Name of Student: _________________________________Date (Return Demo) ________________

Score REMARKS
BASIC PERINEAL CARE RATIONALE 5 4 3 2 1
2
1
2
1. Explain the procedure to
the patient.
2. Secure tray and check if
equipments are complete.
3. Bring bedpan and
perineal tray to bedside.

4. Screen patient.
5. Place rubber sheet and
cotton draw sheet under the
patient’s buttocks. Put
towel over hypogastrium.
6. Position patient in dorsal
recumbent position. Do
diagonal draping.
7. Offer bedpan. Line edge
of table with towel. Let
patient wash his hands.
8. Place waste receptacle in
a convenient area.
9. Pour water over vulva.
Pitcher should be 6 inches
above the vulva.
10. Using each perineal
ball, moistened with soap
solution, clean vulva in the
following manner: Mons
pubis S stroke. Center
without touching the anus,
farther labia majora, nearer
labia majora, farther labia
minora, thighs (start with
farther thigh then nearer
thigh), then perineum to
anus.
11. Flush vulva and dry with
sterile dry cotton ball or
cherry balls in the same
sequence.

12. Remove bedpan and

turn the patient on the side,
dry buttocks with towel from
the hypogastrium.
13. Fix bedding and make
patient comfortable.
14. After care of the
equipment.
15. Chart discharges, type,
color, odor, and condition of
the perineum.
16. Ability to answer
questions.

Total Score:
Final Grade:
Signature of Clinical Instructor:
Signature of Student: