Genitourinary Care Plan

Date: ____ /____ /____ Time:

1. Diagnosis_____________________________________ 2.Allergies: Yes No Unknown 3. Baseline Pain Score:__________
_____________________________________________ Sensitivity: Yes No Unknown Current Pain Score: _____________
_ Specify & Pain Tool used _________________
Surgeries related to Genitourinary with date : Symptoms____________________ _________________________________
_____________________________________________ Medications related to GU ☐ Yes ☐ No Symptoms:
_ ☐Antibiotics ☐ Antipyretic ☐Analgesics ☐Pain ☐Urgency ☐Dysuria
________________________________________________ ☐Anti-inflammatory ☐ Antihistamine ☐Nocturia ☐Irritation ☐ Fever
Special Considerations ☐Antimicrobials ☐ Anti-fungal. ☐Incontinene ☐Hematuria
Genital Warts ☐ Prescribed Bladder Washing. ☐ Hesitancy/dribble.
Dry Excoriated Vagina Specify ____________________________ ☐Urinary Retention ☐Burning
Pruritus / External Genital irritation __________________________________ ☐ Others: ______________________
Prostate
Male Circumcision
Female Circumcision
4.GU Infections 5.Genitalia Discharge ☐ Yes ☐No 6.Menstrual Cycle Yes No NA
Urethritis: ☐ Yes ☐No Treatment:_________________ If yes State Color ___________________ Regular Irregular Menopause
UTI ☐ Yes ☐No Treatment:_________________ If yes State Tecture__________________ Normal Cycle Duration: _______days
Pyelonephritis ☐Yes ☐ No Treatment______________ Urinal Discharge ☐ Yes ☐No LMP: ____/____/____
If yes State Color ___________________ Birth Control Contraceptive Measures
If yes State Tecture__________________ Yes No ☐ Inj.Depo Provera ☐IUD

7.Catheterization Yes No 8.Psychosocial Profile:

Last Changed Yes No Date:___/___/___ ☐ Disturbed body image related to incontinence
Brand:__________ Size:_________ Next change due:___/___/___ ☐ Leg Bag or bedside catheter bag
Residued on Insertion ☐ Prevention of ADLS ☐ Prevention to Pray
☐Clear ☐Cloudy ☐Concentrated ☐ Prevention to socially interact with others.
☐Pus ☐ Hematuria ☐ Sedimented ☐ Diagnosed Depression ☐ Un-Diagnosed Depression.
Resistance on Insertion ☐ Yes ☐ No ___________________________________________________________
If Yes Doctors Advice _______________________________________ 9. Self-Voiding urine freely.
Catherter drainage bag insitu Yes No Leg Bag Urometre Independently using the Toilet.
Drainage Bag Change due date: __/__/__ __/__/___ __/__/__ Requires Assistance of Nurse X________
Using Commode Using the toilet
Drs order for 24 hours collection Using the Bed Pan. Using a Urinal
Start Date___/___/___ Time _____hrs
End Date___/___/___ Time _____hrs 10. Personal Hygiene
Use of Hygiene Wash Yes No
Name of Product: _____________ Frequency X____________Per day
Other Products used_______________________________________

Date No. Plan / Goal Intervention Evaluation Initial & Emp.

No.

Investigations
Date Diagnostic Test Result

Due For:

Nurse Name & Signature (1) ________________________________________________________ Emp_________ Date & Time ________________
Title Index Code Approval Date Edition Last Revised Revision Date
Genitourinary Care Plan MHCS-QR/NUR-CP/FORM/002 August 2016 1 August 2016 August 2018
 Genitourinary Care Plan

Nurse Name & Signature (2) ________________________________________________________ Emp_________ Date & Time ________________
Supervisor Name & Signature________________________________________________________Emp_________ Date & Time ________________

Title Index Code Approval Date Edition Last Revised Revision Date
Genitourinary Care Plan MHCS-QR/NUR-CP/FORM/002 August 2016 1 August 2016 August 2018