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Perineal Care Evaluation Tool
Perineal Care Evaluation Tool
EVALUATION TOOL
NAME:
INSTRUCTION:
1 0 REMARKS
Mark the appropriate column
1. Prepare and gather equipment.
2. Explain the procedures and its purpose.
3. Screen the patient.
Remove underwear and perineal pad, if any. Wrap it with paper and
4.
discard into waste can.
5. Wash hands and wear gloves.
6. Able to give the rationale for hand washing.
7. Loosen the foot part of the top sheet.
8. Place patient in dorsal recumbent position.
9. Able to give the rationale of dorsal recumbent position.
10. Place rubber protector under patient’s buttocks.
11. Able to give the rationale of rubber protector.
12. Place the patient on bedpan; hold bedpan properly.
13. Fan folds the top sheet towards the patient’s knees.
14. Able to give the rationale of fan folding the top sheet towards the knees.
15. Place the bath towel over the abdomen.
16. Able to give the rationale of bath towel over the abdomen.
Placed lined kidney basin outside the tray and position it conveniently for
17.
use.
18. Use perineal balls soaked in a soap sud solution for cleaning the vulva.
Pour warm sterile water over the vulva. Proper manner of pouring the
19.
sterile water( center, farther side then near side)
20. Able to give the rationale of using warm sterile water.
21. Clean the vulva and perineum using perineal balls soaked in solution. Use
a downward stroke in cleaning the vulva. Use fresh perineal ball for each
stroke. Repeat sequence as necessary.
22. Able to give the rationale of downward stroke in cleaning the vulva.
23. Sequence of cleaning the vulva. Center of the vulva
24. Farther labia minora
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PERINEAL CARE
EVALUATION TOOL
________________________________
CI’s Signature over printed name
LEGEND:
1 SKILLED
0 UNSKILLED
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