Genitourinary Reproductive Assessment

Genitourinary Reproductive Assessment

Female Patients
■ Pain: Assess for dysmenorrhea (abnormally severe cramping or pain in the lower abdomen during menstruation).
■ Lesions: Inspect perineum for blisters, ulcers, sores, warts, or rashes.
■ Breast: Inspect for asymmetry. Inspect skin for dimpling or edema. Inspect nipples for color, discharge, or inversion. Palpate in a concentric circle, outward from the nipple, including the axillae, for lumps or tenderness. Does the Pt perform regular breast self-examination?
■ Discharge: Assess for vaginal discharge and note color, odor, amount, and any associated symptoms.
■ Menstruation: Describe last menstrual period. Do periods occur regularly? Have Pt describe her “normal flow.” Bleeding other than the normal menstrual period should be further assessed including frequency, quantity, and associated symptoms.
■ Genitourinary Symptoms: Kidney stones, blood in the urine, change in voiding pattern (frequency), or itching.
■ Sexual History: Is Pt sexually active? Does she use protection against infection? Method of birth control? Multiple or same-sex partners? Any concern with or history of sexually transmitted disease (STD)?
■ Document: assessment, interventions, and outcomes.

Male Patients
■ Pain: Assess for pain in the penis, testes, scrotum, and groin area. Is there any history of painful or burning urination?
■ Lesions: Inspect perineum for blisters, ulcers, sores, warts, or rashes.
■ Testicles: Palpate scrotum and groin area for lumps, masses, or swelling. Does the Pt perform testicular self-examination?
■ Discharge: Inspect meatus for discharge and note color, amount, and any associated symptoms.
■ Genitourinary Symptoms: Kidney stones, blood in the urine, change in voiding pattern (frequency), itching, or erectile dysfunction.
■ Sexual History: Is Pt sexually active? Does he use protection against infection? Method of birth control? Multiple or same-sex partners? Any concern with or history of STD?
■ Document: assessment, interventions, and outcomes.