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Prepared and Compiled by:

LGA Oanes, RN; C.E. Opalia RN; A. Macabada, RN

Mindanao State UniversityCOLLEGE OF HE LTH SCIENCESName of Student: Aisa Alyanna B. Habib Score: _________

Clinical Instructor: Ms. Aisha B. Macabada Date: July 2, 2010

PERINEAL CARE

Purpose:

Equipments: Kelly Pad, Pail, Sterile water, Cleansing solution (Antiseptic solution), Sterile gloves,

Sponge holder or forceps, Sponge or cotton balls

PROCEDURE RATIONALE 3 2 1 0

1.) Wash hands. Handwashing helps prevent the

spread of microorganisms.

2.) Explain procedure and its purpose

to the client.

Explanation reduces anxiety and

enhances cooperation.

3.) Prepare necessary equipment and

supplies.

Organization and planning improve

efficiency.

4.) Pull curtain around the clients bed

or close room door. Assemble

supplies at bedside.

Privacy enhances self-esteem.

5.) Assess genitalia for signs of

inflammation, skin breakdown, orinfection.

Assessing first the genitalia

promotes the safety of the patientand prevents further complications.

6.) Place the Kelly pad under the

client and the area of procedure.

Kelly pad protects the bed from

soiling.

7.) Assist the client to dorsal

recumbent position or lithotomy

position. Lower the side rail and help

the client flex and spread legs. Note

restrictions or limitations in clients

positioning.

Positioning in this manner allows for

good visualization of the perineum.

8.) Place a pail just below the Kelly

pad.

The pail serves as a container of the

water falling from the Kelly pad.

9.) Fold lower corner of blanket up

between clients legs onto abdomen.

This is to expose the working area to

deliver the work efficiently and

effectively.

10.) Wash external genitalia and This way of washing proceeds from

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Prepared and Compiled by:

LGA Oanes, RN; C.E. Opalia RN; A. Macabada, RN

upper thighs by pouring sterile water

6 inches away from the area.

lesser contaminated to a more

contaminated area.

11.) Depending on hospital policies,

wear sterile gloves or use sponge

holder.

This is to promote safety and

prevent cross-contamination of

microorganisms.

12.) Using a cleansing solution(antiseptic solution) and the first

sterile sponge, begin cleansing from

side to side beginning from the mons

pubis up to the umbilicus. Discard

sponge.

This is to oppose the growth ofmicroorganisms in the pubic area.

13.) The second and third sponges are

used to clean the midthigh of each leg

using up-and-down motion and going

outward.

This is to clean and kill the

microorganisms in the thigh region.

14.) The fourth and fifth sponges areused to clean the labia majora (left

and right).

This is to clean and prevent thegrowth of microorganisms in the

labia majora.

15.) The sixth and seventh sponges

are used to clean the labia minora

(left and right).

This is to clean and prevent the

growth of microorganisms in the

labia minora.

16.) The eighth sponge is used to

clean from the clitoris to the vaginal

opening.

This is to ensure that the clitoris and

birth canal are free from

microorganisms.

17.) The last sponge is used to cleanthe anus. Anus is the last since it is the mostcontaminated area.

18.) Wash hands. Handwashing prevents the spread

of possible infection.

19.) Document any findings. Documentation provides a means

for communication and evaluation

of care and client outcomes.

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Prepared and Compiled by:

LGA Oanes, RN; C.E. Opalia RN; A. Macabada, RN

Mindanao State UniversityCOLLEGE OF HE LTH SCIENCESName of Student: Aisa Alyanna B. Habib Score: __________

Clinical Instructor: Ms. Aisha B. Macabada Date: July 2, 2010

VAGINAL EXAMINATION

Purpose: Determine cervical readiness and fetal position and presentation.

Equipments: Sterile examining gloves, sterile lubricant, antiseptic solution

PROCEDURE RATIONALE 3 2 1 0

1.) Wash your hands. Handwashing helps prevent the

spread of microorganisms.

2.) Explain procedure to the client. Explanation reduces anxiety and

enhances cooperation.

3.) Provide privacy. Privacy enhances self-esteem.

4.) Assess client status and adjust plan

to individual client need.

Care is always individualized

according to a clients needs.

5.) Assemble equipments needed. Organization and planning improves

efficiency.

6.) Ask the woman to turn onto her

back with knees flexed (dorsal

recumbent position).

Positioning in this manner allows for

good visualization of perineum.

7.) Put on sterile examining gloves. Use of a sterile glove prevents

contamination of birth canal.

8.) Discard one drop of clean

lubricating solution and drop an

ample supply on tips of gloved

fingers.

Discarding the first drop ensures

that quantity used will not be

contaminated.

9.) Pour antiseptic solution over vulva

using non dominant hand.

This prevents the spread of

organisms from perineum to birth

canal.

10.) Place non dominant hand on the

outer edges of the womans vulva and

spread her labia while inspecting the

external genitalia for lesions. Look for

red, irritated mucous membranes;

open, ulcerated sores; clustered

pinpoint vesicles.

Positioning hands in this way allowsfor good perineal visualization.

Presence of any lesions may indicate

an infection and possibly preclude

vaginal birth.

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Prepared and Compiled by:

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11.) Look for escaping amniotic fluid

or the presence of umbilical cord or

bleeding.

Amniotic fluid implies membranes

have ruptured and umbilical cord

may have prolapsed. Bleeding may

be a sign of placenta previa.

12.) If there is no bleeding or cord

visible, introduce your index and

middle fingers of dominant hand

gently into the vagina, directing them

toward the posterior vaginal wall.

The posterior vaginal wall is less

sensitive than the anterior wall.

Stabilize the uterus by placing your

non-dominant hand on the womens

abdomen.

13.) Touch the cervix with your gloved

examining fingers.

a. Palpate for cervical consistency

and rate if firm or soft.

The cervix feels like a circular rim of

tissue around a center depression.

Firm is similar to the tip of the nose;

soft is as pliable as an earlobe.

b. Measure the extent of

dilatation; palpate for an anterior rim

or lip of cervix.

The width of the fingertip helps to

estimate the degree of dilatation.

An index finger is about 1cm; amiddle finger about11/2 cm. If they

can both enter, the cervix is dilated

to 21/2to 3cm. If there will be room

double for that, it is about 5 to 6cm.

When the space is four times the

width of the fingertips, dilatation is

complete-10cm.

14.) Estimate the degree of

effacement.

Effacement is estimated in

percentage. A cervix before labor is

2 to 21/2cm thick. If it is only 1cmthick now, it is 50% effaced. If it is

tissue paper thin, it is 100% effaced.

15.) Estimate whether membranes

are intact.

The membranes are the shape of a

watch crystal. With a contraction,

they bulge forward and become

prominent and can be felt much

more readily.

16.) Locate the ischial spines. Rate the

station of the presenting part. Identify

the presenting part.

Ischial spines are palpated as

notches at the 4 and 8 oclock

positions at the pelvic outlet.Station is the number of centimeters

above or below the spines where

the presenting part is. Identifying

the presenting part confirms

findings obtained with Leopolds

maneuvers. A vertex has a hard,

smooth surface. Fetal hair may be

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Prepared and Compiled by:

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palpable but massed together and

wet. Palpating the two fontanelles

helps the identification. Buttocks

feel softer and give under fingertip

pressure.

17.) Establish the fetal position. The fontanelle palpated is invariably

the posterior one because the fetus

maintains a flexed position. In an

ROA position, the triangular

fontanelle will point toward the

right anterior pelvic quadrant. In an

LOA position, the posterior

fontanelle will point toward the left

anterior pelvis. In a breech

presentation, the anus can serve as

a marker. When the anus is pointing

toward the left anterior quadrant ofthe pelvis, the position is LSA.

18.) Withdraw your hand. Wipe the

perineum front to back to remove

secretions or examining solution.

Leave client comfortable and turned

to side.

Wiping front to back prevents

moving rectal contamination

forward to the vagina. Side-lying is

the best position to prevent supine

hypotension syndrome in labor.

19.) Document procedure and

assessment findings and how client

tolerated the procedure.

Documentation provides a means

for communication and evaluation

of care and client outcomes.