VISION

“MABINI COLLEGES shall

cultivate a CULTURE of
EXCELLENCE in Education.”

PERFORMANCE
CHECKLIST
Perineal Care

Name of Student______________________________________________________________________
Year/ Group : _____________________ School Year : ___________________________________
Semester /Term : First Semester _____________ Second Semester __________ Summer
____________

Competency Rate

1 - Unsatisfactory (75- 80) 4 - Very Satisfactory ( 91 – 95)

2 - Fair (81 – 85) 5 - Outstanding (96 – 100)
3 - Satisfactory (86 – 90)

Performance Points 5 4 3 2 1 CI’s Remarks

I – KNOWLEDGE (40%)
1. Defines Perineal Care
2. State the purposes
3. Enumerate special considerations.
4. Identify materials/Equipments needed.
5. State preparation of the patient.
6. State the principles/rationale behind specific
action.
II – SKILLS / ABILITY (40%)
1. Perform hand hygiene.
2. Prepare needed equipment and take to the
bedside
3. Explain the procedure to the client
4. Pull curtain or close room door.
5. Position the client in dorsal recumbent
position.
6. Drape patient accordingly.
7. Apply disposable gloves.
8. Place patient on the bedpan.
9. Secure receptacles for soiled pads/cotton
balls.
10. Using pick-up forceps, place enough dry
cotton balls in one kidney basin.
11. In one basin, pour enough soap solution to
moisten the cotton balls.
12. Pour warm water over perineal area.
13. With the sterile forceps take soapy cotton
ball/warm water and gently clean the vulva
using from to back method then discard. Repeat
3X (gently pat episiotomy wound, do not rub).
Using 7 strokes.
 14. Pour warm water over the perineal area.
15. Dry the vulva and perineum with dry cotton
balls.
16. Remove bedpan. Dry patients buttocks.
17. Put a clean perineal pad following aseptic
technique.
18. Leave the patient comfortable and
change/arrange linens.
19. Discard receptacle for soiled pads and
cotton. Remove gloves.
20. Return all equipment to the utility room
21. Record/document color, amount of lochia,
any unusual characteristic such as odor, nature
of episiotomy, etc.
III – ATTITUDE (20%)
1. Demonstrate preparedness, readiness and
confidence in the performance of the
procedure.
2. Accepts corrections/suggestions and shows
willingness to improve performance.
3. Answers questions politely and tactfully.
4. Shows respect and consideration of the
recipient of care.
5. Observe proper decorum and behave as a
mature student nurse.

Evaluated by: Conforme:

_____________________________ ______________________________
Signature over Printed Name / Date Signature over Printed
Name/Date
Clinical Instructor Student