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

Nursing Documentation Activity Exercise Pattern

Activity Exercise Pattern

  • Activities of daily living, including routines of exercise, leisure, and recreation.
  • Activities necessary for personal hygiene, cooking, shopping, eating, maintaining the home, and working.
  • An assessment is made of any factors that affect or interfere with the client’s routine activities of daily living.

Nursing Assessment, History and Diagnosis for Elimination Pattern

Elimination Pattern

  • Adequacy of the client’s bowel and bladder.
  • The client’s bowel and urinary habits.
  • Bowel or urinary problems
  • Use of urinary or bowel elimination devices.

Nursing assessment and Diagnosis for Nutritional-Metabolic Pattern

Nursing History

Assessing the client’s nutritional-metabolic pattern is to determine the client’s dietary habits and metabolic needs. The conditions of hair, skin, nails, teeth and mucous membranes are assessed

Health Assessment Nursing History

Nursing History

Nursing History

  • Systematic collection of subjective data and objective data . used to determine a client functional health pattern status.
  • The nurse collects physiological, socio cultural, developmental, and spiritual client data .These data assist the nurse in identifying nursing diagnosis and collaborative problems.