Genitourinary Reproductive Assessment

Genitourinary Reproductive Assessment

■ Pain: Female Pts: Assess for dysmenorrhea (abnormally severe cramping or pain in lower abdomen during menstruation); Male Pts: Assess for pain in 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.

■ Breast: Inspect for asymmetry. Inspect skin for dimpling or edema. Inspect nipples for color, discharge, or inversion. Palpate in concentric circles, outward from nipple, including axillae, for lumps or tenderness and presence of implants. Does Pt perform regular breast self-examinations?

■ Testicles: Palpate scrotum and groin area for lumps, masses, or swelling. Does Pt perform testicular self-examinations?

■ Discharge: Female Pts: Assess for vaginal discharge and note color, odor, amount, and any associated symptoms; Male Pts: Inspect meatus for discharge and note color, amount, and any associated symptoms.

■ Menstruation: Describe last menstrual period including date. Do periods occur regularly? Have Pt describe her “normal flow.” Bleeding other than normal menstrual period should be further assessed including frequency, quantity, and associated symptoms.

■ Genitourinary Symptoms: Kidney stones, blood in urine, dysuria, change in voiding pattern (frequency), itching, or erectile dysfunction in males.

■ Sexual History: Is Pt sexually active? Does he or she 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.