Performance Checklist- Perineal Care PDF

Title Performance Checklist- Perineal Care
Author Kiminatsu Sy
Course Nursing
Institution University of Northern Philippines
Pages 2
File Size 95.8 KB
File Type PDF
Total Downloads 4
Total Views 145

Summary

Credits to the rightful owner. It is a checklist that we adapt from the internet....


Description

TRINITY VALLEY COMMUNITY COLLEGE ASSOCIATE DEGREE NURSING RNSG 1216 PROCEDURE GUIDE AND CHECK-OFF SHEET PERINEAL CARE Perineal care promotes patient comfort and removes secretions and odors. Delegation: This procedure may be delegated to unlicensed assistive personnel that have proper training. The nurse retains the responsibility of the assessment. Procedure 1.

The following equipment is needed for this skill: a. towels b. gloves c. bath basin & warm water d. soap e. washcloth f. protective pads/linen g. cotton balls/gauze. 2. Prepare the patient by folding the top bed linen to the foot of the bed and fold up the gown to expose the perineal/genital area. 3. Place a bath towel under the patient’s hips. 4. Position and drape the patient. Females: 5. Have the patient lie on their back with knees flexed and spread apart. 6. Drape the legs by covering the torso with an additional sheet or blanket and tuck the corners under to inner sides of the legs. Allow some of the sheet to cover the pubic area until cleaning commences. 7. Clean the labia majora, then spread the labia to wash the folds between the labia majora and the labia minora. 8. Clean in direction from perineum to rectum. 9. Using separate quarters of the washcloth for each stroke, wipe from the pubis to the rectum. 10. For menstruating patients or those with indwelling catheters, disposable cloths, gauze, or cotton balls may be useful. Use a clean area for each stroke.

Scientific Rationale Water is to be warm to allow comfort. Too hot may damage skin and cold may be startling and uncomfortable. Some facilities may have bath blankets and prepared cleansing tissues or towels.

Assessment cannot be completed unless the genital area is visible. Prevents the bed from becoming soiled. Draping the patient minimizes exposure and provides additional warmth for the patient. Allows adequate visibility and access and flexing the knees decreases the stress on the lower back. A separate top sheet may be used to provide additional warmth and comfort to the patient. Decreasing the upper thigh exposure and allowing a loose drape to cover the pubic area decreases the sense of exposure on the part of the patient. Secretions in this area tend to collect and facilitate bacterial growth. Wiping in this manner prevents cross contamination of areas. Using clean portions of the cloth discourages transmission of microorganisms from one area to another. Wiping from an area of least contamination to one of more contamination prevents spreading microorganisms. Additional soiled areas may require the use of additional clean supplies that promote easy disposal of soiled surfaces.

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11. With a catheter, wipe in the direction away from entry site.

Wiping away from the body portal prevents microorganisms from entering into the body cavity.

12. Rinse well. May use a peri-wash bottle or container to flow warm water over the perineal area. Having the patient on a bedpan allows collection of the draining fluid.

Soap residue may act as an irritant and harbor microorganisms. Allowing a free flow of fluid is soothing to the patient and increases the effectiveness of removing residue from the area.

13. Dry thoroughly, paying attention to the folds between the labia. 14. Assess the area for evidence of redness, irritation, and drainage, especially between the labia in females and around indwelling catheters.

Moisture supports and promotes the growth of many microorganisms. Indicates skin breakdown.

15. Reposition the patient on the side facing away and clean between the buttocks. May use tissue first if heavily soiled.

Provides visual inspection of the area. Tissue is more readily disposable and reserves the washcloth for the final cleaning.

Males: 16. Assist the patient to a supine position, knees flexed, and hips slightly rotated externally.

Provides for access and prevents stress on the lower back.

17. Wash and dry the perineal area. Clean the inner thighs and general perineal area first.(Clean to Dirty) 18. Wash and dry the penis, using firm strokes. Begin in circular motion at the glans penis and wash toward the base, using separate quarters of the cloth.

Cleaning from an area of least contamination to one of more contamination prevents spreading of microorganisms. Using clean portions of the cloth discourages transmission of microorganisms from one area to another. Wiping from an area of least contamination to one of more contamination prevents spreading microorganisms.

19. For uncircumcised patients, retract the foreskin exposing the tip of the penis, clean the glans penis, and replace the foreskin.

Smegma collects under the foreskin, which can harbor bacteria and should be removed. Replacing the foreskin prevents constriction of the penis, which may cause edema. The scrotum may be more soiled than the penis since it is in closer proximity to the rectum. Therefore, the penis is usually cleaned first. Indwelling catheters may cause excoriation around the urethra from pressure and friction.

20. Wash and dry the scrotum. (The posterior folds of the scrotum may be cleaned more easily when the rectum is cleaned). 21. Inspect the perineal orifices for intactness, especially in catheterized patients. 22. Reposition the patient on the side facing away and clean between the buttocks. May use tissue first if heavily soiled. Pay particular attention to the posterior scrotal folds. 23. Dry the area well. 24. Assess for redness, excoriation, tenderness, discharge, or drainage. 25. Document condition of skin. 26. Report any abnormal data to the appropriate personnel.

Provides visual inspection of the area. Tissue is more readily disposable and reserves the washcloth for the final cleaning. Moisture supports bacterial growth. Indicates skin breakdown. All data must be entered in patient’s record. Any abnormal finding must have a corresponding nursing action.

N:ADN/ADN Syllabus/CBC Curriculum/Level I/1216/Performance Checklist for Basic Skills - Perineal Care Revised 04/16

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