Altered Sexuality Patterns

Altered
Sexuality Patterns

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Cardiac disease
(_) Chronich respiratory disease
(_) Medication

(_) Metabolic disease
(_) Neurological disease

(_)
Penile prosthesis
(_) Prostatectomy
(_) Other:_____________________________
____________________________________

____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(
Must be
present
)
(_)
Identification of sexual difficulties, limitations, or
changes.

 

Date &
Sign.
Plan and Outcome
[Check
those that apply]
Target
Date:
Nursing Interventions
[Check
those that apply]
Date
Achieved:
  The
patient will:

(_)
Experience sexual pleasure as defined by self and
partner.

(_) Learn alternative
ways of sexual expresiion.

(_) Other:

 

  (_)
Assess patient’s current satisfaction with sexual
functioning.

(_)
Discuss with patient potential etiological factors for a
change in sexual functioning.

(_) Teach patient
necessary information regarding implantable devices. eg.
penile prosthesis.

(_) Referral
to:_________________
________________________

________________________

 

(_)
Other:________________
________________________
________________________
________________________

 

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature