Mindanao State University COLLEGE OF HEALTH SCIENCES Name of Student: Aisa Alyanna B. Habib Clinical Instructor: Ms.

Aisha B. Macabada PERINEAL CARE Purpose: Equipments: Kelly Pad, Pail, Sterile water, Cleansing solution (Antiseptic solution), Sterile gloves, Sponge holder or forceps, Sponge or cotton balls Score: _________ Date: July 2, 2010

PROCEDURE 1.) Wash hands. 2.) Explain procedure and its purpose to the client. 3.) Prepare necessary equipment and supplies. 4.) Pull curtain around the clients bed or close room door. Assemble supplies at bedside. 5.) Assess genitalia for signs of inflammation, skin breakdown, or infection. 6.) Place the Kelly pad under the client and the area of procedure. 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. 8.) Place a pail just below the Kelly pad. 9.) Fold lower corner of blanket up between clients legs onto abdomen. 10.) Wash external genitalia and
Prepared and Compiled by: LGA Oanes, RN; C.E. Opalia RN; A. Macabada, RN

RATIONALE Handwashing helps prevent the spread of microorganisms. Explanation reduces anxiety and enhances cooperation. Organization and planning improve efficiency. Privacy enhances self-esteem.

Assessing first the genitalia promotes the safety of the patient and prevents further complications. Kelly pad protects the bed from soiling. Positioning in this manner allows for good visualization of the perineum.

The pail serves as a container of the water falling from the Kelly pad. This is to expose the working area to deliver the work efficiently and effectively. This way of washing proceeds from

upper thighs by pouring sterile water 6 inches away from the area. 11.) Depending on hospital policies, wear sterile gloves or use sponge holder. 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. 13.) The second and third sponges are used to clean the midthigh of each leg using up-and-down motion and going outward. 14.) The fourth and fifth sponges are used to clean the labia majora (left and right). 15.) The sixth and seventh sponges are used to clean the labia minora (left and right). 16.) The eighth sponge is used to clean from the clitoris to the vaginal opening. 17.) The last sponge is used to clean the anus. 18.) Wash hands. 19.) Document any findings.

lesser contaminated to a more contaminated area. This is to promote safety and prevent cross-contamination of microorganisms. This is to oppose the growth of microorganisms in the pubic area.

This is to clean and kill the microorganisms in the thigh region.

This is to clean and prevent the growth of microorganisms in the labia majora. This is to clean and prevent the growth of microorganisms in the labia minora. This is to ensure that the clitoris and birth canal are free from microorganisms. Anus is the last since it is the most contaminated area. Handwashing prevents the spread of possible infection. Documentation provides a means for communication and evaluation of care and client outcomes.

Prepared and Compiled by: LGA Oanes, RN; C.E. Opalia RN; A. Macabada, RN

Mindanao State University COLLEGE OF HEALTH SCIENCES Name of Student: Aisa Alyanna B. Habib Clinical Instructor: Ms. Aisha B. Macabada VAGINAL EXAMINATION Purpose: Determine cervical readiness and fetal position and presentation. Equipments: Sterile examining gloves, sterile lubricant, antiseptic solution PROCEDURE 1.) Wash your hands. 2.) Explain procedure to the client. 3.) Provide privacy. 4.) Assess client status and adjust plan to individual client need. 5.) Assemble equipments needed. 6.) Ask the woman to turn onto her back with knees flexed (dorsal recumbent position). 7.) Put on sterile examining gloves. 8.) Discard one drop of clean lubricating solution and drop an ample supply on tips of gloved fingers. 9.) Pour antiseptic solution over vulva using non dominant hand. 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.
Prepared and Compiled by: LGA Oanes, RN; C.E. Opalia RN; A. Macabada, RN

Score: __________ Date: July 2, 2010

RATIONALE Handwashing helps prevent the spread of microorganisms. Explanation reduces anxiety and enhances cooperation. Privacy enhances self-esteem. Care is always individualized according to a clients needs. Organization and planning improves efficiency. Positioning in this manner allows for good visualization of perineum. Use of a sterile glove prevents contamination of birth canal. Discarding the first drop ensures that quantity used will not be contaminated. This prevents the spread of organisms from perineum to birth canal. Positioning hands in this way allows for good perineal visualization. Presence of any lesions may indicate an infection and possibly preclude vaginal birth.

11.) Look for escaping amniotic fluid or the presence of umbilical cord or bleeding. 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. 13.) Touch the cervix with your gloved examining fingers. a. Palpate for cervical consistency and rate if firm or soft. b. Measure the extent of dilatation; palpate for an anterior rim or lip of cervix.

Amniotic fluid implies membranes have ruptured and umbilical cord may have prolapsed. Bleeding may be a sign of placenta previa. The posterior vaginal wall is less sensitive than the anterior wall. Stabilize the uterus by placing your non-dominant hand on the womens abdomen. 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. The width of the fingertip helps to estimate the degree of dilatation. An index finger is about 1cm; a middle finger about 11/2 cm. If they can both enter, the cervix is dilated to 21/2 to 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. Effacement is estimated in percentage. A cervix before labor is 2 to 21/2cm thick. If it is only 1cm thick now, it is 50% effaced. If it is tissue paper thin, it is 100% effaced. 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. 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

14.) Estimate the degree of effacement.

15.) Estimate whether membranes are intact.

16.) Locate the ischial spines. Rate the station of the presenting part. Identify the presenting part.

Prepared and Compiled by: LGA Oanes, RN; C.E. Opalia RN; A. Macabada, RN

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 of the pelvis, the position is LSA. 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. Documentation provides a means for communication and evaluation of care and client outcomes.

18.) Withdraw your hand. Wipe the perineum front to back to remove secretions or examining solution. Leave client comfortable and turned to side. 19.) Document procedure and assessment findings and how client tolerated the procedure.

Prepared and Compiled by: LGA Oanes, RN; C.E. Opalia RN; A. Macabada, RN