CALAMBA DOCTORS’ COLLEGE

Parian, Calamba City, Laguna

Performance Evaluation Checklist

Name: ________________________ Date: _______________

Year and Section: _______________

Instruction: Rate the nursing skill performance of the student based as follows: 5 = Perfect (91-100), 4 = Very
Satisfactory (85-90), 3 = Satisfactory (80-84), 2 = Poor (79-75), 1 = Need Improvement (74 and below)

Perineal Preparation

Preparation 5 4 3 2 1 Comments
1 Explain to the client what you are going to do, why it is
necessary
2 Wash hands and observe other appropriate infection control
procedures
3 Provide for client privacy.
4 Assist woman in lithotomy position with buttocks extended
slightly beyond table.
5 Put on clean gloves. Clean the perineal area with skin
cleanser/soap, and water, from above orifice downward toward
sacrum (front to back).
6 Put on sterile gloves and using a sterile gauze or sponge stick
with antiseptic clean side to side from the pubic bone to the
lower abdomen, then discard. (First sponge)
7 Clean the thigh with an up-and-down motion from the labia
majora to the midthigh and do with other side of the thigh. Each
is discarded directly after use. (Second and third sponge)
8 Clean the labia on the right and left of the vagina, avoiding the
rectum, and then discarded. ( Fourth and fifth sponge )
9 The last cleansing sponge passes directly down over the vagina
and anus.
10 The perineum may be rinsed and dried and perhaps sprayed or
painted with an additional antiseptic
11 Drape the client for delivery.
Ave. Score =

Grade: __________

Evaluated by:

__________________________
Clinical Instructor

Rating Scale
Range Descriptive Rating
4.51 - 5.00 Perfect
3.51 - 4.50 Very Satisfactory
2.51 - 3.50 Satisfactory
1.51 - 2.50 Poor
1.00 - 1.50 Need Improvement