and common signs and/or symptoms ii.

Infection treatment regimen and pharmacology iii.


Sexually transmitted infections and their common signs and/or symptoms per Centers for Disease Control and Prevention, 2019 iv.

Risk based screening recommendations outlined by the CDC, 2021 7.

Follow-up: b. Retest in 3 months for assessment of re-exposure.

i.
i.

Test of cure to detect therapeutic failure (i.e., repeat testing 4 weeks after completing therapy) is not advised for non-pregnant persons treated with the recommended or alternative regimens, unless therapeutic adherence is in question, symptoms persist, or reinfection is suspected.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 85 Division of Public Health c. RN should instruct client to follow up at clinic or with primary care provider if signs and/or symptoms persist after 3 days of treatment or recur.

8.
8.

Referral to establish follow-up appointment with physician, APNP, PA, or specialty care provider is required for: b. Pregnancy c. Urgent physical or mental distress d. Signs and/or symptoms requiring physical exam assessment e. STI symptoms consistent with pelvic inflammatory disease (PID), vaginitis, prostatitis, orchitis, or otherwise requiring physical exam assessment f. Retest laboratory result comes back positive indicating treatment failure 9.

Links and resources: a. CDC.

(2021).


Chlamydial infections – STI treatment guidelines.

CDC.

https://www.cdc.gov/std/treatment-guidelines/chlamydia.htm b. STD: Information for Health Care Professionals.

(2019, September 11).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/std/health-pros.htm c. Legal Status of EPT – Wisconsin.

(2020, March 23).

Www.cdc.gov.

https://www.cdc.gov/std/ept/legal/wisconsin.htm d. Centers for Disease Control and Prevention.

(2019).
(2019).

CDC – STD diseases & related conditions.

CDC.

https://www.cdc.gov/std/general/default.htm e. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm f. Walensky, R., Jernigan, D., Bunnell, R., Layden, J., Kent, C., Gottardy, A., Leahy, M., Martinroe, J., Spriggs, S., Yang, T., Doan, Q., King, P., Starr, T., Yang, M., Jones, T., Boulton, M., Brooks, C., Ma, J., Butler, V., & Caine, J.

(2021).
(2021).

Morbidity and Mortality Weekly Report Sexually Transmitted Infections Treatment Guidelines, 2021 Centers for Disease Control and Prevention MMWR Editorial and Production Staff (Serials) MMWR Editorial Board.

https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf g. Wisconsin State Laboratory of Hygiene | Wisconsin’s Public Health and Environmental Laboratory Since 1903.

(n.d.).

Retrieved December 14, 2022, from https://www.slh.wisc.edu h. Legal Status of EPT – Wisconsin.
(2020, March 23).

Www.cdc.gov.

https://www.cdc.gov/std/ept/legal/wisconsin.htm i. Wisconsin State Laboratory of Hygiene: http://www.slh.wisc.edu/ j. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.

http://www.myplate.gov k. Centers for Disease Control and Prevention.

(2019).

Detailed STD Facts- Chlamydia.

Centers for Disease Control and Prevention.

https://www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm Immunization Schedules for Healthcare Professionals.

(2019).
(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html l. Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 86 Division of Public Health Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: a.
Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: a.

Provide information on infection and treatment.

b.

Offer basic information on Chlamydia infection (Centers for Disease Control and Prevention, 2019).

c. Educate about sequelae and complications of untreated infection.
d. Counsel clients regarding the importance of early re-evaluation if symptoms persist or recur.

e. Provide client education on medication.

f. Directions for medication administration and management of potential side effects.

g. Education on the importance of treatment adherence.

h. Educate clients about adverse effects of medications prescribed and document understanding.

i.

Educate client about the laboratory result communication plan if treated presumptively.
Counsel on disease surveillance and communicable disease reporting process and to expect a phone call regarding a communicable disease investigation if lab test returns positive.

ii.

Instruct client to return to clinic in 3 months for retesting.

iii.

Behavioral risk-reduction counseling: 1.

Assist client(s) in developing a personalized STI and/or human immunodeficiency virus (HIV) risk reduction plan and document client’s plan.

2.

Elicit barriers to, and facilitators of, consistent condom use.

3.
3.

Elicit barriers to, and facilitators of, reducing substance abuse.

4.

Assist client to identify 1 or 2 feasible, acceptable, incremental steps toward risk reduction.

5.

Identify and address anticipated barriers to accomplishing planned actions to reduce risk.

6.

Acknowledge the effort required for behavior change.

7.

Reinforce successes 8.

If not fully successful, assess factors interfering with completion of planned actions and assist client to identify next steps.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 87 Division of Public Health i.

Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.

Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.


Health screening education and/or anticipatory guidance: a.

Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to Hepatitis A, Hepatitis B, HPV, and Monkeypox i.

Counsel on and administer immunizations, if applicable.

b.

General reproductive health and family planning topics: i.

Discuss details of pelvic exam and make recommendations, as appropriate.

ii.
ii.

Discuss Pap testing guidelines and make recommendation, as appropriate.
c. Discuss availability of providers for further questions or problems Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 88 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Gonorrhea Treatment Effective Date: [Add Date] Definition and/or scope: Clients seeking medical care at, [clinic name] will be treated for gonorrhea (Neisseria gonorrhoeae) using best practice guidelines.
Procedure: 1.

Subjective: a. Assess reason for treatment: i.

Does client present with a known exposure to gonorrhea, pelvic inflammatory disease (PID), or epididymitis?

ii.

Does client present with positive gonorrhea test?

iii.

Does client present with signs and/or symptoms?

b.

Review current medications c. Review allergies i.

If allergic to cephalosporins or penicillin, assess if client has had desensitization.
d. Review and update sexual history e. Assess for pregnancy or breastfeeding f. Assess for indicated sexually transmitted infections (STI) screenings using RHFP RN Clinical Protocol for Asymptomatic STI Screening.

g. Assess for signs and symptoms of infection reported by client including pelvic inflammatory disease (PID*) that will require consultation and/or referral to MD, APNP, or PA.

Note: most frequent presentation is asymptomatic.

i. Abnormal symptoms: 1.


*Abnormal or increased discharge from vagina 2.

*Intermenstrual or bleeding after intercourse (postcoital) 3.

Dysuria 4.

*Pelvic pain 5.

*Pain with sexual activity 6.

Mucoid or watery urethral discharge 7.

Itching of the urethral meatus 8.

Dysuria, pyuria, urinary frequency 9.

Pain or swelling of the testicles or penis ii.

Anal symptoms: 1.

Rectal pain 2.

Discharge or bleeding 3.

Rectal itching iii.

Other clinical syndromes: 1.

Pharyngitis 2.


Lymphadenopathy h. Assess for suspected therapeutic failure after treatment or symptoms that persist after treatment Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 89 Division of Public Health 2.

Objective: a.

Obtain and document vital signs if client is onsite.

i.

Recommend client come to clinic if not obtained within the last 12 months.

b. Assess for urgent physical and/or mental distress.
c. Positive test (amplification, culture, DNA probe) for Neisseria gonorrhoeae.

3.

Assessment: a. Protocol applies: i.

As a result of positive laboratory result.

ii.

To treat presumptively based on asymptomatic presentation with exposure history.

b. Protocol applies following consultation with MD, APNP, or PA. c. Protocol does not apply, refer to MD, APNP, or PA. 4.

Plan: a.
Plan: a.

Recommend laboratory tests for other sexually transmitted infections (STI) as appropriate using RHFP RN Clinical Protocol for Asymptomatic STI Screening.

i. Chlamydia lab should always be done when gonorrhea is suspected.

b.

Treat gonorrhea infection according to regimens recommended by the current Center for Disease Control and Prevention, 2021. i.
Regimen for uncomplicated gonococcal infection of the cervix, urethra, or rectum among adults and adolescents: Ceftriaxone 500 mg* intramuscular (IM) in a single dose for persons weighing <150 kg * For persons weighing ≥150 kg, 1 g ceftriaxone should be administered.

ii.

If chlamydial infection has not been excluded, treat for chlamydia with: Doxycycline 100 mg orally 2 times per day for 7 days.

iii.
iii.

Alternative regiments if ceftriaxone is not available: Gentamicin 240 mg IM in a single dose PLUS Azithromycin 2 g orally in a single dose OR Cefixime* 800 mg orally in a single dose *If chlamydial infection has not been excluded, treat for chlamydia with doxycycline 100mg orally 2 times per day for 7 days.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 90 iv.

For Consideration: Division of Public Health 1.


Do not give doxycycline to pregnant clients or lactating client(s).

Client(s) must be advised to discontinue breastfeeding or receive alternative regimen.

2.

Dual therapy, using two antimicrobials with different mechanisms of action, improves treatment efficacy and potentially slows the emergence and spread of resistance to cephalosporin.

3.
3.

Co-treatment for gonorrhea and chlamydia, with appropriate drugs and dosage, reduces antimicrobial resistance and enhances pharyngeal treatment of gonorrhea.

4.

Azithromycin should be given via direct observation therapy (DOT) to increase adherence to therapy.

If self- reported allergy to azithromycin, consult with delegating physician for alternate treatment regimen 5.

If vomiting occurs within 1 hour of taking azithromycin, client should contact the clinic.
Dose should be repeated with ondansetron 8mg orally 30 minutes before repeat azithromycin dose.

If vomiting occurs with doxycycline within 1 hour, RN needs to contact prescribing provider for decision to continue doxycycline with ondansetron or use alternative.

c. Document dispensed medication as prescribed by the licensed provider.

i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.

Quantity dispensed v. Name of the delegating prescriber vi.
Date of original prescription vii.

Name of RN dispensing d. Offer the following contraceptive supplies: i.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

e. Report all positive test results within 72 hours.

RN should consult with clinic policy to understand procedure for disease reporting.
See STD: Information for Health Care Professionals, 2019 for more information.

f. Management of sex partners: i.

Educate on abstaining from intercourse until 7 days following the start of the treatment regimen and resolution of symptoms.

Abstain from sex until sex partner(s) have been adequately treated (for 7 days following the start of treatment and resolution of symptoms).

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 91 Division of Public Health ii.
Counsel on the importance of evaluation and treatment for the most recent sexual partner(s) per the Centers for Disease Control and Prevention, 2021.

1.

Recent sex partners (i.e., persons having sexual contact with the infected client within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive treatment.

2.
2.

Provide clients with written educational materials to give to their partner(s), to include notification that partner(s) have been exposed and information about the importance of treatment.

3.

Legal Status of EPT - Wisconsin, 2020 treatment of sex partners.

Refer to the Expedited Partner Therapy Protocol 5.

Physician, APNP, PA management or consultation required during visit: a.

When further medical guidance is needed, and standard protocol is not applicable for therapeutic treatment of client.

b.
b.

If client presents with signs and symptoms of infection.

Note: Most frequent presentation is asymptomatic.

i. Abnormal symptoms: 1.

Abnormal or increased discharge from vagina 2.

Intermenstrual or bleeding after intercourse (postcoital) 3.

Dysuria 4.

Pelvic pain 5.

Pain with sexual activity 6.

Mucoid or watery urethral discharge 7.

Itching of the urethral meatus 8.

Dysuria, pyuria, urinary frequency 9.

Pain or swelling of the testicles or penis ii.

Anal symptoms 1.

Rectal pain 2.


Discharge or bleeding 3.

Rectal itching ii.

Other clinical syndromes 1.

Pharyngitis 2.

Lymphadenopathy c. If vomiting occurs with doxycycline within 1 hour, RN must contact prescribing provider for decision to continue doxycycline with ondansetron or use alternative.

d. If client is allergic to cephalosporins or penicillin.

e. If client is pregnant.

f. If client is breastfeeding.

g. If suspected sexual or physical abuse of children.
h. Suspected therapeutic failure after treatment or symptoms that persist after treatment.

i.

If provider management and/or consultation not available, RN should provide referral.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 92 Division of Public Health 6.

Nursing skills: a.

Skills: i.

Client interviewing ii.

Client education iii.

Shared decision making and client-centered counseling iv.

Proper collection, handling, shipping of biological specimens b.
Clinical content knowledge: v. Infection basics and common signs and/or symptoms vi.

Infection treatment regimen and pharmacology vii.

Sexually transmitted infections and their common signs and/or symptoms per Centers for Disease Control and Prevention, 2019 viii.

Risk based STI screening recommendations outlined by the CDC, 2021 7.

Follow-up: a. Re-test after 3 months for re-exposure.

i.
i.

Test of cure (i.e., repeat testing after completion of therapy) is unnecessary for persons who receive a diagnosis of uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens.

Any person with pharyngeal gonorrhea should return 7–14 days after initial treatment for a test of cure by using either culture or NAAT ii.
If treated with an alternative regimen, the client should return 1 week after treatment for a test-of cure at the infected anatomic site b. RN should instruct client to follow up at clinic or with primary care provider if signs and/or symptoms persist after 3 days of treatment or recur.

8.

Referral to establish follow-up appointment with physician, APNP, PA, or specialty care provider is required for: a. Pregnancy.

b.

Urgent physical or mental distress.


c. Signs and/or symptoms requiring physical exam assessment.

d. STI symptoms consistent with pelvic inflammatory disease (PID), vaginitis, prostatitis, orchitis, or otherwise requiring physical exam assessment.

e. Retest laboratory result comes back positive indicating treatment failure.

9.

Links and resources: a.

Centers for Disease Control and Prevention.

(2021, July 19).

Gonococcal Infections Among Adolescents and Adults – STI Treatment Guidelines.
Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm a. STD: Information for Health Care Professionals.

(2019, September 11).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/std/health-pros.htm b.

Legal Status of EPT – Wisconsin.

(2020, March 23).

Www.cdc.gov.


https://www.cdc.gov/std/ept/legal/wisconsin.htm Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 93 Division of Public Health c. Centers for Disease Control and Prevention.

(2019).

CDC – STD diseases & related conditions.

CDC.

https://www.cdc.gov/std/general/default.htm d. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm b. Gonorrhea – CDC Fact Sheet.
(n.d.).

https://www.cdc.gov/std/gonorrhea/Gonorrhea- FS.pdf a. Walensky, R., Jernigan, D., Bunnell, R., Layden, J., Kent, C., Gottardy, A., Leahy, M., Martinroe, J., Spriggs, S., Yang, T., Doan, Q., King, P., Starr, T., Yang, M., Jones, T., Boulton, M., Brooks, C., Ma, J., Butler, V., & Caine, J.

(2021).
(2021).

Morbidity and Mortality Weekly Report Sexually Transmitted Infections Treatment Guidelines, 2021 Centers for Disease Control and Prevention MMWR Editorial and Production Staff (Serials) MMWR Editorial Board.

https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf b. Wisconsin State Laboratory of Hygiene | Wisconsin’s Public Health and Environmental Laboratory Since 1903.

(n.d.).

Retrieved December 14, 2022, from https://www.slh.wisc.edu c. MyPlate | U.S. Department of Agriculture.
(n.d.).

Www.myplate.gov.

http://www.myplate.gov d. Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: a.
Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: a.

Provide information on infection and treatment.

i.

Offer basic information on the infection (Gonorrhea - CDC Fact Sheet, n.d.) ii.

Educate about sequelae and complications of untreated infection.

iii.
iii.

Counsel clients regarding the importance of early re-evaluation if symptoms persist or recur.

b.

Provide client education on medication.

i.

Directions for medication administration and management of potential side effects.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 94 Division of Public Health ii.

Education on the importance of treatment adherence.

iii.

Educate clients about adverse effects of medications prescribed and document understanding.
c. Educate client about the laboratory result communication plan if treated presumptively.

Counsel on disease surveillance and communicable disease reporting process and to expect a phone call regarding a communicable disease investigation if lab test returns positive.

d. Instruction to return to clinic in 3 months for retesting.

e. Behavioral risk-reduction counseling: i.


Assist client(s) in developing a personalized STI and/or human immunodeficiency virus (HIV) risk reduction plan and document client(s) plan.

ii.

Elicit barriers to, and facilitators of, consistent condom use.

iii.

Elicit barriers to, and facilitators of, reducing substance abuse.

iv.

Assist client to identify 1 or 2 feasible, acceptable, incremental steps toward risk reduction.
v. Identify and address anticipated barriers to accomplishing planned actions to reduce risk.

vi.

Acknowledge the effort required for behavior change.

vii.

Reinforce success viii.

If not fully successful, assess factors interfering with completion of planned actions and assist client to identify next steps.

f. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.


Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.

Health screening education and/or anticipatory guidance: i.

Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to, Hepatitis A, Hepatitis B, HPV, and Monkeypox.

ii.
ii.

Counsel on and administer immunizations, if applicable.

b.

General reproductive health and family planning topics: i.

Discuss details of pelvic exam and make recommendations, as appropriate.

ii.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Discuss availability of providers for further questions or problems.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 95 Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Division of Public Health Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 96 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Syphilis Treatment Effective Date: [Add Date] Definition and/or scope: Clients seeking medical care at [clinic name] will be treated for Syphilis (Treponema pallidum) using best practice guidelines.
Procedure: 1.

Subjective: a. Assess reason for treatment: i.

Does client present with a known exposure to syphilis?

ii.

Does client present with positive syphilis test?

iii.

Does client present with signs and/or symptoms?

b. Assess for causes of biologic false positive VDRL test.

Point of care consultation indicated if client is VDRL positive and presents with: i. Connective tissue disease such as lupus and/or arthritis ii.

Immunizations iii.

Injection and/or illicit drug use iv.


Other infections such as HIV, hepatitis B, infectious mononucleosis v. Pregnancy vi.

Advanced age vii.

Lyme disease, Pinta (Mexico), Yaws (Africa), Hansen's disease (leprosy) c. Review current medications d. Review allergies i.

If allergic to cephalosporins or penicillin, assess if client has had desensitization.
e. Review and update sexual history f. Assess for pregnancy or breastfeeding g. Assess for indicated sexually transmitted infections (STI) screenings using RHFP RN Clinical Protocol for Asymptomatic STI Screening.

h. Assess for signs and symptoms of infection reported by client consistent with pelvic inflammatory disease (PID) that will require consultation and/or referral to MD, APNP, or PA. i. Assess skin for lesions and/or rash.

Document findings as well as symptoms reported by the client.
Syphilis occurs in stages; signs and symptoms associated with each stage are outlined by the CDC, 2019 fact sheet.

i.

If client presents with signs or symptoms, consultation with MD, APNP, or PA is required.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 97 Division of Public Health 2.

Objective: a.

Obtain and document vital signs if client is onsite.

i.

Recommend client come to clinic if not obtained within the last 12 months.
b. Assess for urgent physical and/or mental distress c. Positive test for T. pallidum.

3.

Assessment: a. Protocol applies as a result of positive laboratory result.

b. Protocol applies following consultation with MD, APNP, or PA. c. Protocol does not apply, refer to MD, APNP, or PA. 4.

Plan: a.

Consult with provider for staging of syphilis to guide treatment.

b.

Treat syphilis infection according to regimens recommended by the current CDC, 2019 guidelines.

i.

Recommended regimens for adults: 1.


Primary, secondary, and early latent (asymptomatic with duration less than one year): Benzathine penicillin G 2.4 million units intramuscular (IM) in a single dose 2.

Late Latent syphilis (indeterminate duration or with onset of symptoms >12 months prior to treatment): Benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units IM each at 1-week intervals.

a.

For consideration: i.


If a dose interval is more than 14 days, begin the series again.

ii.

If a client is pregnant, has known HIV, or signs and/or symptoms of neurosyphilis, refer to provider ii.
Alternate regimen for non-pregnant adult with penicillin allergy (primary, secondary syphilis, or clearly defined early latent): Doxycycline 100mg orally every 12 hours for 14 days (if client is 8 years of age or older) OR Tetracycline 500mg orally every 6 hours for 14 days if client is 8 years of age or older Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 98 Division of Public Health iii.
Alternate regimen for non-pregnant adult with penicillin allergy (late latent syphilis or unknown duration): Doxycycline 100mg orally every 12 hours for 28 days (if client is 8 years of age or older) OR Tetracycline 500mg orally every 6 hours for 28 days if client is 8 years of age or older a.

For consideration: i.

Do not administer Doxycycline or Tetracycline to lactating client(s).
Client(s) must be advised to discontinue breastfeeding throughout treatment and for two days after treatment or receive alternative regimen.

ii.

If breastfeeding clients are pumping during treatment, they should not provide pumped breast milk to infant throughout treatment and for two days after completion of treatment.

iii.
iii.

Do not give to minors under the age of 8. d. Recommended regimen for infants and children (consult provider prior to treating infant or child): Benzathine penicillin G 50,000 units/kg body weight IM, up to the adult dose of 2.4 million units in a single dose c. Document dispensed medication as prescribed by the licensed provider.

i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.

Quantity dispensed v. Name of the delegating prescriber vi.
Date of original prescription vii.

Name of RN dispensing d. Document indications for treatment: i.

Stages a.

Primary b.
Secondary c. Early latent (asymptomatic and < 1 year since onset of symptoms) d. Late latent (asymptomatic and > 1 year since onset of symptoms) e. Tertiary (consultation and referral indicated) f. Neurosyphilis (consultation and referral indicated) Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 99 Division of Public Health d. Recommend laboratory tests for other sexually transmitted infections (STI) as appropriate using RHFP RN Clinical Protocol for Asymptomatic STI Screening.

i.
i.

Recommend screening for other STIs as appropriate and refer to STI Screening Protocol ii.

If client presents with signs or symptoms, consult to provider (APNP/MD/PA).

e. Offer the following contraceptive supplies: i.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

f. Report all positive test results within 72 hours.
RN should consult with clinic policy to understand procedure for disease reporting.

See STD: Information for Health Care Professionals, 2019 for more information.

g. Management of sex partners: i.

Counsel on the importance of evaluation and treatment for the most recent sexual partner(s) per the CDC, 2021.

1.

Provide clients with written educational materials to give to their partner(s), to include notification that partner(s) have been exposed and information about the importance of treatment.

6.
6.

Physician, APNP, PA management or Consultation required during visit: a.

When further medical guidance is needed, and standard protocol is not applicable for therapeutic treatment of client.

b.

If client presents with signs and symptoms of infection.

See above table for list of signs and symptoms.

c. If client is pregnant.

d. If client is breastfeeding.

e. If treatment is for an infant or child.

f. If provider management and/or consultation not available, RN should provide referral.

7.
7.

Nursing skills: a.

Skills: i.

Client interviewing ii.

Client education iii.

Shared decision making and client-centered counseling iv.

Proper collection, handling, shipping of biological specimens b.

Clinical content Knowledge: i.

Infection basics and common signs and/or symptoms ii.

Sexually transmitted infections and their common signs and/or symptoms per Centers for Disease Control and Prevention, 2019 iii.
Risk based STI screening recommendations outlined by the CDC, 2021 Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 100 Division of Public Health 8.

Follow-up: a. RN should instruct client to follow up at clinic or with primary care provider at 6 and 12 months after treatment for clinical and serologic evaluation.

More frequent evaluation might be prudent if follow-up is uncertain or if repeat infection is a concern.
b. RN should instruct client to follow up at clinic or with primary care provider if signs and/or symptoms persist or recur after 2 weeks following treatment.

9.

Referral to establish follow-up appointment with physician, APNP, PA, or specialty care provider is required for: a. Pregnancy.

b.

Urgent physical or mental distress.

c. Signs and/or symptoms requiring physical exam assessment.
d. STI symptoms consistent with pelvic inflammatory disease (PID), vaginitis, prostatitis, orchitis, or otherwise requiring physical exam assessment.

e. Retest laboratory result comes back positive.

f. Allergies to treatment options.

g. RN should instruct client to seek emergency evaluation at the emergency room if client presents with signs and/or symptoms of neurologic, oto-, or ocular disease.

12.

Links and resources: a. CDC.

(2019).

STD Facts – Syphilis (Detailed).


Centers for Disease Control and Prevention.

https://www.cdc.gov/std/syphilis/stdfact-syphilis.htm b. CDC.

(2019).

CDC – Syphilis Treatment.

CDC.

https://www.cdc.gov/std/syphilis/treatment.htm c. STD: Information for Health Care Professionals.

(2019, September 11).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/std/health-pros.htm d. CDC.

(2021, July 14).

Syphilis Treatment Guidelines.

Www.cdc.gov.


https://www.cdc.gov/std/treatment-guidelines/syphilis.htm e. Centers for Disease Control and Prevention.

(2019).

CDC – STD diseases & related conditions.

CDC.

https://www.cdc.gov/std/general/default.htm f. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm g. Wisconsin State Laboratory of Hygiene | Wisconsin’s Public Health and Environmental Laboratory Since 1903.
(n.d.).

Retrieved December 14, 2022, from https://www.slh.wisc.edu h. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.

i. http://www.myplate.gov Immunization Schedules for Healthcare Professionals.

(2019).
(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 101 Division of Public Health Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: a.
Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: a.

Provide information on infection and treatment.

i.

Offer basic information on Syphilis infection using the CDC, 2019 fact sheet.

ii.

Educate about sequelae and complications of untreated infection.

iii.
iii.

Counsel clients regarding the importance of early re-evaluation if symptoms persist or recur.

b.

Provide client education on medication.

i.

Directions for medication administration and management of potential side effects.

ii.

Education on the importance of treatment adherence.

iii.

Educate clients about adverse effects of medications prescribed and document understanding.

1.
1.

Counsel the client regarding the possibility of developing a Jarisch-Herxheimer reaction within 24 hours after treatment for syphilis.

Symptoms may include fever, malaise, headache, musculoskeletal pain, nausea, and tachycardia.

A primary lesion may swell, and the lesions of secondary syphilis may increase or appear for the first time.

Reassure the client that if this occurs, it is normal, and they should drink fluids and take oral analgesics if needed.
c. Counsel on disease surveillance and communicable disease reporting process and to expect a phone call regarding a communicable disease investigation if lab test returns positive.

d. Behavioral risk-reduction counseling: i.

Assist client(s) in developing a personalized STD and/or human immunodeficiency virus (HIV) risk reduction plan and document client(s) plan.

ii.

Elicit barriers to, and facilitators of, consistent condom use.

iii.

Elicit barriers to, and facilitators of, reducing substance abuse.
iv.

Assist client to identify 1 or 2 feasible, acceptable, incremental steps toward risk reduction.

v. Identify and address anticipated barriers to accomplishing planned actions to reduce risk.

vi.

Acknowledge the effort required for behavior change.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 102 Division of Public Health vii.

Reinforce success viii.


If not fully successful, assess factors interfering with completion of planned actions and assist client to identify next steps.

e. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.

Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.


Discussion inadvisability of smoking 3.

Health screening education and/or anticipatory guidance: i. indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to, Hepatitis A, Hepatitis B, HPV, and Monkeypox.

ii.

Counsel on and administer immunizations, if applicable b.

General RHFP topics i.

Discuss details of pelvic exam and make recommendations, as appropriate.

ii.
ii.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 103 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Trichomoniasis Treatment Effective Date: [Add Date] Definition and/or scope: Clients seeking medical care at [clinic name] will be tested and treated for Trichomonas (Trichomonas vaginalis) using best practice guidelines.
Procedure: 1.

Subjective: a. Assess reason for treatment: i.

Does client present with a known exposure to trichomonas?

ii.

Does client present with positive trichomonas test?

iii.

Does client present with signs and/or symptoms?

iv.

Review current medications b.

Review allergies c. Review and update sexual history d. Assess for pregnancy or breastfeeding e. Assess for indicated sexually transmitted infections (STI) screenings using RHFP RN Clinical Protocol for Asymptomatic STI Screening.
f. Assess for signs and symptoms of infection reported by client including pelvic inflammatory disease (PID*) reported by client that will require consultation and/or referral to MD, APNP, PA.

Note: most frequent presentation is asymptomatic.

Abnormal symptoms: 1.

*Abnormal or increased discharge from vagina 2.

*Intermenstrual or bleeding after intercourse (postcoital) 3.

Dysuria 4.

*Pelvic pain 5.

*Pain with sexual activity 6.

Mucoid or watery urethral discharge 7.


Itching of the urethral meatus 8.

Dysuria, pyuria, urinary frequency 9.

Pain or swelling of the testicles or penis i. Anal symptoms: 1.

Rectal pain 2.

Discharge or bleeding 3.

Rectal itching ii.

Other clinical syndromes: 1.

Pharyngitis 2.

Lymphadenopathy Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 104 Division of Public Health 2.

Objective: a.

Obtain and document vital signs if client is onsite.

i.
i.

Recommend client come to clinic if not obtained within the last 12 months.

a. Assess for urgent physical and mental distress.

b.

Positive test for Trichomonas vaginalis.

3.

Assessment: a. Protocol applies: i.

As a result of positive laboratory result.

ii.

To treat presumptively based on asymptomatic presentation with exposure history.

b. Protocol applies following consultation with MD, APNP, or PA. c. Protocol does not apply, refer to MD, APNP, or PA. 4.

Plan: a.
Plan: a.

Treat trichomoniasis according to regimens recommended by the current CDC, 2021 guidelines.

i.

Regimen for non-pregnant clients assigned female at birth: Metronidazole 500mg orally 2 times per day for 7 days OR Tinidazole 2 g orally in a single dose ii.

Regimen for clients assigned male at birth: Metronidazole 2g orally in a single dose OR Tinidazole 2 g orally in a single dose iii.

For clients with HIV infection: Metronidazole 500mg orally every 12 hours for 7 days.

iv.
iv.

For Consideration: Refer pregnant or breastfeeding clients to provider.

b.

Document dispensed medications as prescribed by the licensed provider.

i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.

Quantity dispensed v. Name of the delegating prescriber vi.

Date of original prescription vii.


Name of RN dispensing c. Recommend laboratory tests for other sexually transmitted infections (STI) as appropriate using RHFP RN Clinical Protocol for Asymptomatic STI Screening.

d. Offer the following contraceptive supplies: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 105 Division of Public Health i.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.
ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

e. Management of sex partners: i.

Educate on abstaining from intercourse until 7 days following the start of the treatment regimen and resolution of symptoms.

Abstain from sex until sex partner(s) have been adequately treated (for 7 days following the start of treatment and resolution of symptoms).

ii.
ii.

Counsel on the importance of evaluation and treatment for the most recent sexual partner(s) per the CDC, 2021.

1.

Recent sex partners (i.e., persons having sexual contact with the infected client within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive treatment.

iii.
iii.

Provide clients with written educational materials to give to their partner(s), to include notification that partner(s) have been exposed and information about the importance of treatment.

iv.

Legal Status of EPT - Wisconsin, 2020 treatment of sex partners.

Refer to the Expedited Partner Therapy protocol.

5.

Physician, APNP, PA management or consultation required during visit: a.

When further medical guidance is needed, and standard protocol is not applicable for therapeutic treatment of client.
b.

If client presents with signs and symptoms of infection.

c. If client is pregnant d. If client is breastfeeding e. If provider management and/or consultation not available, RN should provide referral.

6.

Nursing skills: a.

Skills: i.

Client interviewing ii.

Client education iii.

Shared decision making and client-centered counseling iv.

Proper collection, handling, shipping of biological specimens b.

Clinical content knowledge: i.

Infection basics and common signs and/or symptoms ii.
Infection treatment regimen and pharmacology iii.

Sexually transmitted infection and their common signs and/or symptoms per Centers for Disease Control and Prevention, 2019 iv.

Risk based STI screening recommendations outlined by the CDC, 2021 Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 106 Division of Public Health 7.
Follow-up: a. Retest clients who are sexually active and high-risk within 3 months following initial treatment regardless of whether they believe their sex partners were treated.

b. RN should instruct client to follow up at clinic or with PCP if signs/symptoms persist or recur.

8.

Referral to establish follow-up appointment with physician, APNP, PA, or specialty care provider is required for: a. Pregnancy.

b.

Urgent physical or mental distress.


c. Signs and/or symptoms requiring physical exam assessment.

d. STI symptoms consistent with pelvic inflammatory disease (PID), vaginitis, prostatitis, orchitis, or otherwise requiring physical exam assessment.

e. Allergies to treatment options.

9.

Links and resources: a. CDC.

(2021, July 20).

Trichomoniasis – STI treatment guidelines.

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/trichomoniasis.htm b.

Legal Status of EPT – Wisconsin.


(2020, March 23).

Www.cdc.gov.

https://www.cdc.gov/std/ept/legal/wisconsin.htm c. Centers for Disease Control and Prevention.

(2019).

CDC – STD diseases & related conditions.

CDC.

https://www.cdc.gov/std/general/default.htm d. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm e. CDC.

(2019).

STD facts – trichomoniasis.

Centers for Disease Control and Prevention.


f. https://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html g. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.

http://www.myplate.gov h. Wisconsin State Laboratory of Hygiene | Wisconsin’s Public Health and Environmental Laboratory Since 1903.

(n.d.).
(n.d.).

Retrieved December 14, 2022, from https://www.slh.wisc.edu i. STD: Information for Health Care Professionals.

(2019, September 11).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/std/health-pros.htm Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.
Periodic Health screening completed annually or as indicated presenting concern: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 107 Division of Public Health a.

Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: a.


Provide information on infection and treatment.

b.

Offer basic information on trichomoniasis infection from the CDC, 2019 fact sheet.

c. Educate about sequelae and complications of untreated infection.

d. Counsel clients regarding the importance of early re-evaluation if symptoms persist or recur.

i.

Provide client education on medication.

e. Directions for medication administration and management of potential side effects.

f. Education on the importance of treatment adherence.
g. Educate clients about adverse effects of medications prescribed and document understanding i.

Educate client about the laboratory result communication plan if treated presumptively.

Counsel on disease surveillance and communicable disease reporting process and to expect a phone call regarding a communicable disease investigation if lab test returns positive.

ii.

Instruction to return to clinic in 3 months for retesting.

h. Behavioral risk-reduction counseling: i.


Assist client(s) in developing a personalized STI and/or human immunodeficiency virus (HIV) risk reduction plan and document client(s) plan.

ii.

Elicit barriers to, and facilitators of, consistent condom use.

iii.

Elicit barriers to, and facilitators of, reducing substance abuse iv.

Assist client to identify 1 or 2 feasible, acceptable, incremental steps toward risk reduction.
v. Identify and address anticipated barriers to accomplishing planned actions to reduce risk.

vi.

Acknowledge the effort required for behavior change.

vii.

Reinforce success viii.

If not fully successful, assess factors interfering with completion of planned actions and assist client to identify next steps.

i.

Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.


Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 108 Division of Public Health vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.

Health screening education and/or anticipatory guidance: a.
Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to, Hepatitis A, Hepatitis B, HPV, and Monkeypox.

i.

Counsel on administer immunizations clients, if applicable.

b.

General reproductive health family planning topics: c. Discuss details of pelvic exam and make recommendations, as appropriate.

d. Discuss Pap testing guidelines and make recommendation, as appropriate.

e. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders [Clinic Name] Reproductive Health RN Protocol Mycoplasma Genitalium Treatment Effective Date: [Add Date] Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 109 Division of Public Health Definition and/or scope: Clients seeking medical care at, [clinic name] will be treated for mycoplasma genitalium (Mgen) using best practice guidelines.
Procedure: 1.

Subjective: a. Assess reason for treatment: i.

Does client present with a known exposure to Mgen?

ii.

Does client present with positive Mgen test?

iii.

Does client present with signs and/or symptoms?

b.

Review current medications c. Review allergies d. Review and update sexual history e. Assess for pregnancy or breastfeeding f. Assess for indicated STI screenings using RHFP RN Clinical Protocol for Asymptomatic STI Screening.
g. Assess for signs and symptoms of infection reported by client including pelvic inflammatory disease (PID*) that will require consultation and/or referral to MD, APNP, or PA.

Note: most frequent presentation is asymptomatic.

i. Abnormal symptoms: 1.

*Abnormal discharge from vagina 2.

*Intermenstrual or bleeding after intercourse (postcoital) 3.

*Pelvic pain or discomfort 4.

*Pain with sexual activity 5.

Mucoid or watery urethral discharge 6.

Itching of the penile urethral meatus 7.


Dysuria, pyuria, urinary frequency 2.

Objective: a.

Obtain and document vital signs if client is onsite.

i.

Recommend client come to clinic if not obtained within the last 12 months.

b. Assess for urgent physical and/or mental distress.

c. Positive test (amplification, culture, DNA probe) for Mgen.

3.

Assessment: a. Protocol applies: i.

As a result of a positive laboratory result.

ii.


To treat presumptively, based on asymptomatic presentation with exposure history, when testing not possible.

b. Protocol applies following consultation with MD, APNP, or PA. c. Protocol does not apply, refer to MD, APNP, or PA. 4.

Plan: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 110 Division of Public Health a.
Recommend laboratory tests for other STIs as appropriate using RHFP RN Clinical Protocol for Asymptomatic STI Screening.

b.

If known exposure and unable to test may initiate presumptive treatment for Mgen.

c. Treat Mgen infection according to regimens recommended by the current Mycoplasma Genitalium - STI Treatment Guidelines, 2021.
Doxycycline 100mg orally every 12 hours for 7 days (Preferred per 2021 CDC STI guidelines) Resistance Testing Available Macrolide Sensitive Macrolide Resistant Follow Doxycycline with Azithromycin 1g orally initial dose, followed by 500mg orally once daily for 3 days Follow Doxycycline with Moxifloxacin 400mg orally once daily for 7 days Resistance Testing NOT Available Follow Doxycycline with Moxifloxacin 400mg orally once daily for 7 days i.

For Consideration: 1.


Do not give doxycycline to pregnant clients or lactating client(s).

Client(s) must be advised to discontinue breastfeeding or receive alternative regimen.

2.

If vomiting occurs within 1 hour of taking azithromycin, client should contact the clinic.

Dose should be repeated with ondansetron 8mg orally 30 minutes before repeat azithromycin dose.
If vomiting occurs with doxycycline within 1 hour, RN needs to contact prescribing provider for decision to continue doxycycline with ondansetron or use alternative regimen.

d. Document dispensed medication as prescribed by the licensed provider.

i.

Name of medication ii.

Dose of medication iii.

Instructions to take the medication iv.

Quantity dispensed v. Name of the delegating prescriber vi.

Date of original prescription vii.

Name of RN dispensing e. Offer the following contraceptive supplies: i.
Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

f. Management of sex partners: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 111 Division of Public Health i.

Educate on future transmission reduction as available through CDC ii.
Counsel on the importance of evaluation and treatment for the most recent sexual partner(s) per the Mycoplasma Genitalium - STI Treatment Guidelines, 2021.

1.

If patient is symptomatic notify sex partners of last 60 days of positive test result and CDC recommendation for partner testing 2.

Provide clients with written educational materials, as available through CDC, to give to their partner(s), to include notification that partner(s) have been exposed and information about the importance of treatment.
3.

If testing is not possible, the same regimen that was provided to the patient can be provided to the partner per CDC guidelines.

Wisconsin Legislature: DHS §145.22 (n.d.) for EPT does not include Mgen.

5.

Physician, APNP, PA management or consultation required during the visit: a.

When further medical guidance is needed, and standard protocol is not applicable for therapeutic treatment of client.

b.

If client presents with signs and symptoms of infection.
Note: Most frequent presentation is asymptomatic.

c. If vomiting occurs with doxycycline within 1 hour, RN must contact prescribing provider for decision to continue doxycycline with ondansetron or use alternative regimen.

d. If client presents with allergies or intolerance to all treatment options.

e. If client is pregnant.

f. If client is breastfeeding.

g. If provider management and/or consultation not available, RN should provide referral.

6.

Nursing skills: a.

Skills: i.

Client interviewing ii.


Client education iii.

Shared decision making and client-centered counseling iv.

Proper collection, handling, shipping of biological specimens b.
Clinical content knowledge: c. Infection basics and common signs and/or symptoms d. Infection treatment regimen and pharmacology e. Sexually transmitted infections and their common signs and/or symptoms per Centers for Disease Control and Prevention, 2019 f. Risk based STI screening recommendations outlined by the CDC, 2021 7.

Follow-up: a. RN should instruct client to follow up at clinic or with primary care provider if signs and/or symptoms persist after 3 days of treatment or recur.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 112 Division of Public Health 8.

Referral to establish follow-up appointment with physician, APNP, PA, or specialty care provider is required for: a. Pregnancy.

b.

Urgent physical or mental distress.

c. Signs and/or symptoms requiring physical exam assessment.

d. STI symptoms consistent with pelvic inflammatory disease (PID), vaginitis, prostatitis, orchitis, or otherwise requiring physical exam assessment.
e. Retest laboratory result comes back positive 9.

Links and resources: a. Mycoplasma genitalium – STI Treatment Guidelines.

(2021, July 14).

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/mycoplasmagenitalium.htm b. Wisconsin Legislature: DHS 145.22.

(n.d.).

Docs.legis.wisconsin.gov.

Retrieved December 14, 2022, from https://docs.legis.wisconsin.gov/code/admin_code/dhs/110/145/iii/22 c. Centers for Disease Control and Prevention.

(2019).

CDC – STD diseases & related conditions.

CDC.


https://www.cdc.gov/std/general/default.htm d. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm e. STD: Information for Health Care Professionals.

(2019, September 11).

Wisconsin f. Department of Health Services.

https://www.dhs.wisconsin.gov/std/health-pros.htm Immunization Schedules for Healthcare Professionals.

(2019).
(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html g. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.

http://www.myplate.gov Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: a.
Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 113 Division of Public Health a.

Provide information on infection and treatment.

b.

Offer basic information on the infection.


c. Educate about sequelae and complications of untreated infection.

d. Counsel clients regarding the importance of early re-evaluation if symptoms persist or recur.

i.

Provide client education on medication.

e. Directions for medication administration and management of potential side effects.

f. Education on the importance of treatment adherence.

g. Educate clients about adverse effects of medications prescribed and document understanding.
i. Behavioral risk-reduction counseling: 1.

Assist client(s) in developing a personalized STI and/or human immunodeficiency virus (HIV) risk reduction plan and document client’s plan.

2.

Elicit barriers to, and facilitators of, consistent condom use.

3.

Elicit barriers to, and facilitators of, reducing substance abuse.

4.

Assist client to identify 1 or 2 feasible, acceptable, incremental steps toward risk reduction.

5.
5.

Identify and address anticipated barriers to accomplishing planned actions to reduce risk.

6.

Acknowledge the effort required for behavior change.

7.

Reinforce successes 8.

If not fully successful, assess factors interfering with completion of planned actions and assist client to identify next steps.

h. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.


Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.

Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Discuss emergency contraception options and availability discussed.
d. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI screening.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 114 e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to Division of Public Health i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.


Monkeypox f. Provide information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.

g. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders [Clinic Name] Reproductive Health RN Protocol Template Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 115 Division of Public Health HIV PrEP Effective Date: [Add Date] Definition and/or scope: Pre-exposure prophylaxis (PrEP) is prescribed to HIV-negative adults and adolescents who are at high risk for getting human immunodeficiency virus (HIV) through sex or injection drug use.
Procedure: 1.

Subjective: a. Assess risk of HIV acquisition and PrEP indication using the CDC, 2020 algorithm below.

b. Assess indications for PrEP in people who inject drugs using CDC, 2020 algorithm below.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 116 Division of Public Health 3.

Objective: a.

Obtain and document vital signs if client is onsite.

i.

Recommend client come to clinic if not obtained within the last 12 months.
b. Assess for urgent physical or mental distress.

4.

Assessment: a. Protocol applies b. Protocol applies following consultation with MD, APNP, or PA. c. Protocol does not apply, refer to MD, APNP, or PA. 5.

Plan: a. Assess type of treatment desired: Oral vs. Injectable b. Assess HIV status based on the CDC, 2020 algorithm Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 117 c. Assess required baseline and ongoing testing based on type of therapy.
Division of Public Health d. Caution prior to PrEP initiation: i.

No antiretroviral regimens should be used for PrEP other than a daily oral dose of tenofovir disoproxil fumarate/emtricitabine (TDF/FTC), or a daily dose of TDF alone as an alternative only for persons who inject drugs and heterosexually active adults.

ii.

Do not use other antiretroviral medications (e.g., 3TC, TAF [tenofovir alafenamide]), either in place of, or in addition to, TDF/FTC or TDF.

iii.
iii.

Do not use other than daily dosing (e.g., intermittent, episodic [pre and/or post sex only], or other discontinuous dosing) iv.

Do not provide PrEP as expedited partner therapy (i.e., do not prescribe for an uninfected person not in your care).

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 118 Division of Public Health e. Prescribe regimen approved for HIV PrEP.

Do not prescribe for more than 3 months at a time.

i.

Note: HIV Rapid test MUST be negative.


Tenofovir DF 300mg-emtricitabine take one tablet orally once daily OR Tenofovir alafenamide 25mg-emtricitabine 200 mg take one tablet orally once daily OR Cabotegravir 600mg intramuscular injection in the buttocks once.

Second dose to be given 1 month after first dose.

Subsequent doses to be given every 2 months after previous dose until therapy is discontinued.

ii.
ii.

The use of a 2-inch needle is recommended for intramuscular injection for participants with a body-mass index (BMI) of 30 or greater, and a 1.5-inch needle for participants with a BMI of less than 30 iii.

Recommendation is to continue PrEP for one month after the last high-risk exposure.

f. Document dispensed medication as prescribed by the licensed provider.

i.

Name of the medication ii.

Dose of the medication iii.

Instructions to take the medication iv.


Quantity dispensed v. Name of the delegating prescriber vi.

Date of original prescription vii.

Name of RN completing visit g. Offer the following contraceptive supplies: i.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

6.
6.

Physician, APNP, PA management or consultation required during visit: a.

If creatinine clearance is less than 60ml/min b.

If any baseline or periodic testing comes back abnormal.

c. If provider management and/or consultation not available, RN should provide referral.

7.

Nursing skills: a.

Skills: v. Client interviewing vi.

Client education vii.


Shared decision making and client-centered counseling Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 119 Division of Public Health i.

Clinical content knowledge: viii.

Infection basics and common signs and/or symptoms ix.

Infection treatment regimen and pharmacology x. Sexually transmitted infections and their common signs and/or symptoms per Centers for Disease Control and Prevention, 2019 xi.
Risk based STI screening recommendations outlined by the CDC, 2021 xii.

Impact of insurance on method coverage; skills to provide assistance with pharmacy benefits, prior authorization, Family Planning Only Servicesc, 2014.

8.

Follow-up: a.

Client should follow up with primary care or specialist after initiation of PrEP.

RN to encourage and facilitate through point of care consultation.

b.

Discontinue PrEP if contraindications to ongoing PrEP.

c. Discontinue PrEP in any client who: i.


Has a confirmed positive HIV test.

The antiretroviral (ARV) regimen should be converted to a fully active antiretroviral therapy (ART) regimen.

Refer to a specialist or primary care provider ii.

Develops a confirmed calculated creatinine clearance (eCrCl) <60 mL/min while taking tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) or eCrCl >30 mL/min while taking tenofovir alafenamide/emtricitabine (TAF/FTC).
d. At every follow up visit: i. Assess side effects, adherence, and HIV acquisition risk behaviors.

ii.

Provide support for medication adherence and risk-reduction behaviors.

iii.

Respond to new questions and provide any new information about PrEP use.

iv.

If other threats to renal safety are present (e.g., hypertension, diabetes), renal function may require more frequent monitoring or may need to include additional tests (e.g., urinalysis for proteinuria).
v. A rise in serum creatinine is not a reason to withhold treatment if eCrCl remains ≥60 ml/min.

vi.

If eCrCl is declining steadily (but still ≥60 ml/min), consultation with a nephrologist or other evaluation of possible threats to renal health may be indicated.

i.

If taking injectable, reassess liver function if symptomatic vii.

Evaluate the need to continue PrEP as a component of HIV prevention Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 120 Division of Public Health 9.
Referral to provider is required for: a. Pregnancy b.

Urgent physical or mental distress c. Creatinine clearance is less than 60ml/min d. Positive HIV test to Vivent Health e. Breastfeeding 9.

Links and resources: a. Pre-Exposure Prophylaxis (PrEP) | HIV Risk and Prevention | HIV/AIDS | CDC.

(2020, June 4).

Www.cdc.gov.

https://www.cdc.gov/hiv/risk/prep b.

Learn About PrEP | Preventing New HIV Infections | Clinicians | HIV | CDC.

(2020, May 19).

Www.cdc.gov.


https://www.cdc.gov/hiv/clinicians/prevention/prep.html c. Centers for Disease Control and Prevention.

(2019).

CDC – STD diseases & related conditions.

CDC.

https://www.cdc.gov/std/general/default.htm d. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm e. Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.


https://www.dhs.wisconsin.gov/fpos/index.htm f. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2017 Update a Clinical Practice.

(n.d.).

https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep- guidelines-2017.pdf g. Vivent Health | Excellence in Health Care.

(n.d.).

Viventhealth.org.

https://viventhealth.org h. CDC.

(2019).

HIV/AIDS.

Centers for Disease Control and Prevention.


i. https://www.cdc.gov/hiv/default.html Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html j. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.


http://www.myplate.gov Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: a.

Intimate partner violence, domestic violence, sexual assault b.
Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 121 2.

Client education: Division of Public Health a.

Offer basic information and the significance of the infection.

Educate about sequelae and complications of untreated infection based on the fact sheet from the CDC, 2019. b.
Duration of PrEP: i.

Educate client to continue PrEP as long as the risk of infection with either main or non-main partners persists.

ii.

Educate client that PrEP should be continued until the HIV- infected partner has achieved a stably suppressed viral load (e.g., typically by six months after initiating antiretroviral therapy [ART]).

c. Medication adherence counseling: i.

Directions for medication administration and management of potential side effects.

ii.
ii.

Educate clients about adverse effects of medications prescribed and document understanding.

iii.

Relationship of adherence to the efficacy of PrEP iv.

Signs and symptoms of acute HIV infection and recommended actions.

v. Identify reminders and devices to minimize forgetting doses.

vi.

Identify and address barriers to adherence.

vii.

Normalize occasional missed doses, while ensuring client understands importance of daily dosing for optimal protection.

viii.

Reinforce success ix.


Identify factors interfering with adherence and plan with client to address them.

x. Assess side effects and plan how to manage them.

d. Behavioral risk-reduction counseling: i.

Assist client(s) in developing a personalized STD and/or HIV risk reduction plan and document client(s) plan.

ii.

Elicit barriers to, and facilitators of, consistent condom use.

iii.

Elicit barriers to, and facilitators of, reducing substance abuse.

iv.
iv.

Assist client to identify 1 or 2 feasible, acceptable, incremental steps toward risk reduction.

v. Identify and address anticipated barriers to accomplishing planned actions to reduce risk.

vi.

Acknowledge the effort required for behavior change.

vii.

Reinforce success viii.

If not fully successful, assess factors interfering with completion of planned actions and assist client to identify next steps.

e. Discontinuing PrEP with ongoing exposure risk: i.
Educate client that protection from HIV infection will wane over 7-10 days after stopping daily PrEP use.

ii.

Discuss alternative methods to reduce risk for HIV acquisition.

iii.

Educate about indications for PEP and how to access it.

iv.

Counsel the client about use of contraception, risks of pregnancy (intended and unintended), and reproductive life plan if applicable.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 122 Division of Public Health v. Educate client about the laboratory result communication plan.

f. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.

Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.


Discussion inadvisability of smoking 3.

Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Discuss emergency contraception options and availability discussed.

d. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI screening.
e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox f. Provide information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.

g. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 123 Division of Public Health [Clinic Name] Reproductive Health RN Protocol HIV nPEP Effective Date: [Add Date] Definition and/or scope: Nonoccupational post-exposure prophylaxis (nPEP) is the use of antiretroviral drugs after a single high-risk event to prevent human immunodeficiency virus (HIV) acquisition.
Procedure: 1.

Subjective: a. Assess for nPEP indications: i. Prescribe a 28-day course of nPEP for HIV-uninfected persons who seek care ≤72 hours after a non-occupational exposure to blood, genital secretions, or other potentially infected body fluids of persons known to be HIV infected or of unknown HIV status when that exposure represents a substantial risk for HIV acquisition.
b. Assess risks for HIV transmission from the CDC, 2019: Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 124 Division of Public Health i. Parenteral exposure risk: 1.

Blood transfusion 2.

Needle sharing during injection drug use 3.

Percutaneous (needlestick) ii.

Sexual exposure risk (Consensual and Assault): 1.

Receptive anal intercourse 2.

Receptive penile-vaginal intercourse 3.

Insertive anal intercourse 4.

Insertive penile-vaginal intercourse 5.


Oral sex with intact oral mucosa: Low Risk iii.

Factors that increase risk of transmission through sexual exposure: 1.

Source with known HIV infection who is not taking ART or has incomplete viral suppression.

2.

Source with high HIV viral load levels 3.

Absence of barrier protection, such as male/insertive or female/receptive condoms.

4.

Presence of genital ulcer disease or other sexually transmitted infection.

5.

Trauma at the site of exposure.

6.


Exposed individual reports frank blood exposure, post- exposure prophylaxis is indicated.

7.

Uncircumcised penis 8.

Non-intact oral mucosa (e.g., oral lesions, gingivitis, wounds) in oral sexual exposure iv.

Other Exposure Types (negligible risk): 1.

Biting 2.

Spitting 3.

Throwing bodily fluids, including semen or saliva 4.

Sharing adult sexual pleasure products v. Factors that increase risk of transmission through other exposures: 1.
Source with high HIV viral load 2.

Activity involving exposure to blood c. Assess for potential barriers to adherence to nPEP: i. Depression ii.

Active substance use iii.

Stigma iv.

Other socioeconomic factors 2.

Objective: a.

Obtain and document vital signs if client is onsite.

i.

Recommend client come to clinic if not obtained within the last 12 months.

b. Assess for urgent mental or physical distress.


Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 125 Division of Public Health 3.

Assessment: a. Protocol applies b. Protocol applies following consultation with MD, APNP, or PA. c. Protocol does not apply, refer to MD, APNP, or PA. 4.

Plan: a. Assessing risk of treatment (baseline and continuous monitoring): b. Prescribe regimen approved for nPEP: i.
Preferred and alternative antiretroviral medication 28-day regimens for nPEP for Adults and Adolescents aged ≥13 years, including pregnant clients, with normal renal function (crCl ≥60mL/min) Tenofovir DF 300mg-emtricitabine 200 mg orally once daily with Raltegravir 400mg orally twice daily OR Tenofovir DF 300mg-emtricitabine 200 mg orally once daily with Dolutegravir 50mg orally once daily Alternate Treatment Tenofovir DF 300mg-emtricitabine 200 mg orally once daily with Darunavir 800mg orally twice daily OR Tenofovir DF 300mg-emtricitabine 200 mg orally once daily with Ritonavir 100mg orally once daily Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 126 Division of Public Health ii.
Preferred and alternative antiretroviral medication 28-day regimens for nPEP for Adults and Adolescents aged ≥13 years with abnormal renal function Zidovudine-Lamivudine (adjusted doses based on renal function) orally with Raltegravir 400mg orally twice daily OR Zidovudine-Lamivudine (adjusted doses based on renal function) orally with Dolutegravir 50mg orally once daily Alternate Treatment Zidovudine-Lamivudine (adjusted doses based on renal function) orally with Darunavir 800mg orally once daily OR Zidovudine-Lamivudine (adjusted doses based on renal function) orally with Ritonavir 100mg orally once daily c. Document dispensed medications as prescribed by the licensed provider: i.
Name of the medication ii.

Dose of the medication iii.

Instructions to take the medication iv.

Quantity dispensed v. Name of the delegating prescriber vi.

Date of original prescription vii.

Name of RN completing visit d. Offer the following contraceptive supplies: i.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

5.
5.

Physician, APNP, PA management or consultation required during visit: a.

If Creatinine Clearance is less than 60ml/min.

b.

If a client presents with exposure to antiretroviral (ARV)-resistant HIV.

c. If an exposed client presents with limited options for PEP medications due to potential drug-drug interactions or comorbidities.

d. If the exposed client is pregnant.

e. If provider management and/or consultation not available, RN should provide referral.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 127 Division of Public Health 6.

Nursing skills: a.

Skills: i.

Client interviewing ii.

Client education iii.

Shared decision making/client-centered counseling b.

Clinical content knowledge: i.

Infection basics and common sign and/or symptoms ii.

Infection treatment regimen and pharmacology iii.

Sexually transmitted infections and their common signs and/or symptoms per Centers for Disease Control and Prevention, 2019 iv.
Risk based STI screening recommendations outlined by the CDC, 2021 v. Impact of insurance on method coverage; skills to provide assistance with pharmacy benefits, prior authorization, Family Planning Only Services, 2014.

7.

Follow-up: a.

One day after initial visit: i.

Call client to make sure they were able to get their medication at the pharmacy.

b. HIV test at 30 and 90 – days post exposure i.

If either is a Positive test result refer to Vivent Health 8.
Referral to establish follow-up appointment with physician, APNP, PA, or specialty care provider is required: a.

If creatinine clearance is less than 60ml/min.

b.

A source with ARV-resistant HIV c. An exposed individual with limited options for PEP medications due to potential drug-drug interactions or comorbidities.

d. An exposed individual who is pregnant.

e. Positive laboratory testing for HIV (Vivent Health), Hepatitis C, Hepatitis B 9.

Links and resources: a. CDC.

(2019).

HIV Transmission.


CDC.

https://www.cdc.gov/hiv/basics/transmission.html b. Dominguez, K.L., Smith, D.K., Thomas, V., Crepaz, N., Lang, K., Heneine, W., McNicholl, J.M., Reid, L., Freelon, B., Nesheim, S.R., Huang, Y.A., & Weidle, P.J.

(2016).

Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV – United States, 2016.

Cdc.gov.

https://stacks.cdc.gov/view/cdc/38856 c. CDC.

(2019).

HIV/AIDS.
(2019).

HIV/AIDS.

Centers for Disease Control and Prevention.

https://www.cdc.gov/hiv/default.html d. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm e. Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/fpos/index.htm f. Vivent Health | Excellence in Health Care.

(n.d.).

Viventhealth.org.


https://vienthealth.org g. HIV 101 Without treatment.

(2020).
(2020).

https://www.cdc.gov/hiv/pdf/library/consumer- info-sheets/cdc-hiv-consumer-info-sheet-hiv-101.pdf Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 128 Division of Public Health Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.
Periodic Health screening completed annually or as indicated presenting concern: a.

Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: a.

Offer basic information and the significance of HIV infection.
Educate about sequelae and complications of untreated infection with the HIV, 2020 fact sheet.

b.

Medication adherence counseling: i.

Directions for medication administration and management of potential side effects.

ii.

Educate clients about adverse effects of medications prescribed and document understanding.

iii.

Relationship of adherence to the efficacy of post-exposure prophylaxis.

iv.

Signs and symptoms of acute HIV infection and recommended actions.
v. Identify reminders and devices to minimize forgetting doses.

vi.

Identify and address barriers to adherence.

vii.

Normalize occasional missed doses, while ensuring client understands importance of daily dosing for optimal protection.

viii.

Reinforce success ix.

Identify factors interfering with adherence and plan with client to address them.

x. Assess side effects and plan how to manage them.

c. Behavioral risk-reduction counseling: i.


Assist client(s) in developing a personalized STD and/or HIV risk reduction plan and document client(s) plan.

ii.

Elicit barriers to, and facilitators of, consistent condom use.

iii.

Elicit barriers to, and facilitators of, reducing substance abuse.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 129 Division of Public Health iv.

Assist client to identify 1 or 2 feasible, acceptable, incremental steps toward risk reduction.
v. Identify and address anticipated barriers to accomplishing planned actions to reduce risk.

vi.

Acknowledge the effort required for behavior change.

vii.

Reinforce success viii.

If not fully successful, assess factors interfering with completion of planned actions and assist client to identify next steps.

d. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.


Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.

Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Discuss emergency contraception options and availability discussed.
d. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI screening.

e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox f. Provide information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.
g. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 130 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Template Pregnancy Testing and Counseling Effective Date: [Add Date] Definition and/or scope: [Clinic name] will provide pregnancy testing, counseling, education, and referral as part of core family planning services.
Pregnancy testing provides an important entry point for contraceptive needs assessment, providing education and counseling about reproductive life plan, and referral, if indicated.

Procedure: 1.

Subjective: a.

Obtain pertinent medical health history, including: i.

Review current medications and allergies.

ii.

Reproductive and sexual health history: a. Menstrual history, including last menstrual period (LMP) b.
Contraceptive history c. Pregnancy history d. Sexual history including sexually transmitted infection (STI) iii.

Family health history: a.

History of poor pregnancy outcomes, still birth, birth defects, developmental disabilities, genetic defects.

iv.

Previous surgeries, hospitalizations, serious illnesses, or injuries v. Previous and current medical conditions vi.

Social history a.

Substance use disorder b.

Intimate partner violence ii.

Dietary and activity history vii.

Immunization history viii.


Depression Screen ix.

Assess for signs and symptoms reported by the client in the review of systems that will require consultation and/or referral to MD, APNP, or PA: a.

Positive pregnancy test with vaginal bleeding or pelvic or abdominal pain 2.

Objective: a.

Obtain and document vital signs if client is onsite.

i.

Recommend client come to clinic if not obtained within the last 12 months.

b. Assess for urgent physical or mental distress.


c. Obtain urine hCG (human chorionic gonadotrophin) pregnancy test.

d. Fetal heart rate (if applicable) Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 131 Division of Public Health e. Clients presenting for pregnancy testing should also be offered STI screening as appropriate based on CDC, 2021 and WSLH selective screening criteria (SSC).

i.
i.

Recommend laboratory tests for other sexually transmitted infections (STI) as appropriate using RHFP RN Clinical Protocol for Asymptomatic STI Screening.

3.

Assessment: a. Protocol applies b. Protocol applies following consultation with MD, APNP, or PA. c. Protocol does not apply, refer to MD, APNP, or PA. 4.

Plan: Negative Pregnancy Test Pregnancy is not desired Pregnancy is desired a.

Discuss reproductive life plan a.


Discuss reproductive life plan using PATH model or similar client-centered counseling technique.

b. Assess current contraceptive method, including client satisfaction with method and need for further management.

c. Educate about contraceptive options as appropriate and offer contraceptive management.

d. Offer internal & external condoms and EC.

using PATH model or similar client-centered counseling technique.

b.

Educate on preconception health.


c. Provide prescription for folic acid supplement 400mcg orally once daily.

d. Or provide prescription for prenatal vitamins with folic acid orally once daily.

Positive Pregnancy test 1.

If the client is <18 years of age, complete family engagement plan.

2.

Offer clients the opportunity to be provided information and counseling regarding each of the following options: a. Prenatal care and delivery b.
Infant care, foster care, or adoption c. Pregnancy termination 3.

If requested, provide such information and counseling; provide neutral factual information and nondirective counseling on each of the options, and referral upon request, except with respect to any option(s) about which the pregnancy client indicates they do not wish to receive such information and counseling.

4.

If client chooses option a. or b. a.

Provide prescriptions for prenatal vitamins orally daily.

b.
b.

Provide referral and/or warm handoff to follow up care.

5.

If client chooses option c., the clinic will provide the client with a directory of services.

6.

Complete client education on relevant topics as outlined below.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 132 Division of Public Health 5.

Physician, APNP, PA management or consultation required during visit: a. Abnormal findings or symptoms b.
Indications for lab testing identified c. Request for physical exam d. If provider management and/or consultation not available, RN should provide referral.

6.

Nursing skills: a.

Skills: i.

Client assessment ii.

Client-centered counseling iii.

Client education b.

Knowledge: i. Pregnancy educational topics, including but not limited to: 1.

Nutrition during pregnancy.

2.

Social support programs available in your area.

3.

Pregnancy risk factors.

4.

Pregnancy danger signs.

7.

Follow-up: a.


Provide referral for the following or assist with enrollment, if applicable.

Document the appointment dates and follow up plan of care: i.

First breath program ii.

Prenatal Care Coordination (PNCC) iii.

Women, Infants and Children Nutrition Program (WIC) iv.

Badger Care Plus v. Family Planning Only Services (FPOS) vi.

Primary care services vii.

Mental health and/or psychiatric services viii.

Substance abuse services ix.


Prenatal care services (family medicine, OB/GYN, certified nurse midwife) x. Infertility services 8.

Referral to provider is required for: a.

Positive Pregnancy test with vaginal bleeding or pelvic pain b.

Urgent Physical or mental distress 9.

Links and resources: a. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm a. CDC.

(2019, June 11).

Pregnancy.


Centers for Disease Control and Prevention.

https://www.cdc.gov/pregnancy/index.html b. ACOG Committee Opinion Prepregnancy Counseling.

(n.d.).

https://www.acog.org/- /media/project/acog/acogorg/clinical/files/committee- opinion/articles/2019/01/prepregnancy-counseling.pdf c. First Breath.

(n.d.).

Retrieved December 14, 2022, from https://wwhf.org/first-breath/ d. Immunization Schedules for Healthcare Professionals.

(2019).
(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 133 Division of Public Health e. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.

http://www.myplate.gov Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.
Periodic Health screening completed annually or as indicated presenting concern: a.

Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: a.

Document education provided in client’s health record.

b.

Provide client educational handouts, as appropriate.
c. Pregnancy educational topics: i.

What to expect from prenatal care or other follow-up care ii.

Avoiding alcohol, tobacco, and recreational drugs during pregnancy 1.

If a smoker, refer to First Breath, n.d. iii.

Nutrition during pregnancy iv.

Social determinants of health needs (housing, food insecurity, etc.)

and refer to social support programs as appropriate (see referral list below).

v. Preventing exposure to STI during pregnancy through barrier methods, as appropriate.

vi.
vi.

Review drugs/medications that client is taking (prescription, OTC or other) to ensure they are safe to use during pregnancy.

vii.

Review pregnancy risk factors, as applicable: 1.

Hypertension 2.

Polycystic ovarian syndrome (PCOS) 3.

Diabetes 4.

Kidney disease 5.

Thyroid disease 6.

Autoimmune disease Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 134 Division of Public Health 7.

Obesity 8.

Sexually transmitted infections (STIs) 9.


Teen pregnancy 10.First pregnancy after age 35 11.Multiple pregnancy (twins, etc.)

viii.

Review pregnancy danger signs: 1.

Blurred vision, spots, or light flashes with or without a headache.

2.

Pain or burning when you urinate, or unusually frequent urination.

3.

Temperature above 100.4 degrees Fahrenheit lasting longer than 24 hours.

4.

Sudden severe or continuous pain or cramping in the lower abdomen.

5.

Bleeding or spotting from your vagina.

6.


Sudden, severe swelling of your hands, feet or face.

7.

Symptoms of vaginal infection: itching, burning and increase of unusual discharge.

8.

Continuous vomiting, nausea, or diarrhea.

d. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.

Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.
What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.

Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Discuss emergency contraception options and availability discussed.

d. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI screening.
e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox f. Provide information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.

g. Discuss availability of providers for further questions or problems.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 135 Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Division of Public Health Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 136 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Preconception Counseling and Basic Infertility Services Effective Date: [Add Date] Definition and/or scope: [Clinic name] will provide basic infertility services and preconception counseling around achieving pregnancy as part of family planning reproductive health services.
RN will provide preconception counseling with basic infertility services.

Procedure: 1.

Subjective: a.

Obtain comprehensive medical health history, including: i.

Review current medications and allergies.

ii.

Reproductive and sexual health history: a. Menstrual history b.
Contraceptive history c. Pregnancy history d. Cervical cancer screening results and follow-up treatment e. Sexually transmitted Infection (STI) history f. Coital frequency and timing, fertility awareness g. Reproductive Life plan iii.

Family health history: a.

History of poor pregnancy outcomes, still birth, birth defects, developmental disabilities, and genetic defects.

iv.

Previous surgeries, hospitalizations, serious illnesses, or injuries v. Previous and current medical conditions vi.
Social history a.

Substance use disorder b.

Intimate partner violence vii.

Occupation and exposure to environmental hazards viii.

Nutrition and physical activity ix.

Immunizations x. Depression Screen xi.

Assess for signs and symptoms reported by the client in the review of systems that will require consultation and/or referral to MD, APNP, or PA: a.

Symptoms of thyroid disease a.

Nervousness or irritability b.


Muscle weakness c. Trouble sleeping d. Tremors e. Irregular heartbeat, bradycardia, or tachycardia f. Weight loss or gain g. Mood swings h. Fatigue Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 137 Division of Public Health i.

Trouble tolerating cold and/or heat j.

Joint and muscle pain k. Chronic Constipation or diarrhea l. Dry skin m. Dry, thinning hair n. Decreased sweating o.
Heavy or irregular menstrual periods p. Depression q. Goiter, an enlarged thyroid that may cause your neck to look swollen.

Sometimes it can cause trouble with breathing or swallowing.

b. Pelvic or abdominal pain c. Dyspareunia (painful intercourse) d. Galactorrhea (discharge from breast) e. Hirsutism 2.

Objective: a.

Obtain and document vitals including height, weight, body mass index (BMI) and blood pressure.

b. Assess for urgent physical and/or mental distress.
c. Physical exam, as indicated, for individuals seeking basic infertility services: i.

General appearance ii.

Thyroid gland exam to identify any enlargement, nodule, or tenderness iii.

Assessment of cardiac rate, rhythm, and murmur iv.

Skin exam to identify dry skin, or dry, thinning hair, hirsutism, cystic acne, acanthosis nigricans v. Abdominal exam for tenderness or palpable mass 3.
Assessment: a. Protocol applies b. Protocol applies following consultation with MD, APNP, or PA. c. Protocol does not apply, refer to MD, APNP, or PA. 4.

Plan: a.

Provide prescription for those planning or capable of pregnancy: Folic acid supplementation for 400mcg orally once daily OR Prenatal vitamins orally once daily b.

Discontinue contraception for those seeking pregnancy.

i.
i.

There is no evidence to recommend that a period of time lapse between the cessation of hormonal contraception use and initiation of a planned pregnancy.

c. Address emotional needs of infertility, refer as needed.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 138 Division of Public Health 5.

Physician, APNP, PA management or consultation required during visit: a.
Signs and symptoms reported by the client in the review of systems that will require consultation and/or referral to MD, APNP, or PA: i.

Symptoms of thyroid disease (see above in subjective) ii.

Pelvic or abdominal pain iii.

Dyspareunia (painful intercourse) iv.

Galactorrhea (discharge from breast) v. Hirsutism b.

History of irregular menstrual cycles c. Exposure or environmental risk factors that could cause fertility problems are known to be present.
d. If provider management and/or consultation not available, RN should provide referral.

6.

Nursing skills: a.

Skills: i.

Client education ii.

Shared decision making and client-centered counseling iii.

Interviewing and assessment of client reproductive planning goals and priorities iv.

Interviewing and assessment of health risk factors v. Physical exam skills b.

Clinical content knowledge: i.

Fertility, achieving pregnancy, and preconception health ii.
Wisconsin Family Planning Only Services, 2014 and covered services 7.

Follow-up: a.

Positive Pregnancy test b.

Referral appointment 8.

Referral to provider is required for: a.

Positive pregnancy b.

Mental or physical distress c. Rapid and irregular heartbeat d. Follow-up appointment after laboratory assessment e. A breast exam and pelvic exam f. History of poor pregnancy outcomes, still birth, birth defects, developmental disabilities, or genetic defects.
g. Client and partner trying to conceive for 12 months.

h. Client is over the age of 35 and trying to conceive for 6 months.

9.

Links and resources: a.

Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/fpos/index.htm b.

Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs.

(n.d.).

Www.cdc.gov.


https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm?s_cid=rr6304a1_w Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 139 Division of Public Health c. Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html d. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.

http://www.myplate.gov e. (2021, March).

Preconception Counseling Checklist.

Rhntc.org.


https://rhntc.org/sites/default/files/resources/fpntc_preconcptn_counsel_chklst_2019- 06.pdf f. Infertility Workup for the Women’s Health Specialist.

(n.d.).

Www.acog.org.

https://www.acog.org/clinical/clinical-guidance/committee- opinion/articles/2019/06/infertility-workup-for-the-womens-health-specialist g. Social Needs Screening Tool.

(n.d.).

Www.aafp.org.


https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/hops19- physician-form-sdoh.pdf h. Pregnant Travelers | Travelers’ Health | CDC.

(n.d.).

Www.cdc.gov.

https://wwwnc.cdc.gov/travel/page/pregnant-travelers Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.
Periodic Health screening completed annually or as indicated presenting concern: a.

Intimate partner violence, domestic violence, sexual assault b.

Child abuse (screening followed by mandatory reporting if indicated) c. Human trafficking d. Sexual coercion and reproductive autonomy e. Substance abuse f. Depression g. Reproductive life plan (RLP) 2.

Client education: a.

Education is to be documented in client’s health record.
b. Anatomy and physiology c. Menstrual cycle d. Fertility Awareness techniques and timing of intercourse: i.

Peak fertility days ii.

Vaginal intercourse every 1-2 days following menses iii.

Avoiding vaginal lubricants e. Health risks that can reduce fertility: i.

Overweight or underweight ii.

Age Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 140 Division of Public Health iii.

Substance use and smoking and tobacco use iv.


Certain medical conditions and family history f. Preconception and achieving pregnancy: i. Nutritional counseling ii.

Abstaining from substance use iii.

Need for early and continued prenatal care during pregnancy iv.

Spacing pregnancy v. Social needs screening tool, n.d. vi.

Travel guidance from Pregnant Travelers | Travelers' Health | CDC, n.d. g. Educate clients regarding possible lab tests for infertility or preconception planning.
Lab tests may include: i. Sexually transmitted infections (STIs) ii.

Thyroid function tests (T4, TSH) iii.

Prolactin levels iv.

HbgA1C v. Semen Analysis vi.

Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels h. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.

Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.
What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.

Health screening education and/or anticipatory guidance: a.

Discuss details of pelvic exam and make recommendations, as appropriate.

b.

Discuss Pap testing guidelines and make recommendation, as appropriate.

c. Discuss emergency contraception options and availability discussed.

d. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI screening.
e. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox f. Provide information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.

g. Discuss availability of providers for further questions or problems.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 141 Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Division of Public Health Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 142 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Template RN Wellness Visit Effective Date: [Add Date] Definition and/or scope: RN will assess and document a client’s medical health history, perform relevant screenings, and educate regarding preventive exams, and provide relevant education and counseling.
RN will also arrange referrals for any services not available on-site, or as needed for specialty care follow-up.

RN will assist client, through shared decision making, in developing a plan of care that includes the client’s desired reproductive health goals.

Procedure: 1.

Subjective: a.

Review and update history: i.

Review current medications and allergies.

ii.

Review reproductive and sexual health history.


a. Assess STI screening needs utilizing CDC, 2021 and Wisconsin State Laboratory of Hygiene (WSLH) selective screening criteria (SSC).

b. Menstrual history, if applicable c. Contraceptive history d. Pregnancy history, if applicable e. Cervical cancer screening per American College of Obstetricians and Gynecologists, 2021/ASCCP Management Guidelines, n.d. f. Breastfeeding, if applicable iii.

Family health history iv.


Previous surgeries, hospitalizations, serious illnesses, or injuries v. Previous and current medical conditions vi.

Social history vii.

Review of systems viii.

Immunizations ix.

Mental health history b.

Health maintenance, including: i.

Diet and nutrition ii.

Activity and exercise iii.

Sleep iv.

Stress management 2.

Objective: a.

Obtain and document vital signs if client is onsite.

i.

Recommend client come to clinic if not obtained within the last 12 months.
b. Assess for urgent physical and/or mental distress.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 143 Division of Public Health 3.

Assessment a. Protocol applies b. Protocol applies following consultation with MD, APNP, or PA. c. Protocol does not apply, refer to MD, APNP, or PA. 4.

Plan a.

Follow up as appropriate on any abnormal findings from subjective and objective assessment, consulting provider during visit and/or making any necessary referrals b.
Renew contraceptive prescription method, as applicable, using pertinent RFHP RN Clinical Protocols for appropriate contraceptive method.

c. Renew prenatal vitamin and/or folic acid for clients seeking pregnancy.

Refer to RHFP RN Clinical Protocol for Preconception and Basic Infertility.
d. Order recommended laboratory tests for other sexually transmitted infections (STI) as appropriate using RHFP RN Clinical Protocol for Asymptomatic STI Screening e. Obtain pregnancy testing as needed, following RFHP RN Clinical Protocols for Pregnancy Testing and Counseling.

f. Offer the following contraceptive supplies: i.

Emergency contraception using RHFP RN Clinical Protocol for Emergency Contraception.

ii.
ii.

Internal and/or external (insertive and/or receptive) condoms using RHFP RN Clinical Protocol for Internal and/or External Condoms.

g. Provide relevant education: i.

Discussion of cancer screenings as appropriate for age group per WPSI Recommendations from ACOG, 2021. a.

Breast exam 1. Review recommendations for breast self-exam.

2.

Refer to primary care provider for exam and/or mammography, if needed.

b. Cervical cancer prevention 1.

HPV status and vaccination status (clients of all ages).

2.
2.

Assess need for Pap/HPV co-testing per American College of Obstetricians and Gynecologists, 2021/ASCCP Management Guidelines, n.d. and refer as appropriate.

c. Testicular exam 1. Review recommendations for self-testicular exam.

2.

Refer to primary care provider for exam.

d. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to, Hepatitis A, Hepatitis B, HPV, and Monkeypox.
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 144 Division of Public Health 5.

Physician, APNP, PA management or consultation required during visit: a. Abnormal findings or symptoms b.

Indications for lab testing identified c. Request for physical exam d. If provider management and/or consultation not available, RN should provide referral.

6.

Nursing skills: a.

Skills: i.

Client assessment ii.

Client-centered counseling iii.

Client education b.
Client education b.

Clinical content knowledge: i.

Insurance impact on method coverage; skills to provide assistance with pharmacy benefits, prior authorization, Family Planning Only Services, 2014. ii.

ASCCP Management Guidelines, n.d. pap screening guidelines ix.

Indications for routine Immunization Schedules for Healthcare Professionals, 2019 iii.

CDC, 2021 STI Screening Recommendations and Considerations 7.

Follow-up: a.

Educate client on need for wellness visit each year 8.
Referral to provider is required for: a. Pregnancy b.

Urgent mental or physical distress.

c. Three blood pressures greater than 140/90 on 3 separate dates of services.

d. Abnormal exam or lab finding requiring physical exam assessment.

e. Indications for lab testing identified.

f. Services outside of RN scope of practice or clinic site service capacity.

9.

Links and resources: a. CDC.

(2021, August 12).

STI Screening Recommendations.

Www.cdc.gov.


https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm b. American College of Obstetricians and Gynecologists.

(2021, April).

Updated Cervical Cancer Screening Guidelines.

Www.acog.org.

https://www.acog.org/clinical/clinical- guidance/practice-advisory/articles/2021/04/updated-cervical-cancer-screening- guidelines c. ACOG.

(2021, January).

WPSI: Recommendations for Well-Woman Care – A Well- Woman Chart.
https://www.womenspreventitivehealth.org/wp- content/uploads/WPSI_WWC_11x17_2021Update.pdf d. Immunization Schedules for Healthcare Professionals.

(2019).

https://www.cdc.gov/vaccines/schedules/hcp/index.html e. Family Planning Only Services.

(2014, November 17).

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/fpos/index.htm f. ASCCP Management Guidelines Web Application.

(n.d.).

App.asccp.org.


https://app.asccp.org/ Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 145 Division of Public Health g. The Guide to Clinical Preventive Services.

(2014).

https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians- providers/guidelines-recommendations/guide/cpsguide.pdf h. American Heart Association.

(2018, April 18).

American Heart Association Recommendations for Physical Activity in Adults and Kids.

Www.heart.org.
Www.heart.org.

https://www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical- activity-in-adults i. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.

http://www.myplate.gov Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.
Periodic Health screening completed annually or as indicated presenting concern: A.

Intimate partner violence, domestic violence, sexual assault B.

Child abuse (screening followed by mandatory reporting if indicated) C. Human trafficking D. Sexual coercion and reproductive autonomy E. Substance abuse F. Depression G. Reproductive life plan (RLP) 2.

Client education: Education is to be documented in the client’s health record.

A.

Provide client educational handouts, as appropriate.

B.
B.

Teach and provide hands-on education, as appropriate (i.e., self-breast exam, testicular exam, ABCD’s of skin cancer).

C. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.

Emergency contraception iii.

Mechanism of action iv.

Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.


Health screening education and/or anticipatory guidance: The following list is suggested as possible topics for conversation.

Not every topic will be Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 146 Division of Public Health appropriate or applicable for every client; RN to use findings from assessment as well as clinical judgement to decide which topics to highlight.

A.
A.

Discuss details of pelvic exam and make recommendations, as appropriate.

B.

Discuss Pap testing guidelines and make recommendation, as appropriate.

C. Discuss emergency contraception options and availability discussed.

D. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI screening.

E. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.
Hepatitis A ii.

Hepatitis B iii.

HPV iv.

Monkeypox F. Provide information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.

G. Educate clients regarding possible lab tests if referral appointment is needed.

Lab tests may include: i. CBC (complete blood count) ii.

CMP (comprehensive metabolic panel) iii.


Lipids panel “Men aged 20-35 and women over age 20 who are at increased risk for coronary heart disease; all men aged 35 and older.” (The Guide to Clinical Preventive Services, 2014) iv.

Thyroid function tests (T4, TSH) v. HbG A1C “Asymptomatic adults with sustained BP > 135/80” (The Guide to Clinical Preventive Services, 2014) vi.

Urinalysis H. Review age and risk appropriate counseling.
Use motivational interviewing to elicit healthy lifestyle behavior change, when applicable.

i.

Sexual health: a.

High risk sexual behaviors b.

Consent behaviors c. Pregnancy prevention, contraceptive options or postponing sexual involvement d. Internet/phone safety e. Barrier protection and emergency contraception f. Internal/external condoms and emergency contraception g. Vaccine-preventable STIs h. Sexual function and pleasure ii.
Fitness and nutrition: a. Multivitamin with folic acid b. Calcium intake with vitamin D c. Diet and nutrition d. Counsel on 150 minutes of moderate-intensity aerobic exercise weekly, per the American Heart Association, 2018.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 147 Division of Public Health iii.

Psychosocial factors: a.

Acquaintance rape prevention b.


Bullying c. Intimate partner violence d. Lifestyle and/or stress e. Peer relationships f. School experience g. Self-mutilation h. Sexual orientation and/or gender identity i.

Sleep disorders j.

Support systems discussed k. Work satisfaction l. Suicide risks, depressive symptoms iv.

Health risk assessment: a.


Driving under the influence (DUI) risks/distracted driving b. Hygiene, dental care, and fluoride use c. Injury prevention (helmet use, occupational and recreational safety) d. Piercing and tattoo safety e. Seat belt use and distracted driving f. Tanning and UV bed use g. Yearly eye exams h. Osteoporosis risks i.

Use of smoke and carbon monoxide detectors j.


Personal items such as guns; locked k. Appropriate and safe use of medications and household cleaners l. Poison Control Center number v. Preconception counseling as needed vi.

Breastfeeding support as needed vii.

Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 148 Division of Public Health [Clinic Name] Reproductive Health RN Protocol Expedited Partner Therapy Effective Date: [Add Date] Definition and/or scope: [clinic name] will provide expedited partner therapy (EPT) for clients who test positive for chlamydia, gonorrhea, and/or trichomoniasis and who have sexual partner(s) who is (are) unable or unwilling to obtain medical evaluation as an alternative strategy to reduce the likelihood of reinfection.
Procedure: 1.

Subjective: a.

Sexual partner of a client with a laboratory confirmed diagnosis of trichomoniasis, gonorrhea, or chlamydia infection.

b.

Sexual partner unable or unlikely to seek timely clinical services.

c. Screen client for sexual activity with males, females, non-binary and/or trans individuals.

i. MSM (men having sex with men) with gonorrhea have a high risk for coexisting infections among partners; shared clinical decision- making regarding EPT for MSM is recommended.

2.
2.

Objective: a.

Laboratory confirmed or suspected clinical diagnosis of trichomoniasis, gonorrhea, or chlamydia infection of an index case.

3.

Assessment: a. Protocol applies b. Protocol applies following consultation with MD, APNP, or PA. c. Protocol does not apply, refer to MD, APNP, or PA. 4.

Plan: a.
Plan: a.

Attempt to notify and refer partners from the previous 60 days for complete clinical evaluation, STI and/or HIV testing, counseling, and treatment per RHFP RN Clinical Protocol for Asymptomatic STI Screening.

i.

The most recent sex partner should be evaluated and treated, even if the time of the last sexual contact was greater than 60 days before symptom onset or diagnosis.

ii.
ii.

Counsel on the importance of evaluation and treatment for the most recent sexual partner(s) per the Expedited Partner Therapy, 2020.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 149 Division of Public Health b. Prescribe recommended drug regimen for sex partners receiving EPT: Chlamydia EPT: Doxycycline 100mg orally 2 times/day for 7 days Gonorrhea EPT: Cefixime (Suprax) 800 mg orally in a single dose (if chlamydia infection has been excluded).
If chlamydia has not been excluded, treat with Cefixime (Suprax) 800 mg orally in a single dose and Doxycycline 100 mg orally 2 times/day for 7 days.

Trichomoniasis EPT: Clients with a vagina: Metronidazole 500mg times daily for 7 days Clients with a penis: Metronidazole 2 grams orally in a single dose c. For Consideration: i.

Every effort should be made to ensure that a sex partner of a client that tested positive for Gonorrhea be evaluated and treated.
However, because that is not always possible, EPT can be consider for partners of clients.

ii.

Number of doses allowed: one for each sex partner during the 60 days prior to the diagnosis of the index client (or most recent sex partner if none identified in the previous 60 days).

iii.

If self-reported allergy to all treatment options consult with delegating provider for alternate treatment regimen.

iv.

Do not give EPT to partner who is pregnant or lactating.
v. Prescription should be written in the partner’s name (and address) or can also be written in ordinary bold faced capital letters with “EXPEDITED PARTNER THERAPY” or “EPT” in place of a name and address, when the medical provider is unable to obtain the partner’s name d. Document a note in the client’s medical record that EPT was provided.

The note should include: i.

Number of doses provided, and whether a prescription was provided including the medication and the quantity dispensed.

a.
a.

Name of medication b.

Dose of medication c. Instructions to take the medication d. Quantity dispensed e. Name of the delegating prescriber f. Date of original prescription: g. Name of RN dispensing 5.
Physician, APNP, PA management or consultation required during visit: a. EPT recipient is pregnant b. EPT recipient is breastfeeding c. Suspected therapeutic failure after STI treatment or symptoms that persist after treatment d. EPT recipient reports allergy to all treatment options e. If provider management and/or consultation not available, RN should provide referral.

Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 150 Division of Public Health 6.

Nursing skills: a.

Skills: i.


Client education ii.

Shared decision making and client-centered counseling iii.

Interviewing and assessment of client reproductive planning goals and priorities iv.

Interviewing and assessment of STI risk reduction plan b.

Clinical content knowledge: ix.

Infection basics and common signs and/or symptoms x.

Infection treatment regimen and pharmacology xi.

STIs and their common signs and/or symptoms per Centers for Disease Control and Prevention, 2019 xii.
Risk based STI screening recommendations outlined by the CDC, 2021 7.

Follow-up: a. Retesting in three months.

8.

Referral to provider is required for: a.

Not Applicable 9.

Links and resources: a.

Expedited Partner Therapy.

(2020, May 12).

Www.cdc.gov.

https://www.cdc.gov/std/ept/default.htm b.

Centers for Disease Control and Prevention.

(2019).

CDC – STD diseases & related conditions.

CDC.

https://www.cdc.gov/std/general/default.htm c. CDC.

(2021, August 12).

STI Screening Recommendations.


Www.cdc.gov.

https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm d. Walensky, R., Jernigan, D., Bunnell, R., Layden, J., Kent, C., Gottardy, A., Leahy, M., Martinroe, J., Spriggs, S., Yang, T., Doan, Q., King, P., Starr, T., Yang, M., Jones, T., Boulton, M., Brooks, C., Ma, J., Butler, V., & Caine, J.

(2021).
(2021).

Morbidity and Mortality Weekly Report Sexually Transmitted Infections Treatment Guidelines, 2021 Centers for Disease Control and Prevention MMWR Editorial and Production Staff (Serials) MMWR Editorial Board.

https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf f. e. (2010, May 25).

2009 Wisconsin Act 280.

State of Wisconsin.

https://docs.legis.wisconsin.gov/2009/related/acts/280.pdf (2013, May).
Expedited Partner Therapy for Chlamydia trachomatis Infection, Neisseria gonorrhoeae Infection and Trichomoniasis: Guidance for Health Care Professionals in Wisconsin.

STD Control Section Division of Public Health Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/publications/p0/p00253.pdf g. (2010, June).

Chlamydia Treatment Information Sheet.

Wisconsin Department of Health Services.


https://www.dhs.wisconsin.gov/publications/p0/p00197.pdf h. Centers for Disease Control and Prevention.

(2019).

Detailed STD Facts- Chlamydia.

Centers for Disease Control and Prevention.

https://www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm (2010, June).

Gonorrhea Treatment Information Sheet.

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/publications/p0/p00196.pdf i. j. Gonorrhea – CDC Fact Sheet.

(n.d.).
(n.d.).

https://www.cdc.gov/std/gonorrhea/Gonorrhea- FS.pdf k. (2010, June).

Trichomoniasis Treatment Information Sheet.

Wisconsin Department of Health Services.

https://www.dhs.wisconsin.gov/publications/p0/p00198.pdf l. CDC.

(2019).

STD facts – trichomoniasis.

Centers for Disease Control and Prevention.


https://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 151 Division of Public Health m. MyPlate | U.S. Department of Agriculture.

(n.d.).

Www.myplate.gov.


http://www.myplate.gov Approval – Medical Director Signature: ____________________________________ Name: [Enter Full Name and Credentials] Title: [Medical Director] Initial Effective Date: Reviewed Dates: Revision Dates: Family Planning Health Screening and Education 1.

Periodic Health screening completed annually or as indicated presenting concern: A.

Intimate partner violence, domestic violence, sexual assault B.
Child abuse (screening followed by mandatory reporting if indicated) C. Human trafficking D. Sexual coercion and reproductive autonomy E. Substance abuse F. Depression G. Reproductive life plan (RLP) 2.

Client education: A.

Provide clients with written educational materials to give to their partner(s) about specific STI exposure in general, to include notification that partner(s) have been exposed and information about the importance of treatment.

i.
i.

Treatment information sheet must accompany each medication or prescription and must include clear instructions, warnings and referrals: a. Chlamydia – i. Chlamydia Treatment Information Sheet, 2010 ii.

CDC, 2019 Chlamydia fact sheet b. Gonorrhea – i. Gonorrhea Treatment Information Sheet, 2010 ii.

Gonorrhea - CDC Fact Sheet, n.d. c. Trichomoniasis - i. Trichomoniasis Treatment Information Sheet, 2010 ii.

CDC, 2019 Trichomoniasis fact sheet B.


Education and counseling of the correct usage of protective barriers (condoms, dental dams, etc.).

C. Counsel on abstaining from intercourse until 7 days following the start of the treatment regimen and resolution of symptoms.

Abstain from sex until sex partner(s) have been adequately treated (for 7 days following the start of treatment and resolution of symptoms).
Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 152 Division of Public Health D. Education and counseling on the responsibility of the sex partner to inform their sex partners of the risk of STIs and importance of examination and treatment.

E. Advise the person receiving EPT to contact the physician, pharmacist, or local health department with questions.

F. Other instruction: i. Dual protection (benefits of using condoms with other preventative method) ii.
Emergency contraception iii.

Mechanism of action iv.

Failure rate (typical use and/or perfect use as appropriate) v. Side effects and/or what to watch for vi.

What to expect vii.

Other drug interactions viii.

Discussion inadvisability of smoking 3.

Health screening education and/or anticipatory guidance: A.

Assist client(s) in developing a personalized STI and HIV risk reduction plan and document client(s) plan.

B.

Discuss details of pelvic exam and make recommendations, as appropriate.
C. Discuss Pap testing guidelines and make recommendation, as appropriate.

D. Discuss emergency contraception options and availability discussed.

E. Assess for asymptomatic STI screening needs and offer services following RHFP RN Clinical Protocol for Asymptomatic STI screening.

F. Review indications for routine Immunization Schedules for Healthcare Professionals, 2019, including but not limited to i.

Hepatitis A ii.

Hepatitis B iii.

HPV iv.


Monkeypox G. Provide information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.

H. Discuss availability of providers for further questions or problems.
Sexuality • High risk sexual behaviors • Pregnancy prevention, contraceptive options or postponing sexual involvement • Internet/phone safety • Barrier protection • Vaccine preventable STIs • Sexual function Fitness and Nutrition • Multivitamin with Folic acid • Calcium with Vitamin D • Discuss healthy eating and portion control (MyPlate) • Diet/nutrition for weight control or eating disorders • Recommend aerobic exercise 3-4 times weekly Psychosocial Factors • Acquaintance rape prevention • Bullying • Intimate partner violence • Lifestyle/stress • Peer relationships • School experience • Self-mutilation • Sexual orientation/gender identity • Sleep disorders Reproductive Health Family Planning Program (RHFP) RN Clinical Protocols 153