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Perimenstrual Syndrome: Nursing Diagnosis Among Taiwanese Nursing Students

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Han-Fu Cheng, RN, PhD

PURPOSE. To determine the frequency and distribution of various perimenstrual symptoms experienced by

Taiwanese nursing students.

METHODS. A descriptive “management of menstrual cramps survey” was utilized to collect information from 2,758 female nursing students in southern Taiwan. FINDINGS. Of the participants, the most frequently reported perimenstrual symptom was a combination of four symptom categories, including mood change, pain, gastrointestinal disturbance, and functional ability decline.

CONCLUSIONS. A potentially new nursing diagnosis of perimenstrual syndrome including four symptom

categories may be established.

PRACTICE IMPLICATIONS. The results are important for the education of healthcare professionals and the public. Understanding the interaction among perimenstrual symptoms may help guide nursing professionals in women’s health care.

Search terms:

Dysmenorrhea, nursing diagnosis, perimenstrual syndrome, Taiwanese nursing students, Venn diagram

Han-Fu Cheng, RN, PhD, is an assistant professor at the School of Nursing at Fooyin University, Kaohsiung, Taiwan.

Background

Dysmenorrhea is the most common gynecological problem in women of reproductive age (McEvoy, Chang, & Coupey, 2004). It is a symptom complex that not only affects quality of life (QOL) but also reduces productivity (Andersch & Milsom, 1982; Klein & Litt, 1981). Dysmenorrhea is not just pain, and there is evi-dence that symptoms associated with dysmenorrhea represent three symptomatic clusters: cyclic pelvic pain, perimenstrual discomfort, and perimenstrual negative affect (Collins Sharp, Taylor, Thomas, Killeen, & Dawood, 2002). In 2002, Collins Sharp et al. referred to these symptomatic clusters of dysmenorrhea “nursing diagnoses.” However, dysmenorrhea is cur-rently not part of the nursing diagnoses covered by NANDA-International. Instead, these three diagnoses were referred to together as a syndrome, defined as a “clinical judgment describing a specific cluster of diag-noses that occur together, are best addressed together,

and through similar interventions”

(NANDA-International, 2008, pp. 2–3), and this has been dis-cussed in the nursing literature as perimenstrual syndrome (PS) (Collins Sharp et al., 2002).

Using the idea of PS and 18 of the 23 symptoms from the model of Collins Sharp et al. (2002), this researcher recategorized the diagnostic categories (symptom clusters) and used them for data collection purposes. Joint aches, fluid retention, leg/thigh dis-comfort, breast tenderness, and guilt were not included because of language issues. For example, fluid retention, leg/thigh pain, joint pain, and guilt are not terms commonly used in the description of peri-menstrual symptoms among Taiwanese. This is sup-ported by PubMed searches. While there were 66 citations retrieved on November 15, 2009, using the terms “Taiwan AND dysmenorrhea,” there were no © 2011, The Author

International Journal of Nursing Terminologies and Classifications © 2011, NANDA International doi: 10.1111/j.1744-618X.2011.01185.x

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citations found when the terms “fluid retention,” “bloating,” “guilt,” “leg OR thigh,” or “joint” were added to the advanced searches. On the other hand, “swollen abdomen” and “breast tenderness” were listed among the top five symptoms mentioned by adolescents in Taiwan (Chen & Chen, 2005).

While Collins Sharp et al. (2002) had described three symptom clusters of dysmenorrhea, this researcher decided upon five symptom clusters: mood change, pain, functional ability, gastrointestinal (GI) distur-bance, and decreased QOL. Collins Sharp et al.’s symptom cluster of cyclic pelvic pain contained symp-toms of nausea, vomiting, diarrhea, and bowel fre-quency. However, these are not symptoms of pain but symptoms of GI disturbance. Therefore, they were placed along with decreased appetite in the GI distur-bance category.

Review of the Literature

Literally, dysmenorrhea only refers to menstrual cycle pain. Some define it more broadly to include symptoms of abdominal or low back pain, GI distur-bances (nausea and vomiting), headache, fatigue, sweating, lethargy, breast tenderness, and emotional symptoms, and these symptoms may continue for a few days during menstruation (Golomb, Solidum, & Warren, 1998; McEvoy et al., 2004). Some investigators refer to the signs and symptoms of the menstrual cycle as premenstrual syndrome. These include anger, irri-tability, crying spells, decreased energy, decreased appetite, decreased ability to concentrate, headache, and cramps (Ghanbari, Haghollahi, Shariat, Foroshani, & Ashrafi, 2009).

Collins Sharp et al. (2002), in their examination of cyclic changes, call the entire constellation of related signs and symptoms PS. This syndrome is divided into three categories: cyclic pelvic pain, perimenstrual discomfort, and perimenstrual negative affect. This is an important development in the description and classification of the condition. Its importance becomes apparent when considering how it defined

dysmenorrhea in the relevant classification. While this is an important development, the description has limi-tations. For example, diarrhea was categorized into the diagnosis of cyclic pelvic pain. Yet diarrhea more prop-erly belongs in the GI disturbance category. For the purpose of data collection in this study, five perimen-strual categories were generated: mood change, pain, functional ability, GI disturbance, and decreased QOL.

Commonly used classifications are also limited in the definition of dysmenorrhea. NANDA-International (2009) defines acute pain and chronic pain as a single diagnosis. It does not include a diagnosis for the cyclic pain called dysmenorrhea, nor does it include Collins Sharp et al.’s (2002) three nursing diagnoses of cyclic pelvic pain, perimenstrual discomfort, and perimen-strual negative affect.

The International Classification of Functioning, Disability, and Health (ICF, n.d.) lists menstruation functions and impairments within its body function category (b650). Among impairments, there is no mention of dysmenorrheic pain, only premenstrual tension. While not using the term “dysmenorrhea,” the ICF does refer to “discomfort associated with the menstrual cycle, including pre- and post-menstrual phases” (b6701). Still, this characterization does not capture the functional impairments associated with PS as well as that of Chiou and Wang (2008), who indi-cated that dysmenorrhea may decrease functional ability, such as inability to attend school, inability to attend physical education, or a decrease in extracur-ricular activities.

In the International Classification of Diseases (ICD-9, n.d.), there are two related diagnoses: dysmen-orrhea and premenstrual tension syndrome. The former is defined as “painful menstruation, excluding psychogenic.” ICD-9 defines premenstrual tension syndrome as a combination of distressing physical, psychological, or behavioral changes that occur during the luteal phase of the menstrual cycle. These symp-toms are diverse, including pain, fluid retention, anxiety, cravings, depression, irritability, and increased

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of a university in Kaohsiung in southern Taiwan.

Instrument

The MMCS is a simple checklist with questions in four different sections over four pages. It requires about 30 min for completion. The MMCS was devel-oped by this researcher who has worked with women with PS for 4 years. This survey included a demo-graphic information section. In addition there is a table listing the perimenstrual symptoms within five catego-ries. The researcher-generated diagnostic categories constituting PS were:

• Mood change (anger/hostility, tension/anxiety, irritability/impatience, crying spells, feeling out of control, depression, decreased sexual desire, decreased energy, decreased ability to concentrate, fatigue, nervousness, dizziness, and headache). • Pain (abdominal pain/cramps, pelvic pain, and low

back pain).

• Functional ability decline (inability to attend school, inability to attend physical education, or decrease in extracurricular activities).

• GI disturbance (nausea, vomiting, increased GI motility/diarrhea, and decreased appetite).

• Decreased QOL.

QOL was included as its own category as it cap-tured the overall experience. Collins Sharp et al. (2002,

doctoral and one master’s-prepared nurses) were asked to judge the tool. Each reviewer received a detailed package that included a description of the purpose of the measures and instructions for assessing content validity. The experts were requested to put the comments and suggestions regarding clarity and read-ability of each item. Based on this expert opinion, the researcher made corrections until all three experts agreed on all items in the tool.

In order to make sure the design was appropriate for the population, five Taiwanese female nursing stu-dents were selected to take part in the pilot study of the survey before its use in this study. The researcher gave instructions to the students before conducting the survey and checked the answers to determine the level of agreement among different persons using the same tool. The results showed the inter-rater reliability was 100% consistent.

Results Participant Background Information

Of all the participants, 2,232 (80.9%) reported expe-riencing menstrual pain and 2,643 (95.8%) had experi-enced one or more premenstrual symptoms during their last menstruation. Out of a total of 2,888 partici-pants recruited to the study, 133 participartici-pants were excluded for failure to return the survey. The remain-ing 2,758 (95.4%) were enrolled in the study. The mean

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age of the study population was 20.5 years (range, 18–55) and SD 4.0.

Frequency and Distribution of Perimenstrual Symptoms Within Categories

Perimenstrual symptoms constitute a syndrome, and are a constellation of symptom clusters. In this study, the following symptom clusters were used: mood change, pain, GI disturbance, functional ability decline, and decreased QOL. QOL was eliminated as a category within this study, for it was not operational in this study because its meaning was unclear among Taiwanese students. For example, some subjects indi-cated that QOL improved as perimenstrual symptoms increased. As a result, the meaning of a “yes” response was not interpretable. Consequently, study results focus on the remaining four perimenstrual symptom categories.

Table 1 presents the numbers and percentages of participants reporting one or more within-category symptoms. For example, 916 (33.2%) participants reported at least one symptom from within the mood change (A), pain (B), GI disturbance (C), and functional ability decline (D) categories. This was the most fre-quently reported.

The Venn diagram (Figure 1) is especially useful in displaying probabilities among interacting/ overlapping sets. Therefore, it was developed to illus-trate the proportions of participants reporting symptom(s) within each category. The legend to Figure 1 further assists in interpreting the diagram. For example, the “A alone” space represents the 6.9% who reported mood change only. The “A + B + C” space represents the 20.1% who reported mood change, pain, and GI disturbance.

The Venn display supports the notion that perimen-strual symptom is not just pain, nor a combination of pain and mood change, but a complex phenomenon involving the interaction of at least four symptom clus-ters. Of the participants, 33.2% reported an interaction of perimenstrual symptoms, representing all four

cat-egories: mood change, pain, GI disturbance, and func-tional ability decline. This interaction was the most frequently reported. Next in frequency were the 20.1% who reported an interaction of perimenstrual symp-toms representing three categories (mood change, pain, and GI disturbance) and the 19.8% who reported symptoms representing two categories (mood change and pain).

Discussion

As far back as 1931 (Moline & Zendell, 2000), the idea was promoted that perimenstrual symptoms are limited to pain and possibly mood change. The results reported in this study support perimenstrual symp-toms being more complex. Findings shown here indi-cate that PS is a complex phenomenon, analogous to those of Collins Sharp et al. (2002).

Table 1. Frequency and Distribution of Perimenstrual Symptom Categories

PS Categories Frequency %

Mood change (A) + pain (B) + GI disturbance (C) + FA decline (D)

916 33.2 Mood change (A) + pain (B) + GI

disturbance (C)

555 20.1 Mood change (A) + pain (B) 546 19.8 Mood change (A) + pain (B) + FA

decline (D)

224 8.1

Mood change (A) only 190 6.9

No symptom 115 4.2

Mood change (A) + GI disturbance (C) 78 2.8

Pain (B) only 64 2.3

Mood change (A) + FA decline (D) 19 0.7 Mood change (A) + GI disturbance (C)

+ FA decline (D) 18 0.7 Pain (B) + GI disturbance (C) 18 0.7 FA decline (D) only 7 0.3 Pain (B) + GI disturbance (C) + FA decline (D) 5 0.2 Pain (B) + FA decline (D) 3 0.1 Total 2,758 100

FA, functional ability; GI, gastrointestinal.

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decline” was a label consistent with Taiwanese descrip-tions of perimenstrual complaints (ICF, n.d.).

These four categories were displayed in a Venn diagram (Figure 1), yielding 15 possible ways in which perimenstrual symptom categories may interact. Among these 15 possibilities, 33.2% of the participants reported symptoms representing all four categories. This was the most frequently reported interaction.

The idea that PS is a complex phenomenon is also reflected in the very few subjects who reported peri-menstrual symptoms within an isolated category only. The Venn sets (Figure 1) show 6.9% in the mood change category only, 2.3% in the pain category only, 0.3% in the functional ability decline only, and 0% in the GI disturbance category only. This study advances Venn diagram use in its graphic display of the com-plexity of the interactions among the signs and symp-toms of perimenstrual sympsymp-toms. Hence, this study may be of methodological use in the development in nursing terminology.

Nursing Implications

Dysmenorrhea is defined as severe menstrual cycle cramps and pain for at least 2 days (Andersch & Milsom, 1982; Proctor & Murphy, 2001). However, it is important to distinguish nursing diagnoses from medical diag-noses. In order to make an appropriate nursing diagno-sis, work of in-depth assessment is necessary. Nursing diagnosis provides standards for directing healthcare + Pain + Functional Ability Decline; A + C

+ D: Mood Change + GI Disturbance +Functional Ability Decline; B + C + D:

Pain + GI Disturbance + Functional Ability Decline; A + B + C + D: Mood Change + Pain + Functional Ability Decline + GI Disturbance

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providers in nursing interventions. After a diagnosis is made, the next steps of nursing interventions and evaluation will be undertaken.

The display of the probabilities associated with the various interactions among the perimenstrual symptom clusters helps to explain the complexity of perimenstrual symptoms as compared with a simpler medical definition of dysmenorrhea as pain and mood change only. In addition to being more reflective of the experience, a more complete explanation is important for the education of both healthcare professionals and the lay public, as well as for the purpose of practice, especially in terms of assessment and research. These findings have implications for health education regard-ing menstruation, for clinical assessment of those with dysmenorrhea complaints, and for researchers study-ing the effectiveness of treatments to relieve perimen-strual symptoms. The methodology has implications for terminology developers studying syndromes or other complex diagnoses.

Limitations

The intrinsic limitation of this survey study is that it relies on a self-report method of data collection. There-fore, intentional deception, poor memory, or misun-derstanding of the question can all contribute to inaccuracies in the data. Survey research is useful in gathering information about a particular incident and emphasizes standardized procedures; however, it cannot offer insights into cause-and-effect relation-ships. The use of a self-report inventory presented the possibility of eliciting a socially desirable response bias, thereby underreporting certain items. This pre-sents a threat to construct validity. For example, the PS of decreased sexual desire was the least reported symptom. This may be because it actually is the least experienced symptom, or it may be that sexual desire is not a topic to be discussed in this culture. Despite its limitations, this study has value.

Ideally, the sample would be chosen randomly from a cross section of the entire population of young adult

women and not limited to nursing students within one school; however, this study was not randomized because of limitations in sampling. While nursing students may be more aware of their body and its functions, and report perimenstrual symptoms with greater frequency, it is also possible that such aware-ness may be common knowledge among all young Taiwanese women regardless of educational back-ground. Since convenience-sampling techniques produce a sample that may not be representative of the greater population, the generalizability of the findings in this study is thus limited.

Conclusions

The prevalence of perimenstrual symptoms is as high as 43–90% worldwide in women of reproductive age. In this study of Taiwanese nursing students of the same age group, this prevalence was found to be around 80%. Even though the methodology needs improvement, this attempt to better understand their presentations in terms of the ways in which the catego-ries interact has advanced the ability of nursing profes-sionals to describe, assess, teach, and research PS. The results advance the knowledge underlying nursing assessment, diagnosis, and management of perimen-strual symptoms. For example, the results showed that perimenstrual symptom is not only pain, as defined in the ICD, rather, a cluster of symptoms including mood change, GI disturbance, and functional ability decline, in addition to pain. In the sense that dysmenorrhea is more than just pain and can be described as a syn-drome, the results of this study are not dissimilar to those of Collins Sharp et al. (2002). The display of Venn diagrams supports the notion that perimenstrual symptom is, in fact, a complex phenomenon involving a constellation of symptoms for at least four different symptom categories.

Acknowledgments. This research was financially sup-ported by Saint Louis University, North American Nursing Diagnosis Association (NANDA) Scholarship

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Chen, H. M., & Chen, C. H. (2005). Related factors and consequences of menstrual distress in adolescent girls with dysmenorrhea.

Kaohsiung Journal of Medical Sciences, 21(3), 121–127.

Chiou, M. H., & Wang, H. H. (2008). Predictors of dysmenorrhea and self-care behavior among vocational nursing school female stu-dents. Journal of Nursing Research, 16(1), 17–25.

Collins Sharp, B. A., Taylor, D. L., Thomas, K. K., Killeen, M. B., & Dawood, M. Y. (2002). Cyclic perimenstrual pain and discomfort: The scientific basis for practice. Journal of Obstetric, Gynecologic,

and Neonatal Nursing, 31(6), 637–649.

Ghanbari, Z., Haghollahi, F., Shariat, M., Foroshani, A. R., & Ashrafi, M. (2009). Effects of calcium supplement therapy in women with

Journal of Maternal Child Nursing, 29(1), 41–49.

Moline, M. L., & Zendell, S. M. (2000). Evaluating and managing premenstrual syndrome. Medscape Women Health, 5(2), 1. NANDA-International. (2008). Diagnosis. Retrieved October 1, 2009,

from http://www.nanda.org/DiagnosisDevelopment.aspx NANDA-International. (2009). Nursing diagnosis: Definition and

clas-sification 2009–2011. Indianapolis, IN: Wiley-Blackwell.

Proctor, M. L., & Murphy, P. A. (2001). Herbal and dietary therapies for primary and secondary dysmenorrhoea. Cochrane Database of

數據

Table 1 presents the numbers and percentages of participants reporting one or more within-category symptoms

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