o Neuromuscular or musculoskeletal

PERINEAL CARE impairment

• Perineal Care involves thorough cleansing of o Medically imposed restriction
the client’s genital area, anal area and o Therapeutic procedure restraining
surrounding skin. mobility (e.g., intravenous infusion, cast)
• Also called peri-care or perineal-genital care. o Severe anxiety
• It involves washing of the external genitalia with o Environmental barriers
soap and water or with water alone or in • During perineal care it is also the best time for
combination with any commercially prepared nurses to assess the client’s genital or perineal
periwash or perineal wash. area. We need to assess the perineal area for us
• Can be delegated to nursing assistive personnel. to check any abnormalities on the client’s
• Carried out as part of the patient’s bath or as a genitals after the delivery.
separate procedure. • Assessment:
• We need to do perineal care because the 1. It is a must for us to Assess presence of
Perineal area is a conducive environment to the Irritation, excoriation, inflammation,
growth of pathogenic organism because it warm swelling, excessive vaginal discharge,
and moist. And also, not well ventilated. odor, pain and discomfort, urinary and
• Cleanliness is essential to prevent bad odor and fecal incontinence, recent perineal or
promote comfort. rectal surgery, indwelling catheter.
• It is important for us nurses to render perineal 2. Assess for client’s self care abilities.
care to our client before delivery, after delivery, ▪ Can the client perform the
and as needed by our client. procedure by themselves? Do
• Purpose of Perineal Care: they need assistance?
1. To prevent or eliminate infection, odor 3. Assess for client’s perineal-genital
and promote healing. hygiene practices.
2. To remove secretions and provide ▪ What products do the patient use
comfort. on their genital area? What are
• Principle: their practices?
1. To clean the perineum from the cleanest ▪ For us to do health teaching on
to the less clean area. the proper technique and
2. Follow Standard Precautions. procedures on doing perineal
3. Maintain patient’s privacy. care.
4. Proximal level of functioning. • Materials and Equipment Needed:
• Patients who need frequent perineal care: o Wash cloths
o Who are unable to do self-care. o Bath towels (used for privacy or covering)
o Patients with Genito-urinary tract o Bath blanket
infections o Soap and soap dish
o With fecal and urinary incontinence o Toiletry items
o An indwelling foley catheter o Tissue paper or diaper wipes
o Who are recovering from rectal or genital o Water proof pad
surgery or childbirth. o Bed pan
o Patients with excessive vaginal drainage ▪ Made of metal or plastic and
o Patients with injury and ulcers come in two sizes (pedia and
o Uncircumcised males adult)
o Morbid obesity ▪ Standard bed pan and fracture
pan
• Delegation Considerations:
o Disposable gloves
o Importance of not massaging reddened
o Solution bottle or prescribed rinsing
skin areas during bathing.
solution
o Recognizing early signs of impaired skin
o Warm water 43-46’C
integrity.
o Cotton balls or swab
o Proper ways to position male and female
o Perineal pads
clients with musculoskeletal limitations or
o Urinals
who have an indwelling foley catheter or
▪ Made of plastic or metal with a
other equipment (e.g. intravenous
bottle-like configuration
tubing)
o When to report changes in the skin or PERINEAL CARE PROCEDURE
perineal area to the nurse. 1. Assess the client’s self-care abilities.
• Nursing Diagnosis: Self-Care Deficit • Is the client able or not able to do perineal
(Hygiene) related to care by themselves?
o Decreased or lack of motivation 2. Wash hands.
o Weakness or tiredness • To prevent cross contamination or to
o Pain or discomfort spread any infection.
o Perceptual or cognitive impairment 3. Prepare and gather the materials to be use.
o Inability to perceive body part or spatial • To save time and energy.
relationship
4. Identify and greet the patient. Explain the movement, cognitive ability, musculoskeletal
procedure. function, presence of shortness of breath.
• It is important that we identify the right o Determines client’s ability to perform
client to perform the right procedure on perineal care.
them.
3. Assess client’s visual status, ability to sit without
• Greet the client and explain the
procedure to them to lessen their anxiety. support, hand grasp, ROM of extremities
5. Provide privacy throughout the procedure. o Determines degree of assistance patient
• To preserve the client’s dignity. needs for bathing, ROM may be
6. Place the water proof pad. delegated to assistive personnel.
• To prevent spillage of water to the client’s 4. Assess for presence of equipment (eg. Foley
bed. Catheter, Condom Catheter)
7. Place the client in a back-lying position with the o Affects how you plan bathing activities
knee flexed and spread well apart.
8. Fold the top bed linen to the foot of the bed. and positioning. Helps determine how to
9. Cover the body and legs with the bath blanket. set up supplies.
• Only expose the part where you are 5. Assess for allergy or sensitivity to Chlorhexidine
going to do perineal care... to prove gluconate (CHG).
privacy. o When allergy or sensitivity is present,
10. Drape the legs by tucking the bottom corners of select another cleansing solution.
the bath blanket under the inner sides of the 6. Ask if patient has noticed any problems related
legs.
11. Bring the middle portion of the base of the to condition of genitalia, excess moisture,
blanket up over the pubic area. inflammation, drainage or excretions from
12. Place a bedpan under the patient’s buttocks. lesions or body cavities and rashes
• Make sure that the wider part of the o Provides you with information to direct
bedpan is placed under the patient’s physical assessment of genitalia. Also
buttocks and the narrow part is where the influences selection of skin care
nurse will hold it. products.
13. Wear clean gloves.
7. Assess patient’s knowledge of perineal hygiene
14. Clean the perineal area. First, the meatus
down, then the labia minora, and the labia in terms of its importance, preventive measures
majora using the figure of seven strokes. Use to take, and common problems.
new cotton balls/gauze in every stroke. o Determine patient’s learning needs
15. Rinse the area well. Dry the perineum thoroughly 8. If patient is able to maneuver and handle
paying particular attention to the folds between washcloth, allow them to clean perineum on their
the labia.
own.
16. Note if there’s any signs of inflammation or
swelling. Also, note for excessive secretions o Maintain patient’s dignity and self-care
from the orifices and the presence of odors. ability
17. Assist the client to turn to side facing away from PLANNING
you. Clean between the buttocks and dry the 1. Review orders for specific precautions
area well. concerning patient’s movement or
18. Dispose linens and garbage appropriately. positioning.
• Soiled garbage should be placed in the o Prevents injury to patient during
yellow trash bin.
19. Remove gloves and wash hands. bathing activities. Determine level of
20. Document the procedure. Note any unusual assistance required by the patient.
findings 2. Explain procedure and ask patient for
• Write the date & time, your assessment suggestions on how to prepare supplies. If
findings, and how the client tolerated the using CHG, explain benefit of reducing
procedure. infection and that solution leaves a sticky
PROCEDURE BASED BY VILLARAN feeling
ASSESSMENT: o Promotes cooperation and
1. Introduce self and identify patient using two participation. Patients who prefer
identifiers (eg. Name and birthday; name and using own perineal hygiene solutions
medical record number, according to agency may need to discuss benefits of
policy). Explain to the client what you are going CHG.
to do, why it is necessary, and how he or she can 3. Prepare equipment and supplies. If it is
cooperate, being particularly sensitive to any necessary to leave room, be sure that call
embarrassment felt by the client. light is within patient’s reach.
2. Assess client’s tolerance for perineal care:
activity tolerance, comfort level during
 oAvoids interrupting procedure or dominant hand wash carefully in skin folds.
leaving patient unattended to retrieve Wipe in direction from perineum to rectum.
missing equipment. Repeat on opposite side with separate
IMPLEMENTATION section of washcloth. Rinse and dry area
FEMALE CLIENT thoroughly.
o Perineal care involves thorough
cleaning of patient’s external
genitalia and surrounding skin. Skin
folds may contain body secretions
that harbor microorganisms. Wiping
from front to back reduces chance of
transmitting fecal organisms to
urinary meatus.
1. Assess environment for safety (eg. Check 7. Gently separate labia with non dominant
room for spills, make sure that equipment is hand to expose urethral meatus and vaginal
working properly and that the bed is in orifice. With dominant hand, wash downward
locked, low from pubic area toward rectum in one smooth
o Identifies safety hazards that could stroke. Wash middle and both sides of
cause or potentially lead to harm. perineum. Use separate section of cloth for
2. Closed room, door, and windows, draw room each stroke. Clean thoroughly around labia
divider curtain. Offer patient bedpan or minora, clitoris, and vaginal orifice. Avoid
urinal. Provide toilet tissue placing tension on indwelling catheter if
o Provides for patient privacy. Helps present and clean area around it thoroughly.
patient feel more comfortable after o cleansing method reduces transfer of
voiding. Prevents interruption of bath. microorganisms to urinary meatus
3. Perform hand hygiene. If patient has non- (for menstruating women or patients
intact skin or skin is soiled with drainage, with indwelling catheters, clean with
excretions, or body secretions, apply clean cotton balls.)
gloves. Ensure that patient is not allergic to 8. Provide catheter care as needed.
latex. o Cleaning along catheter from exit site
o Reduces transmission of reduces incidence of health care-
microorganisms. Prevents allergic associated urinary infection.
reaction if latex gloves are used. 9. Rinse thoroughly. May use bedpan and pour
4. Lower side rail. Help patient into dorsal warm water over perineal area. Dry
recumbent position. Note restrictions or thoroughly from front to back.
limitations in patient’s positioning. Place o Rinsing removes soap and
waterproof pad under patient’s buttocks. microorganisms more effectively than
Drape patient with bath blanket placed in wiping. Retained moisture harbors
shape of a diamond. Lift lower edge of bath microorganisms.
blanket to expose perineum. 10. Fold lower corner of bath blanket back
o Provides full exposure of female between patient’s legs and over perineum.
genitalia. If patient is totally Ask patient to lower legs and assume
dependent, provide assistance to comfortable position.
support her in side-lying position and MALE
raise leg as perineum is bathed. If
position causes patient discomfort,
reduce degree of abduction in her
hips.
5. Fold lower corner of bath blanket up between
patient’s legs onto abdomen. Wash and dry
patient’s upper thighs.
o Keeping patient draped until
procedure begins minimizes anxiety.
Buildup of perineal secretions soils
surrounding skin surfaces. 1. Apply pair of clean gloves. Lower side rail.
6. Wash labia majora. Use nondominant hand Help patient to supine position. Note any
to gently retract labia from thigh, with restriction in mobility.
 o Provides full exposure of male • Assist the client to turn on the side. Separate the
genitalia. Position patients who are client’s buttocks and use toilet paper if
unable to lie supine on their side. necessary, to remove fecal materials.
2. Fold lower half of bath blanket up to expose o Removing fecal material provides for
upper thighs. Wash and dry thighs. easier cleaning
o Buildup of perineal secretions soils • Cleanse the anal area, rinse thoroughly, and dry
surrounding skin surfaces. with a towel. Change sponge towel as
3. Cover thighs with bath towels. Raise bath necessary.
blanket up to expose genitalia. Gently raise o Keep the anal area clean to minimize the
penis and place bath towel underneath. risk of skin irritation and breakdown.
Gently grasp shaft of penis. If patient is • For postpartum or menstruating females, apply a
uncircumcised, retract foreskin. If patient has perineal pad as needed from front to back.
an erection, defer procedure until later. o This prevents contamination of the
o Draping minimizes patient anxiety. vagina and urethra from the anal area.
Towel prevents moisture from • Apply skin care products to the area according
collecting in inguinal area. Gentle but to need of doctor’s order.
firm handling of penis reduces o Creams or ointments may be prescribed
chances of an erection. Secretions to treat skin irritation.
capable of harboring microorganisms • Folded bath blanket over
collect underneath foreskin. • Observe perineal area for any irritation, redness,
4. Wash tip of penis at urethral meatus first. or drainage that persisted after hygiene.
Using circular motion, clean from meatus • Remove soiled gloves and discard in trash; raise
outward. Discard washcloth and repeat with side rail before leaving bedside to dispose of
clean cloth until penis is clean. Rinse and dry water and obtain fresh water. Perform Hand
gently. hygiene.
o Direction of cleaning moves from o Prevents transmission of infection.
area of least contamination to area of Protects patient from injury.
most contamination, preventing
• Document the procedure, describing the client’s
microorganisms from entering
skin condition (redness, excoriation, skin
urethra.
breakdown, discharge or drainage, and any
5. Return foreskin to its natural position. This is
localized areas of tenderness.) and tolerance to
extremely important in patients with
the care. Sign the chart.
decreased sensation in their lower
o To provide continuity of care. Giving
extremities.
signature maintains professional
o Tightening of foreskin around shaft of
accountability.
penis causes local edema and
discomfort. Patients with reduced VAGINAL DOUCHING
sensation do not feel tightening of
• Douching is washing or cleaning out the inside
foreskin. of the vagina with water or other mixtures of
6. Gently clean shaft of penis and scrotum by fluids.
having patient abduct legs. Pay special • Indication:
attention to underlying surface of penis. Lift o To cleanse the vagina after menses or
scrotum carefully and wash underlying before or after sexual intercourse,
skinfolds. Rinse and dry thoroughly. o To prevent or ameliorate an odor,
o To prevent or treat vaginal symptoms
o Vigorous massage of penis may
such as itching and discharge,
cause an erection. Underlying o Less commonly, to prevent pregnancy or
surface of penis is an area where sexually transmitted diseases.
secretions accumulate. Abduction of
legs provides easier access to scrotal
tissues. Secretions collect easily
between skinfolds
7. Avoid placing tension on indwelling catheter
if present and clean area around it
thoroughly. Provide catheter care.
o Clean along catheter from exit site
reduces incidence of nosocomial
urinary infection.