Table-1.Care Pathway for Nurse- led Youth Friendly Reproductive and Sexual Health Services (YFRSH) for HIV / AIDS Prevention

Stage	No. of Visits	Purpose	Initial Visit	Follow up Visit	Documentation
I	2-3 (Applicable for all youth)	Establishing rapport and initial engagement	¶ Introduce yourself in a non-threatening way ¶ Establish warm, open and trusting environment. Avoid professional jargon ¶ Use appropriate eye contact. ¶ Ask general questions	Enquire reason for coming. If presented with menstrual disorders ¶ Provide symptomatic treatment for premenstrual tension, dysmenorrhea etc. ¶ Counsel for menstrual problems and hygiene	Record the findings ______________ ______________ ______________
			Collect information related to ¶ Age, class (education) ¶ relationship with family, friends, marital status ¶ Exposure to media, hobbies, habits ¶ Document the above data & fix the next visit ¶ Provide information on services of YFRSH centre^(.3)	¶ Refer for any investigation if presented with severe puberty- related problem. If presented with excessive vaginal discharge ask for associated symptoms like, ¨ excessive vaginal discharge, ¨ itching, ¨ burning micturition	Treatment taken ______________ ______________ Response of the client ______________ ______________ ______________ Evaluate the care
			Give IEC on 1) Fertility Awareness The reproductive system, fertility, menstrual cycle, cultural norms. 2) Gender Awareness Emphasize communication and shared responsibility between boys & girls	¶ abdominal pain ¶ discuss the ill effects of self treatment ¶ initiate treatment as per standard protocol ¶ arrange for lab test if needed.
II	1-2	Sexual health and HIV risk assessment	Initial visit a) Assessment of knowledge, attitude related to, ¶ Pregnancy, contraception ¶ Sexuality ¶ HIV/ AIDS, RTI, STI (show the chart that illustrate signs and symptoms) ¶ Document gaps and misconceptions	2^nd Visit Sexual health assessment: Ask meaningful relevant open ended questions Ex. I would like to review any sexual health concerns you may have. Is that OK with you? ¶ What to do you understand by the word “Sex”? Where do you find out about ‘sex’?	Document the factors influencing, the client’s risk. _______________
			b) Assess HIV risk perception ¶ Ask her to rate on a scale of 1-10 about her risk of acquiring HIV. ¶ Ask if she had any untested blood transfusion. ¶ Address specific questions posed by the client, provide appropriate learning material.	¶ Have you had any sexual experiences? (Give opportunity to share her situation). ¶ Check if she is sexually active (Yes/ No) (If yes – refer stage IV) (If No – refer stage III guidelines)	_______________ _______________
III	1-2	Goal:- To empower youth to delay the sexual activity	If not sexually active counsel on sexuality⁽³⁾ Give Information on How their bodies, minds, feelings change How to communicate about sexuality How to handle social and peer pressures, coercion How to make responsible decision about sexual activity. ¶ Strengthen their values against unprotected sex ¶ Have open discussion on the above matters.	Next Visit Counsel on:- consequences of early marriage, pregnancy, HIV/ STI ¶ Risks of youth and risk reduction strategies ¶ Sero prevalence of HIV/ STI in the community ¶ Emphasize on abstinence ¶ Enhance sexual self-efficacy skills ¶ Provide alternative to risky behaviour (like holding hands)	Give home work related to the sexual self-efficacy skills. Nurse encourages, praises them for healthy behaviour. Response of the Client:- _______________ _______________ Document the outcome
IV	1-2	Goal:- To enable them Learn their, own and partner’s HIV risk status & apply sexual self efficacy skills	If sexually active and engaged in a mutually monogamous relationship Ask:- Questions like ¶ When was the last time you had sexual activity? ¶ What sexual experience or act you are involved? (Give a check list containing masturbation, oral sex, sexual penetration etc.) ¶ How often? ............ times in the past three months. Explore further:- ¶ What does it mean to you to have unsafe sex with your boy friend? ¶ What does it mean for you to have a baby right now? ¶ I hear, you want to protect Yourself from HIV, what are you doing to protect you?	According to the response given for the questions open up discussion on:- a) Attitude about and history of condom use:- Ask:- · What is your experience with condom? · Do you see the need to use them? · What makes you use them/ avoid them? · Are you using regularly? b) Testing for HIV/ STI · How do you feel about getting a HIV test? · Has your partner been tested? · Have you been tested? · What would keep you from getting one?	Record the Response Usage of condom ______________ ______________ Partner’s risk ______________ ______________ Clients’ risk _______________ _______________
V	1-2	Goal:- To motivate youth for safe sex and to enhance sexual self efficacy skills	If youths’ partner has multiple partners or is unsure of partner’s status ¶ Ask about partner’s risk status ¶ Check for consistent condom use ¶ History of substance use, History of STI. ¶ Invite partner for discussion. (Above questions are applicable if the client or client’s partner exhibits multiple sexual relationship)	Decision making & Goal setting a) Assess the partner’s risk status · ask him to rate his risk on a scale of 1 to 10. b) Educate on importance of dual protection · Impart knowledge on correct and consistent condom usage. · Explain relationship between HIV/ STI. · Complications of STI including infertility, pelvic inflammatory disease.	Record the agreed upon goals. Follow up for risk reduction in terms of · safe sex
				c) Screen for signs & symptoms of STI and refer for further syndromic management d) Refer to VCTC for HIV testing e) Provide services for emergency contraception · do contraceptive counselling f) Facilitate mutual decision making and goal setting for risk reduction. g) Support the self efficacy and choice of the client to proceed with her action plan.	· absence of adolescent pregnancy · If ended up with unwanted pregnancy (refer pathway for unwanted pregnancy) · Instruct them to come with VCTC/ STI lab results
VI.	1-2	Goal: To Promote institutional delivery and prevent unsafe abortions	If Pregnant:- 1. Wants to continue pregnancy · Provide care of adolescent pregnant · Provide package of ANC, nutrition and birth preparedness · Information on danger signals · Identify and refer to First referral unit for a safe pregnancy · Support institutional delivery and supervised post partum care	Continue to provide reproductive health counselling	Document the program _______________ _______________ _______________ _______________
			2. Wants to terminate · Refer to MTP service, for safe abortion · Provide post abortion counseling	Screen for reproductive morbidity and refer
			3. Terminated by self · Check for obstetric complications · Refer to hospital for further management
VII	2	To screen and manage STI	Screen both partners for Signs and Symptoms of STI like · Excessive vaginal/ urethral discharge · Burning micturition · Abdominal pain · Inguinal bulbo · Pereneal ulcer
			If found with STI/ RTI Privacy: Ensure audio and visual privacy Treatment Compliance: Emphasis on compliance with drug regimen, personal hygiene and safe sex. Partner Management: · Explain the importance of treatment of partner · Refer for management of STI (as per WHO protocol) · Distribute condoms⁶	Follow up for ¶ adherence to treatment ¶ safe sex/ abstinence ¶ Refer to supportive network / groups. ¶ Give information on medical male circumcision.	Document the extent of problem ______________ ______________ Evidence of Reduction of risk _______________ _______________
VIII	1-2	Identification of sexual health problems & promote sexual health	Management of Sexual Problems among Young Married Women Screen for ¶ Lack of interest ¶ insufficient lubrication ¶ Pain during/ after intercourse ¶ diminished orgasms ¶ post coital bleeding ¶ check for intimate partner violence apply (guidelines for IPV in stage IX)².	¶ Assess for reduction of problems ¶ If it is a sexual disorder or dysfunction refer to therapist	Document ______________ ______________
			Follow PLISSIT Model ⁽³⁾ P à Give permission LI à Offer limited information SS à Make specific suggestions IT à Intensive therapy
IX	1-3	Identify and treat intimate partner violence or rape by others.	For Partner Violence Physical Assessment ¶ Assess Trauma ¶ Document ¶ Refer or treat the injuries	¶ Assess current status new trauma. If yes document with body map ¶ Refer for IPV counselling ¶ Discuss the long term health consequences & follow up.	Do multiple visits to ensure the status - sum up the sessions, - ask for any other concerns
			If sexual trauma/ abuse or rape ¶ Ask about forced or undesired sex ¶ Discuss about emergency contraception and options for preventing STI.	¶ Remain alert to possibility ¶ Take history of child abuse/ rape ¶ Inform client to do a HIV test, discuss the impact ¶ Refer for counselling, and support groups.	- Review support system- friends, parents, home environment - Negotiate for further goals
			If Pain ¶ Assess site, type, severity and duration
			¶ If Yes: assess pain in relation to violence history, ¶ rule out for illnesses related to neurological, GI, abdomen, chronic stresse.	¶ Check the progress ¶ Advice for admissions and treatment
			¶ do mental health assessment ¶ Screen for current substance abuse of client and the partner.
X	5	Provide Mental health services including Management of substance abuse	If found with substance abuse Ask:-When client used ¶ How long he/ she used ¶ What type of drugs used Provide ¶ Information, motivation ¶ Psychological, social support Initiate BCC (behaviour change communication) ¶ Assess his readiness for change	Negotiate for Plan of action ¶ Share stories of others who succeeded. Work with client ¶ Explore his/ her ambivalence ¶ Current problem ¶ Listen actively ¶ Encourage / reward for healthy behaviours	Document the behaviour change ______________ ______________ Follow up until maintenance stage Refer for therapy if needed Refer to support groups.

Continued… Fig.-1:.

Fig.-1:

Received on 13.02.2015 Modified on 06.03.2015

Int. J. Adv. Nur. Management 3(3): July- Sept. 2015; Page 283-288

DOI: 10.5958/2454-2652.2015.00017.7