Nursing Documentation: Sexuality-Reproduction Pattern

Female Reproduction system

Subjective Data

Menstrual history:

  • Last cycle begin?
  • Duration ?
  • Any change or abnormality ?
  • Describe any mood changes or discomfort before, during, or after your cycle

Obstetric history

  • How many times have you been pregnant?
  • Describe the outcome of each of your pregnancies.
  • If you have children, what are the ages and sex of each?
  • Explain any health problems or concerns you had with each pregnancy. If pregnant now .

Contraception

  • What do you or your partner do to prevent pregnancy?
  • Describe any discomfort or undesirable effects this method produces.
  • Have you had any difficulty with fertility? Explain.

 

Special problems

  • Do you have or have you ever had a sexually transmitted disease? Describe.
  • Describe any pain, burning, or discomfort you have while voiding.

 

Objective Data

Refer to Breast Assessment, d Abdominal Assessment, and urinary-Reproductive Assessment

 

Associated nursing Diagnoses

Wellness Diagnosis:

Opportunity to enhance sexuality patterns

Risk-Diagnosis

Risk for altered sexuality pattern

Actual Diagnoses

Sexual Dysfunction, Altered Sexuality Patterns

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