Perineal care

fundamentals of nursing skills

1. PERINEAL CARE Katherine C. Villaran , RN, MAN

2. Learning Outcomes: At the end of lecture-discussion and demonstration, the students will be able to: 1. Assess the patient effectively to determine the need for assistance with perineal care. 2. Analyze data to determine special needs, concerns, and self-care abilities in completing perineal care.

3. Learning Outcomes: At the end of lecture-discussion and demonstration, the students will be able to: 3. Determine appropriate patient outcomes of the perineal care procedures, and recognize the potential for adverse outcomes. 4 . Choose the appropriate procedure and equipment for the specific perineal care needed.

4. Learning Outcomes: At the end of lecture-discussion and demonstration, the students will be able to: 5. Determine the assistance needed to complete the procedure. 6. Demonstrate the proper techniques for assisting with perineal care. 7. Evaluate the effectiveness of the perineal care techniques for specific patient.

5. Learning Outcomes: At the end of lecture-discussion and demonstration, the students will be able to: 8. Document the procedure in the patient’s plan of care as well as specific observations of any abnormal findings and the patient’s comfort level.

6. PERINEAL CARE involves thorough cleansing of the client’s external genitalia, anal area and surrounding skin. “ peri -care” or “perineal-genital” care Involves washing the external genitalia with soap & water or with water alone or in combination with any commercially prepared periwash . Can be delegated to nursing assistive personnel.

7. PERINEAL CARE Carried out as part of the pt’s bath or as a separate procedure. Perineal area is conductive to the growth of pathogenic organism because it is warm, moist, and is not well ventilated . Cleanliness is essential to prevent bad odor & promote comfort.

8. To prevent or eliminate infection, odor and promote healing Purpose: Remove secretions, and provide comfort

9. To clean the perineum from the cleanest to the less clean area. Principle: 1 Follow Standard Precautions. 2 Maintain patient’s privacy . 3 Proximal level of functioning. 4

10. Patients who need frequent perineal care: Who are unable to do self care Patients with genito -urinary tract infections With fecal & urinary incontinence An Indwelling foley catheter Who are recovering from rectal or genital surgery or childbirth Patients with excessive vaginal drainage Patients with injury and ulcers Uncircumcised males Morbid obesity

11. Delegation Considerations:

12. Nursing Diagnosis Self-Care Deficit (Hygiene) related to Decreased or lack of motivation Weakness or tiredness Pain or discomfort Perceptual or cognitive impairment Inability to perceive body part or spatial relationship Neuromuscular or musculoskeletal impairment Medically imposed restriction Therapeutic procedure restraining mobility (e.g., intravenous infusion, cast) Severe anxiety Environmental barriers

13. Assess presence of: Irritation, excoriation, inflammation, swelling Excessive discharge Odor; pain or discomfort Urinary or fecal incontinence Recent rectal or perineal surgery Indwelling catheter Determine Perineal-genital hygiene practices Self-care abilities

14. Bedpans - are made of metal or plastic and come in two sizes ( pedia , adult) - standard bed pan and fracture pan Equipment:

15. Urinals - made of plastic or metal with a bottle-like configuration. Equipment:

16. Procedures: ASSESSMENT Introduce self and identify patient using two identifiers ( eg . Name and birthday; name and medical record number, according to agency policy). Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate, being particularly sensitive to any embarrassment felt by the client. Ensure correct patient. Complies with the Joint Commission Standards and improve patient safety. (TJC, 2016)

17. 2. Assess client’s tolerance for perineal care: activity tolerance, comfort level during movement, cognitive ability, musculoskeletal function, presence of shortness of breath. Determines client’s ability to perform perineal care. 3. Assess client’s visual status, ability to sit without support, hand grasp, ROM of extremities Determines degree of assistance patient needs for bathing, ROM may be delegated to assistive personnel. Procedures:

18. 4. Assess for presence of equipment ( eg . Foley Catheter, Condom Catheter) Affects how you plan bathing activities and positioning. Helps determine how to set up supplies. 5. Assess for allergy or sensitivity to Chlorhexidine gluconate (CHG). When allergy or sensitivity is present, select another cleansing solution. 6. Ask if patient has noticed any problems related to condition of genitalia, excess moisture, inflammation, drainage or excretions from lesions or body cavities and rashes. Provides you with information to direct physical assessment of genitalia. Also influences selection of skin care products. Procedures:

19. 7. Assess patient’s knowledge of perineal hygiene in terms of its importance, preventive measures to take, and common problems. Determine patient’s learning needs. Procedures:

20. 8. If patient is able to maneuver and handle washcloth, allow them to clean perineum on their own. Maintain patient’s dignity and self-care ability Procedures:

21. PLANNING Review orders for specific precautions concerning patient’s movement or positioning. Prevents injury to patient during bathing activities. Determine level of assistance required by the patient. 2. Explain procedure and ask patient for suggestions on how to prepare supplies. If using CHG, explain benefit of reducing infection and that solution leaves a sticky feeling Promotes cooperation and participation. Patients who prefer using own perineal hygiene solutions may need to discuss benefits of CHG. Procedures:

22. 3. Prepare equipment and supplies. If it is necessary to leave room, be sure that call light is within patient’s reach. Avoids interrupting procedure or leaving patient unattended to retrieve missing equipment. Procedures:

23. IMPLEMENTATION FEMALE CLIENT Assess environment for safety ( eg . Check room for spills, make sure that equipment is working properly and that the bed is in locked, low position) Identifies safety hazards that could cause or potentially lead to harm. Procedures:

24. B. Closed room, door, and windows, draw room divider curtain. Offer patient bedpan or urinal. Provide toilet tissue Provides for patient privacy. Helps patient feel more comfortable after voiding. Prevents interruption of bath. C. Perform hand hygiene. If patient has non-intact skin or skin is soiled with drainage, excretions, or body secretions, apply clean gloves. Ensure that patient is not allergic to latex. Reduces transmission of microorganisms. Prevents allergic reaction if latex gloves are used. Procedures:

25. D. Lower side rail. Help patient into dorsal recumbent position. Note restrictions or limitations in patient’s positioning. Place waterproof pad under patient’s buttocks. Drape patient with bath blanket placed in shape of a diamond. Lift lower edge of bath blanket to expose perineum. Provides full exposure of female genitalia. If patient is totally dependent, provide assistance to support her in side-lying position and raise leg as perineum is bathed. If position causes patient discomfort, reduce degree of abduction in her hips. E. Fold lower corner of bath blanket up between patient’s legs onto abdomen. Wash and dry patient’s upper thighs. Keeping patient draped until procedure begins minimizes anxiety. Build up of perineal secretions soils surrounding skin surfaces. Procedures:

26. Draping the patient for perineal-genital care

27. Female Genitalia

28. F. Wash labia majora . Use nondominant hand to gently retract labia from thigh, with dominant hand wash carefully in skin folds. Wipe in direction from perineum to rectum. Repeat on opposite side with separate section of washcloth. Rinse and dry area thoroughly. 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 . Procedures:

29. G. Gently separate labia with non dominant hand to expose urethral meatus and vaginal orifice. With dominant hand, wash downward from pubic area toward rectum in one smooth stroke. Wash middle and both sides of perineum. Use separate section of cloth for each stroke. Clean thoroughly around labia minora , clitoris, and vaginal orifice. Avoid placing tension on indwelling catheter if present and clean area around it thoroughly. cleansing method reduces transfer of microorganisms to urinary meatus (for menstruating women or patients with indwelling catheters, clean with cotton balls.) Procedures:

30. H. Provide catheter care as needed. Cleaning along catheter from exit site reduces incidence of health care-associated urinary infection. I. Rinse thoroughly. May use bedpan and pour warm water over perineal area. Dry thoroughly from front to back. Rinsing removes soap and microorganisms more effectively than wiping. Retained moisture harbors microorganisms. Procedures:

31. J. Fold lower corner of bath blanket back between patient’s legs and over perineum. Ask patient to lower legs and assume comfortable position. Procedures:

32. IMPLEMENTATION MALE Apply pair of clean gloves. Lower side rail. Help patient to supine position. Note any restriction in mobility. Provides full exposure of male genitalia. Position patients who are unable to lie supine on their side. B. Fold lower half of bath blanket up to expose upper thighs. Wash and dry thighs. Buildup of perineal secretions soils surrounding skin surfaces. Procedures:

33. Male Genitalia

34. C. Cover thighs with bath towels. Raise bath blanket up to expose genitalia. Gently raise penis and place bath towel underneath. Gently grasp shaft of penis. If patient is uncircumcised, retract foreskin. If patient has an erection, defer procedure until later. Draping minimizes patient anxiety. Towel prevents moisture from collecting in inguinal area. Gentle but firm handling of penis reduces chances of an erection. Secretions capable of harboring microorganisms collect underneath foreskin. Procedures:

35. D. Wash tip of penis at urethral meatus first. Using circular motion, clean from meatus outward. Discard washcloth and repeat with clean cloth until penis is clean. Rinse and dry gently. Direction of cleaning moves from area of least contamination to area of most contamination, preventing microorganisms from entering urethra. Procedures:

36. E. Return foreskin to its natural position. This is extremely important in patients with decreased sensation in their lower extremities. Tightening of foreskin around shaft of penis causes local edema and discomfort. Patients with reduced sensation do not feel tightening of foreskin. F. Gently clean shaft of penis and scrotum by having patient abduct legs. Pay special attention to underlying surface of penis. Lift scrotum carefully and wash underlying skinfolds . Rinse and dry thoroughly. Vigorous massage of penis may cause an erection. Underlying surface of penis is an area where secretions accumulate. Abduction of legs provides easier access to scrotal tissues. Secretions collect easily between skinfolds Procedures:

37. G. Avoid placing tension on indwelling catheter if present and clean area around it thoroughly. Provide catheter care. Clean along catheter from exit site reduces incidence of nosocomial urinary infection. Assist the client to turn on the side. Separate the client’s buttocks and use toilet paper if necessary, to remove fecal materials. Removing fecal material provides for easier cleaning Procedures:

38. Cleanse the anal area, rinse thoroughly, and dry with a towel. Change sponge towel as necessary. Keep the anal area clean to minimize the risk of skin irritation and breakdown. For postpartum or menstruating females, apply a perineal pad as needed from front to back. This prevents contamination of the vagina and urethra from the anal area. Apply skin care products to the area according to need of doctor’s order. Creams or ointments may be prescribed to treat skin irritation. H. Folded bath blanket over patient’s perineum, assisted patient to comfortable position. Procedures:

39. Observe perineal area for any irritation, redness, or drainage that persisted after hygiene. Remove soiled gloves and discard in trash; raise side rail before leaving bedside to dispose of water and obtain fresh water. Perform Hand hygiene. Prevents transmission of infection. Protects patient from injury. Procedures:

40. Document the procedure, describing the client’s skin condition ( redness, excoriation, skin breakdown, discharge or drainage, and any localized areas of tenderness.) and tolerance to the care. Sign the chart. To provide continuity of care. Giving signature maintains professional accountability. Procedures: