PERINEAL CARE

EVALUATION TOOL

NAME:

YEAR & SECTION: SCORE

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

704470566.doc Page 1 of 2
 PERINEAL CARE
EVALUATION TOOL

25. Nearer labia minora.

26. Farther labia majora.
27. Nearer labia majora.
28. Center of the vulva down to the anus
29. Mons pubis/ veneris in zigzag motion.
30. Farther thigh (sunshine motion from top to bottom)
31. Nearer thigh (Sunshine motion from top to bottom)
32. Discard used perineal balls into waste receptacle.
33. Rinse area with warm sterile water.(correct manner of rinsing the area).
34. Able to give the rationale of rinsing the area.
Dry vulva and perineum with dry perineal or cotton balls. (same manner
35.
of cleaning the vulva).
36. Remove bedpan and turn patient to side near you.
Able to give the rationale of turning the patient to side near you away
37.
from the health care provider.
Dry buttocks and anus using tissue paper. (correct manner of drying the
38.
buttocks and anus)
39. Assist patient to assume a dorsal recumbent position.
40. Able to give the rationale of dorsal recumbent postion.
41. Remove the bed protector (optional)
42. Arrange the beddings and make patient comfortable.
43. Able to give the rationale of arranging the bedding.
44. Do after care.
45. Remove gloves and wash hands.
TOTAL
PERFECT SCORE: 45 = 100%

________________________________
CI’s Signature over printed name

LEGEND:
1 SKILLED
0 UNSKILLED

704470566.doc Page 2 of 2