URINARY

CATHETERIZATION
GENERAL OBJECTIVE:
After the discussion and demonstration, the BSN 2 students will able to
develop positive attitude, acquire basic knowledge and skills in
catheterization.
Specifically, the BSN 2 Students will be able to:

1. Recognize the importance of Catheterization in facilitating

urinary drainage when medically necessary.
2. Define related terms correctly.
3. Practice the procedure at home following the steps written in
RLE Manual.
4. Prepare needed materials for catheterization before the
procedure.
5. Return Demonstrate catheter insertion/removal and care
utilizing the correct steps written in RLE Manual.
 URINARY
CATHETERIZATION
Definition of terms:
• INCONTINENCE
- THE INABILITY TO CONTROL URINE OR FECES

• VOID
- TO URINATE/excrete (waste matter)

• MICTURATE
- TO URINATE

• DYSURIA
- PAINFUL URINATION
• DYSURIA – PAINFUL OR DIFFICULT URINATION

• HEMATURIA – BLOOD IN THE URINE

• NOCTURIA – FREQUENT URINATION AT NIGHT

• POLYURIA –is a condition • URINARY
where the body urinates FREQUENCY –
more than usual and passes VOIDING AT
excessive or abnormally FREQUENT
large amounts of urine each INTERVALS
time you urinate. Polyuria is
defined as the frequent • URINARY URGENCY
passage of large volumes of – THE NEED TO
urine – more than 3 litres a VOID AT ONCE
day compared to the normal
daily urine output in adults
of about 1 to 2 litres.
ANATOMY OF URINARY SYSTEM
URINARY
CATHETERS
• CATHETER –
A TUBE USED TO DRAIN IT CAN BE TEMPORARY
OR INJECT FLUID OR LEFT IN PLACE. A
THROUGH A BODY BALLON IS INFLATED TO
OPENING . INSERTED HOLD THE CATHETER IN
PLACE. THE END OF THE
THROUGH THE URETHRA, CATHETER IS ATTACHED
INTO THE BLADDER TO TO A DRAINAGE BAG.
DRAIN THE URINE.
DRAINAGE BAG
Urinary drainage bags are used as a
urine collection bag for catheters and
designed to be hygienic and user-
friendly. They provide improved care
for the patient and comfort handling for
the caregiver.

Urinary drainage bags come in

basically two types:
Bedside drainage bags that hang from the
bedside or a wheelchair and Urine leg
bags that can be strapped to the thigh of
the user.

1. Urinary drainage bags are for use by

bed-ridden patients, hospitalized patients
or for night-time usage by those who
suffer from incontinence.

2. Leg Bags are appropriate for more

active users who suffer from urinary
incontinence.
Types of Urinary Catheter
Indwelling Catheter
An indwelling urinary catheter (IUC),
generally referred to as a “Foley”
catheter, is a closed sterile system with
a catheter and retention balloon that is
inserted either through the urethra or
suprapubically to allow for bladder
drainage. External collecting devices
(e.g. drainage tubing and bag) are
connected to the catheter for urine
collection.
Indwelling urinary catheters are
recommended only for short-term use,
defined as less than 30 days or no
longer than 14 days. The catheter is
inserted for continuous drainage of
the bladder for two common bladder
dysfunction: urinary incontinence (UI)
and urinary retention.
Two Types of Indwelling
Catheters Indwelling
urinary catheters are either
inserted:

ü Transurethrally
ü Suprapubically
Transurethral indwelling
catheterization or urinary
catheterization is defined as
passage of a catheter into the
urinary bladder via the urethra
(urethral catheter).
Suprapubic catheterization is the insertion
of a catheter into the bladder via the
anterior abdominal wall.
The catheter is inserted through an incision
made above the pubic bone and below the
umbilicus. The insertion of this type of
catheterization is done by a urologic
specialist.
Long term catheterization can be
associated with many serious problems
including urinary tract infections, urethritis,
bladder spasms with pain and urinary
leakage, and other bladder complications.
Long-term use, defined as greater
than 30 days, is discouraged because it
provides access for bacteria from a
contaminated environment into a
vulnerable body organ and system.
As a result, catheter-associated
urinary tract infection (CAUTI) is the
most common type of infection acquired
in hospitals and nursing homes.
At least 15% to 25% of patients may
have an indwelling catheter inserted
sometime during their hospital stay, with
most only used for the short-term
(defined as < 30 days).
Prevalence is greater in high
acuity patient units, with critical
care and intensive care units
having the highest prevalence.
CAUTIs are associated with
multiple complications and side
effects, can lead to increased
length of stays, mortality rates,
and ultimately higher hospital
costs.
Condom catheters

Condom catheters Men often prefer

are external urinary condom
catheters that are catheters over
worn like a condom. internal urinary
They collect urine as
catheters
it drains out of
your bladder and because they’re
send it to a collection easier to use,
bag strapped to your can be changed
leg. They’re typically at home, and
used by men who
are noninvasive
have urinary
incontinence (can’t (that is, nothing
control their bladder). is inserted into
their body).
Straight catheters
Straight catheters
- are a type of intermittent catheter and
often called “in-and-out” catheters. Straight
catheters are small hollow, flexible tubes
that are used to empty urine from the
bladder intermittently.
Straight catheters can be inserted through
the urethra or through a surgical opening
called a stoma that connects the bladder to
the outside of the body.
According to the FDA, straight catheters are
disposable, and for single-use only.
There are two main parts of a straight catheter:

ü Insertion end: contains oval-shaped holes

called eyelets that allow urine to pass in
through the bladder
ü Non-insertion end: usually contains a plastic
funnel that allows urine to drain into a
collection device (toilet bowl, urine bag, etc.)
NURSING CARE
üLEAVE THE
SYSTEM CLOSED
AS MUCH AS
POSSIBLE
üDO NOT ALLOW
THE BAG OR
TUBING TO TOUCH
THE FLOOR
üALWAYS KEEP THE
DRAINAGE BAG BELOW
THE LEVEL OF THE
BLADDER
üKEEP THE CATHETER
AND DRAINAGE TUBING
FREE OF KINKS
ü NOTICE THE CATHETER
TAPED TO THE INNER THIGH.
ü NOTICE THE DRAINAGE BAG
HOOKED ON THE BEDFRAME.
IF A DRAINAGE
SYSTEM IS
ACCIDENTALLY
DISCONNECTED:

üTell the nurse

at once.
üDo not touch
the ends of the
catheter or
tubing.
üPractice hand
hygiene and
put on gloves.
üWipe the end
of the tube üDiscard the
with an wipes into a
antiseptic wipe. biohazard
üWipe the end bag.
of the catheter
with another üRemove
antiseptic wipe. the gloves
and practice
üConnect the
hand hygiene.
tubing to the
catheter.
ü THE CATHETER SITE WILL
NEED REGULAR
CLEANING TO HELP
PREVENT INFECTION
ü WEAR GLOVES AND
FOLLOW STANDARD
PRECAUTIONS
ü WASH AWAY FROM THE
URINARY MEATUS
ü CLEAN FOUR INCHES
DOWN THE CATHETER
ü USE A DIFFERENT PART
OF THE WASHCLOTH OR
A CLEAN ANTISEPTIC
ü MOST FACILITIES CHANGE THE
EXTERNAL CATHETER ON A DAILY BASIS.

ü PERFORM PERINEAL CARE BEFORE

REAPPLYING THE EXTERNAL CATHETER.

ü NOTE THAT THE CATHETER IS TAPED TO

THE PERSON’S LEG TO KEEP IT FROM
ü PULLING.
ü DO NOT WITHHOLD
FLUIDS
ü FOLLOW THE PERSON’S
ROUTINES
ü ASSIST THE PERSON TO
THE BATHROOM AS
NEEDED. PROVIDE THE
BEDPAN OR URINAL IF
NEEDED
ü ASSIST THE PERSON TO
ASSUME A NORMAL
VOIDING POSITION
ü PROVIDE FOR PRIVACY
ü ALLOW TIME TO VOID
ü RUN WATER TO HELP
START URINATION
ü PROVIDE PERINEAL CARE
IF NEEDED
ü ALLOW PERSON TO WASH
HANDS AFTER TOILITING
INSERTING A STRAIGHT OR INDWELLING CATHETER: MALE

EQUIPMENT:

ü Indwelling or straight catheter

ü 10 cc syringe, prefilled with water
ü Urinary bag with drainage tubing
ü Sterile KY Jelly
ü Adequate lighting source
ü Plaster and bandage scissor
ü Disposable sterile gloves
ü Warm water, soap
ü Towel, blanket
ü Sterile forceps
PROCEDURE: INSERTING A STRAIGHT OR INDWELLING CATHETER: MALE

1.Gather the equipment needed.

6. Assist the client to a supine
2. Provide for privacy and explain
position.
procedure.
7. Drape legs to mid-thigh. Position
3. Provide client with opportunity to
rubber sheet on buttocks.
perform personal hygiene. Assist as
8. Ensure adequate lighting of the
necessary.
perineal area.
4. Wash hands.
9. Pull on sterile gloves.
5. Obtain, prepare and arrange
10. Place fenestrated drape over
equipment according to use. Carry at
client’s genitalia.
bedside.
Open cleansing solution and pour
over half of the sterile cotton ball.
Attach the catheter to the urine
drainage bag if it is not connected.
11. With non-dominant hand. Hold
penis at 90 angle to his body. If
uncircumcised, pull down foreskin
with his hand to visualize urinary
meatus. (This hand is now
unsterile).
12. Using the sterile forceps, pick
up antiseptic solution saturated
cotton ball. Cleanse meatus with
one downward stroke or use
circular motion from meatus to
base of penis.
13. With sterile hand, pick up
catheter and lubricate generously
6-4 inches from tip.
14. gently insert catheter into
urethra approximately 6-8 inches
until urine begins from tip.
If catheter resist entry, ask patient
to breath deeply and rotate catheter
slightly another inch and allow
bladder to empty and remove
straight catheter.
15. If using straight catheter. Insert
catheter another inch and allow
bladder to empty and remove
straight catheter.
16. If using indwelling catheter.
Continue inserting 1-3 inches.
17. Attach the water-filled 10 cc
syringe to the inflation port. Inflate
the retention balloon.
18. Check placement by gently
pulling catheter until balloon is
resting snugly against the bladder
neck. (Resistance will be felt when
balloon is in place).
19. Tape catheter securely to the
abdomen.
20. Attach drainage bag to bed
frame, below the level of the
bladder. Make sure the tubing lies
over, not under the leg. Do not let
it rest on the floor.
21. Remove the discard gloves.
Do after care and wash hands.
22. Do proper documentation:
time the procedure was
completed, size & type of catheter
used, client’s response and
amount, color quality of urine.
ROUTINE CATHETER CARE

EQUIPMENT:

ü Antiseptic
Solution
ü Sterile swabs
ü Clean Gloves
ü Washcloth,
soap and water
PROCEDURE:ROUTINE CATHETER CARE

1. Wash hands.
2. Check institutional protocol or 8. Cleanse meatus in circular motion from the
care plan most inner surface to the outside. Use soap and
water unless these is purulent drainage. The
3. Identify the client and explain non-irritating antiseptic solutions on cotton
the procedure maybe used.
4. Provide privacy 9. Cleanse catheter from meatus out to end of
5. Place client in a supine the catheter, taking care not to pull the catheter.
position and expose the perineal 10. Be sure to repeat catheter care anytime it
becomes soiled with stool or drainage.
area and catheter. 11. place linen or cotton balls in proper
6. Put on gloves. receptacle.
7. Cleanse the perineal area with 12. Wash hands.
soap and water.
REMOVING AN INDWELLING CATHETER

EQUIPMENT:

ü 100 cc syringe
ü Clean Gloves
ü Paper towel or gauze
ü Waste receptacle
PROCEDURE: REMOVING AN INDWELLING CATHETER
1. Verify doctor’s order
2. Identify patient and explain the
procedure.
3. Wash hands.
4. Obtain necessary equipment and carry
to the bedside and arrange according to
use.
5. Screen patient properly.
6. Assist patient to supine position.
7. Don on clean disposable position.
8. Loosen tape holding catheter in place.
9. Insert hub of syringe into balloon inflation of
catheter and draw out all liquid.
10. Ask client to breathe in and out deeply.
Gently remove catheter as client exhales.
11. Wrap end catheter in paper towel and
dispose properly.
12. Assist client to cleanse and dry genitals.
Make patient comfortable.
13. Do after care. Wash hands.
14. Measure and document urine in drainage bag
and time of catheter removal.
ADMINISTERING
ENEMAS
 ADMINISTERING ENEMAS
GENERAL OBJECTIVES: After the discussion and demonstration, the
BSN 2 students will able to develop positive attitude, acquire basic
knowledge and skills in administering enema.
Specifically, the BSN 2 students will be able to:
1. Recognize the importance administering enema in preparation for
various procedure.
2. Define related terms correctly.
3. Practice the procedure at home following the steps written in RLE
Manual.
4. Prepare needed materials for enema before the procedure
5. Return Demonstrate Fleet Enema utilizing the steps written in RLE
Manual.
 ENEMA
• ENEMA – IS A SOLUTION INTRODUCED INTO
THE RECTUM AND LARGE INTESTINE.
• THE ACTION OF AN ENEMA IS TO DISTEND
THE INTESTINE AND SOMETIMES TO
IRRITATE THE INTESTINAL MUCOSA,
THEREBY INCREASING PERISTALSIS AND THE
EXCRETION OF FECES AND FLATUS.
• ENEMA SOLUTION SHOULD BE AT 37.7
DEGREES CELCIUS BECAUSE THE SOLUTION
THAT IS TOO COLD OR TOO HOT IS
UNCOMFORTABLE AND CAUSES CRAMPING.
 PURPOSES OF
ADMINISTERING ENEMA

• PREVENT THE ESCAPE OF FECES DURING

SURGERY
• PREPARE THE INTESTINE FOR CERTAIN
DIAGNOSTIC TESTS SUCH AS X-RAY OR
VISUALIZATION TESTS (E.G. COLOSCOPY)
• REMOVE FECES IN INTANCES OF
CONSTIPATION OR IMPACTION
TABLE 49.4 COMMONLY USED ENEMA SOLUTION
SOLUTION CONSTITUENTS ACTION TIME TO TAKE ADVERSE
EFFECT EFFECTS
HYPERTONIC 90-120 ML SOL’N Draws water into 5-10 min Retention of
(e.g., sodium the colon sodium
phosphate fleet)

Hypotonic 500-1000ml of tap Distends colon, 15-20 min Fluid and

water stimulates electrolyte
peristalsis, and imbalance water
softens feces intoxication

Isotonic 500-1000ml Distends colon, 15-20 min Possible sodium

stimulates retention
peristalsis, and
softens feces

Soapsuds 500-1000ml (3-5ml Irritates mucosa, 10-15 min Irritates and may
soap to 1000 ml distends colon damage mucosa
water)
Oil (mineral, olive, 90-120 ml Lubricates the 0.5-3 h Irritates and may
cottonseed) feces and the damage mucosa
colonic mucosa
 Hypertonic solutions
• Exert osmotic pressure, which draws fluid from the interstitial
space into the colon. The increased volume in the colon
stimulates peristalsis and hence defecation. A commonly used
hypertonic enema is the commercially prepared Fleet phosphate
enema.
 Hypotonic solutions
• Example tap water, exert a lower osmotic pressure than
the surrounding interstitial fluid, causing water to move
from the colon into the interstitial space. Before the water
moves from the colon, it stimulates peristalsis and
defecation. Because the water moves out of the colon, the
tap water enema should not be repeated because of the
danger of circulatory overload when the water moves
from the interstitial space into the circulatory system.
 SAFETY ALERT

• SPECIAL PRECAUTIONS MUST BE USED TO ALERT

NURSES TO POSSIBLE CONTRAINDICATIONS WHEN
FLEET ENEMAS ARE PRESCRIBED FOR CLIENTS WITH
RENAL FAILURE. THE LABEL ON THE FLEET ENEMA
WARNS THAT USING MORE THAN ONE ENEMA
EVERY 24 HOURS CAN BE HARMFUL. CLIENTS AND
FAMILY MAY UNDERESTIMATE THE RISKS FOR A
CLIENT WITH DECREASED RENAL FUNCTION
BECAUSE A FLEET ENEMA CAN BE OBTAINED OVER
THE COUNTER OVER THE COUNTER IN STORES
(COHEN, 2012)
 Isotonic solutions
• Such as physiologic (normal) saline, are considered the safest
enema solutions to use. They exert the same osmotic pressure as
the interstitial fluid surrounding the colon. Therefore, their is no
fluid movement into or out of the colon. The instilled volume
of saline in the colon stimulates peristalsis. Soapsuds enemas
stimulate peristalsis by increasing the volume in the colon and
irritating the mucosa. Only pure soap (i.e Castile soap) should
be used in order to minimize mucosa irritation.
• Some enemas are large volume (i.e. 500-1000 ml) for an
adult and others are small volume (90-120 ml), including
hypertonic solutions. The amount of solution administered
for a high-volume enema will defend on the age and
medical condition of the individual.
• For example, clients with certain cardiac or renal diseases
would be adversely affected by significant fluid retention
that might results from large-volume hypotonic enemas.
• Cleansing enemas may also be described as high of low. A
high enema is given to cleanse as much of the colon as
possible.
• The client changes from the left lateral position to the
dorsal recumbent position and then to the right lateral
position during administration.
Left lateral position
• The low enema is used to clean the rectum and
sigmoid colon only.
• The client maintains a left lateral position during
administration.
 CLASSIFICATION OF ENEMA
• CARMINATIVE ENEMA IS GIVEN PRIMARILY TO EXPEL FLATUS. THE
SOLUTION INSTILLED INTO THE RECTUM RELEASES GAS, WHICH IN
TURN DISTENDS THE RECTUM AND THE COLON, THUS
STIMULATING PERISTALSIS. FOR AN ADULT 60 TO 80 ML OF FLUID IS
INSTILLED.
• RETENTION ENEMA INTRODUCES OIL OR MEDICATION INTO THE
RECTUM AND SIGMOID COLON. THE LIQUID IS RETAINED FOR A
RELATIVELY LONG PERIOD (E.G. 1-3 HOURS). AN OIL RETENTION
ENEMA ACTS TO SOFTEN THE FECES AND TO LUBRICATE THE
RECTUM AND ANAL CANAL, THUS FACILITATING PASSAGE OF THE
FECES
• ANTIBIOTIC ENEMAS ARE USED TO TREAT INFECTIONS LOCALLY,
ANTIHELMINTIC ENEMAS TO KILL HELMINTHS SUCH AS WORMS
AND INTESTINAL PARASITES AND NUTRITIVE ENEMAS TO
ADMINISTER FLUIDS AND NUTRIENTS TO THE RECTUM
• RETURN-FLOW ENEMA IS ALSO CALLED A HARRIS FLUSH, IS
OCCASIONALLY USED TO EXPEL FLATUS. ALTERNATING FLOW OF
100 TO 200 ML OF FLUID INTO AND OUT OF THE RECTUM AND
SIGMOID COLON STIMULATES PERISTALSIS. THIS PROCESS IS
REPEATED FIVE OR SIX TIMES UNTIL THE FLATUS IS EXPELLED
AND ABDOMINAL DISTENTION IS RELIEVED.
• PURPOSE: TO ACHIEVE ONE OR MORE OF THE
FOLLOWING ACTIONS: CLEANSING, CARMINATIVE,
RETENTION OR RETURN-FLOW
• ASSESSMENT
• ASSESS
• WHEN THE CLIENT LAST HAD A BOWEL MOVEMENT
AND THE AMOUNT, COLOR, AND CONSISTENCY OF
THE FECES
• PRESENCE OF ABDOMINAL DISTENTION
• WHETHER THE CLIENT HAS SPHINCTER CONTROL
• WHETHER THE CLIENT CAN USE A TOILET OR
COMMODE OR MUST RENDERED IN BED AND USE A
BEDPAN

ASSESSMENT
• PURPOSE: TO ACHIEVE ONE
OR MORE OF THE
FOLLOWING ACTIONS:
CLEANSING, CARMINATIVE,
RETENTION OR RETURN-
FLOW

DIAGNOSE
Before
administering
enema,
determine that
there is a
primary care
provider’s order

PLANNING
• ADMINISTRATION OF SOME ENEMAS MAY
BE DELEGATED TO UNLICENSED ASSISTIVE
PERSONNEL (UAP). HOWEVER, THE NURSE
MUST ENSURE THE PERSONNEL ARE
COMPETENT IN THE USE OF STANDARD
PRECAUTIONS. ABNORMAL FINDINGS SUCH
AS INABILITY TO INSERT THE RECTAL TIP,
CLIENT INABILITY TO RETAIN THE
SOLUTION, OR UNUSUAL RETURN FROM
THE ENEMA MUST BE VALIDATED AND
INTERPRETED BY THE NURSE.

DELEGATION
• PREPARATION
• LUBRICATE ABOUT 5CM (2 IN.) OF THE RECTAL TUBE (SOME COMMERCIALLY
PREPARED ENEMA SETS ALREADY HAVE LUBRICATED NOZZLES).
RATIONALE: LUBRICATION FACILITATES INSERTION THROUGH THE SPHINCTER
AND MINIMIZES TRAUMA.
• RUN SOME SOLUTION THROUGH THE CONNECTING TUBING OF A LARGE
VOLUME ENEMA SET AND THE RECTAL TUBE TO EXPEL ANY AIR IN THE
TUBING, THEN CLOSE THE CLAMP. RATIONALE: AIR INSTILLED INTO THE
RECTUM, ALTHOUGH NOT HARMFUL, CAUSES UNNECESSARY DISTENTION.
• PERFORMANCE
1. PRIOR TO PERFORMING THE PROCEDURE, INTRODUCE SELF AND VERIFY
THE CLIENT’S IDENTITY USING AGENCY PROTOCOL. EXPALIN TO THE
CLIENT WHAT YOU ARE GOING TO DO, WHY IT IS NECESSARY, AND HOW HE
OR SHE CAN PARTICIPATE. DISCUSS HOW THE RESULTS WILL BE USED IN
PLANNING FURTHER CARE OR TREATMENTS. INDICATE THAT THE CLIENT
MAY EXPERIENCE A FEELING OF FULLNESS WHILE THE SOLUTION IS BEING
ADMINISTERED. EXPLAIN THE NEED TO HOLD THE SOLUTION AS LONG AS
POSSIBLE.
2. PERFORM HAND HYGIENE AND OBSERVE OTHER APPROPRIATE INFECTION
PREVENTION PROCEDURES.

IMPLEMENTATION
3. APPLY CLEAN GLOVES.
4. PROVIDE FOR CLIENT PRIVACY
5. ASSISST THE ADULT CLIENT TO A LEFT LATERAL
POSITION, WITH THE RIGHT LEG AS ACUTELY
FLEXED AS POSSIBLE. 1. WITH THE LINEN-SAVER PAD
UNDER THE BUTTOCKS. RATIONALE: THIS POSITION
FACILITATES THE FLOW OF SOLUTION BY GRAVITY
INTO THE SIGMOID AND DESCENDING COLON,
WHICH ARE ON THE LEFT SIDE. HAVING THE RIGHT
LEG ACUTELY FLEXED PROVIDES FOR ADEQUATE
EXPOSURE OF THE ANUS.
6. INSERT THE ENEMA TUBE.
FOR CLIENTS IN THE LEFT LATERAL POSITION.
LIFT THE UPPER BUTTOCK
RATIONALE: THIS ENSURES GOOD VISUALIZATION OF
THE ANUS.
IMPLEMENTATION
3. APPLY CLEAN GLOVES.
4. PROVIDE FOR CLIENT PRIVACY
5. ASSISST THE ADULT CLIENT TO A LEFT LATERAL
POSITION, WITH THE RIGHT LEG AS ACUTELY FLEXED AS
POSSIBLE. 1. WITH THE LINEN-SAVER PAD UNDER THE
BUTTOCKS. RATIONALE: THIS POSITION FACILITATES THE
FLOW OF SOLUTION BY GRAVITY INTO THE SIGMOID AND
DESCENDING COLON, WHICH ARE ON THE LEFT SIDE.
HAVING THE RIGHT LEG ACUTELY FLEXED PROVIDES FOR
ADEQUATE EXPOSURE OF THE ANUS.
6. INSERT THE ENEMA TUBE.
FOR CLIENTS IN THE LEFT LATERAL POSITION. LIFT
THE UPPER BUTTOCK
RATIONALE: THIS ENSURES GOOD VISUALIZATION OF THE
ANUS.

IMPLEMENTATION
• ASSUMING A LEFT LATERAL POSITION
FOR AN ENEMA. NOTE THE
COMMERCIALLY PREPARED ENEMA.

IMPLEMENTATION
INSERTING ENEMA TUBE
DIRECTION OF THE
RECTUM
INSERTING THE ENEMA
TUBE
INSERTING THE ENEMA
TUBE
• PERFORM A DETAILED FOLLOW-UP
BASED ON FINDINGS THAT DEVIATED
FROM EXPECTED OR NORMAL FOR THE
CLIENT. RELATE FINDINGS TO
PREVIOUS ASSESSMENT DATA IF
AVAILABLE. REPORT SIGNIFICANT
DEVIATIONS FROM EXPECTED TO THE
PRIMARY CARE PROVIDER

EVALUATION

NCM 109: MCN LAB, RLE
PERINEAL CARE
LECTURE
Definition of terms
 Perineal Care – cleansing and maintaining
hygiene in the external genetalia,
perineum and surrounding area
 Perineal Shaving – the removal of hair
from the skin around the delivery area in
preparation for the birth of the baby
 Perineum – muscle and fascia that lie
across the pubic arch
 Episiotomy – incision of the vulva-
perineal area to facilitate delivery and
prevent tearing
 Vulva – external female reproductive
organs – mons pubis, labia majora and
minora, clitoris, the vestibule, urethral
opening and hymen
 Mons Veneris or Mons Pubis –a skin-
covered pad of fat over the symphisis
pubis.
 Labia Majora or “Large Lips”
– Covered with pigmented skin and hair
on the outer surface and are smooth
and free from hair on the inner
surface.
– They are composed mainly of
sebaceous and apocrine (sweat)
gland.
 Labia Minora or “Small Lips”
– Located within the labia majora
– Covered with modified skin.
o These two lips come together anteriorly at
the midline.
 Vestibule – The area between the labia
minora
Made by: The Insomniac
Page |1
Purpose of Perineal Care and Shaving
o To remove the normal secretions and
body discharges
o To clean the perineum following the
delivery and aid in the maintenance of a
germ-free environment during delivery.
o To provide optimal visualization and
access to genitalia during the delivery
process.
o To prevent of eliminate infections and
odors.
o To promote healing after episiotomy and
perineal surgery.
Indication of Perineal Care
o Incontinence of urine and feces
o Excessive secretions
o Concentrated urine causing skin
irritations or excoriations
o Presence of indwelling urinary (foley)
catheter
o Post-partum care
o Post perineal surgery
o Before giving birth to protect from
contamination
PROCEDURES
Equipment needed:
o Pitcher with warm irrigating fluid (300-
500 ml) at 40.5°C-43.3°C)
o Sterile balls
o Bath blanket
o Betadine cleanser
o Absorbent pad/cotton draw sheet
o Clean gloves
o Waste receptacle
o Screen for ward use
o Rubber sheet
o Pail
o Kidney basin
o Bed pan
Procedures:
1. Explain the procedures in a way that
patient can understand.
2. Always wash from the “cleanest” to
“dirtiest” parts. Because perineal
orifices are located close to each other,
cross contamination is possible.
3. Assist the client to dorsal recumbent
position, help client flex knees and
spread legs. (Note restrictions or
limitations in client when positioning.
 Page |2
NCM 109: MCN LAB, RLE
4. Provide easy access and full exposure
of the female genetalia prior to the
procedure.
5. Wash of flush first with tap water or
sterile water or the solution used in the
facility over the perineum.
6. Cleanse the perineal area using
sponges soaked in betadine cleanser or
per institution policy.
7. Cleansing should be done from the
vagina outward. Follow the figure below
which shows the typical pattern for
cleansing the perineal area, using 8
strokes.

TYPICAL PATTERN FOR CLEANSING THE

PERINEAL AREA
1. Using the first sponge, beginning with the
mons, the area is cleansed up to the lower
abdomen.
2. The second sponge is used to cleanse the
inner groin and thigh of one leg.
3. The third one is used to cleanse the other
leg, moving outward to avoid carrying
material from surrounding areas to the
vaginal outlet.
4. The fourth and fifth are used to cleanse
the sides of the labia with a downward
sweep.
5. The sixth, seventh, and eight are used in
the center giving much importance on the
area of delivery.
6. Using each one for only one wipe and then
discard. Use extra sponges or wipes as
needed.

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NCM 109: MCN LAB, RLE
PERILITE EXPOSURE
LECTURE
Definition of terms
 Hot Sitz Bath
– A procedure whereby patient’s
perineal area is submerged to water
with solutions depending on the needs
of the client.
– A bath in which only the pelvic area is
immersed in warm fluid.
– A prolonged immersion of buttocks
and lower trunk in water with an initial
temperature of 98◦F to 110◦F,
gradually increased to temperature of
110◦F-120◦F (43.5◦C-48.7◦C) or as hot
as the patient can tolerate.
 Perilite Exposure
Variables that Influences Effectiveness of Heat
– Application of dry heat to perineal area
in order to provide comfort and
increase blood circulation and hasten
wound healing by means of perineal
lamp.
– 20-50 centimeters or 18-24 inches
away from the body to be exposed.
 Heat application – a process of applying
heath through radiation and convection
 Dry heat – requires a higher temperature
and a longer period of heating
 Moist heat – utilizes hot air that is heavily
laden with water vapor
 Episiotomy
– Refers to an incision through the
perineum that allows for less pressure
on the fetal head during delivery
– Prevents lacerations of the perineum
 Episiorraphy – operation for repairing the
episiotomy
 Perineorrhaphy – operation for repairing
laceration of perineum usually following
delivery
Physiologic Response to Heat
o Vasodilation or increase in capillary
surfaces
– Heat causes vasodilation and
increases blood flow to the affected
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area bringing oxygen nutrients,
antibodies and leukocytes.
o Increase in capillary permeability
– Heat increases capillary
permeability which allows extra
cellular fluid and substances such
as plasma proteins to pass through
the capillary walls and may result in
edema or an increase in pre-
existing edema.
o Increase blood flow
o Increase cell metabolism
o Increase supply of nutrients
o Increase removal of wastes
o Relaxation of muscles
o Softening of exudates
o Increase peristalsis
1. Individual tolerance
o Tolerance is influenced to some
degree by age, condition of skin, the
condition of nervous and circulatory
system.
o Young children, elderly clients,
diabetic clients and individuals with
circulatory or sensory alterations
have low tolerance for heat.
o The very young and the very old
generally have the lowest tolerance.
Persons who have neurosensory
impairments may have a high
tolerance, but the risk of injury is
greater.
2. General conditions of patient
o Shock or metabolic disorders such as
diabetes increase the hazard of
tissue damage. Impaired perception
because of individual’s level of
consciousness, medications and
mental impairment may make it
difficult to determine patient’s
response to end potential damage
from application of heat.
3. Intactness of the Skin
o Injured skin areas are more sensitive
to temperature variations whether
the heat is moist or dry

NCM 109: MCN LAB, RLE
o Moist heat penetrates more deeply
than dry heat because water is a
good conductor of heat.
o Application of moist heat should be
at a lower temperature than
applications of dry heat.
4. Size of Skin Area to be treated
o The greater the body area to be
treated, the lower the temperature
should be.
5. Environmental temperature
o In warm or in humid environment,
heat can’t be dissipated through
evaporation to some degrees that it
can dry or cool circumstances.
6. Length of Exposure
o People feel hot applications most
while the temperature is changing.
After a period of time, tolerance
increases.
7. Location of area to be covered
o Individual tolerance to heat depends
on the number of heat receptors in
body parts.
o In general, the inner aspects of thighs
and arms, the axillae, the chest and
the abdomen are more sensitive to
heat than the other parts of the body.
o The back of the hand and foot are not
very temperature sensitive.
o In contrast the inner aspect of the
wrist and forearm, the neck, and the
perineal area are temperature
sensitive.
Therapeutic Use of Heat
Physiologic effects of heat:
1. Vasodilation
2. Viscosity
3. Increased nerve stimulation
4. Increased pain threshold
5. Changes in muscle strength
6. Increased metabolic rate
7. Increased tissue extensibility/effects on
collagenous tissue
8. Increased sweating
9. Effect on pulse rate and blood pressure
10. Increased rate of breathing
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Importance of Perilite Exposure
o Relief of pain and muscular spasm
o Provides comfort by relief of pain
o It relaxes muscles and capillaries making
pain tolerable
o Increases blood circulation
o Hastens wound healing following an
episiotomy repair
o Increases circulation of blood
o Increases supply of oxygen and nutrient
which promote wound healing
o Reduces edema and soreness
o It releases dry heat and thus help reduce
edema and soreness.
o Alleviated by relax muscles and
capillaries.
Indications of Perilite Exposure
o Patients who have undergone rectal and
perineal surgery
o Post-partum patients with episiotomy
wounds
o Patients having vaginal inflammation or
bladder spasm
o Patients with painful or local irritation
from hemorrhoids
Contraindications of Perilite Exposure
o Patients with cardiovascular condition
o Presence of cyst or malignancy in the
area
o Patients with open wounds with
hemorrhage
o Patients with burns or fracture at the
lower limbs
o Heat lamps are contraindicated in
pressure ulcer care
Principles involved in Perilite Exposure
o Human Anatomy and Physiology
– Through blood vessels and nerves,
skin and skin and connections they
make with nerves and blood vessel
of body, practically all parts of body
may be influenced by application of
heat to skin
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NCM 109: MCN LAB, RLE
o Microbiology to avoid burning the patient. Connect
– The application of heat to open electricity.
wounds of lesions may rupture 14. Leave the lamp according to the
demands a sterile technique prescribed duration and check patient
o Body Mechanics twice during the treatment procedure is
– Position of mother is dorsal administered for any discomfort,
recumbent with legs and knees burning reaction or untoward reaction.
flexed to allow proper exposure of 15. Instruct patient not to change position
are to be treated. nor touch lamp during the entire
o Physics procedure.
– Application of heat employs physical 16. Disconnect electricity and remove lamp
agents: heat, water, and light. after 15 minutes or as ordered by the
– Heat maybe transferred from one physician.
place to another by radiation (perilite 17. Assess the surrounding area that
exposure) and convection (hot sitz) receives the treatment and reposition
bath. patient comfortably.
18. Do after care:
PROCEDURE  Disinfect the lamp by wiping it
with alcohol.
Equipment needed:
 Return equipment to store room.
o Perilite or heat lamp
 Dispose soiled dressings to
o Blanket
infectious waste bin
o Perineal flushing set
19. Do documentation:
o Incontinent pad
 Time treatment done.
o Hand towel
 Part exposed.
Procedure:
 Duration of treatment.
1. Review physician's order.
2. Gather equipment and check it for  Condition of part or of patient.
safety factors.  Amount and character of
3. Bring equipment to patient's room. drainage if any.
4. Explain procedure to the patient.  Signature of nurse.
5. After getting, let patient void first.
6. Wash hands.
7. Provide bedscreen/curtains and
arrange beddings to expose only part to
which treatment is to be given.
8. Assist patient into a dorsal recumbent
position.
9. Check and assess the condition of the
perineum. Remove any ointment or
dressings if present.
10. Provide bedpan and render perineal
flushing.
11. Dry perineum thoroughly with clean
hand towel/dry cotton balls and remove
bedpan.
12. Place incontinent pad under patient’s
perineum.
13. Place heat lamp under the blanket
about 18-24 inches from the perineum

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NCM 109: MCN LAB, RLE
After the patient is in the tub or the chair,
HOT SITZ BATH o
check to see whether or not there is
LECTURE pressure against the patient’s thighs or
legs.
Importance of Hot Sitz Bath
o Support patients back in the lumbar
o To relieve muscle spasm
region.
o To soften exudates
o To hasten the suppuration process PROCEDURE
o To hasten healing
o To reduce congestion and provide Equipment needed:
comfort in the perineal area o Sitz tub half filled with water 110F-120F
o Empty pitcher (may be small)
Purpose of Hot Sitz Bath o Pitcher with hot water
1. To aid healing a wound in the area by o Bath thermometer
cleaning on discharges and slough. o Fresh camisa/patient’s clean clothes
2. To induce voiding in urinary retention o Bath towel
3. To relieve pain, congestion and o 2-3 Blankets
inflammation in cases of: o 1 Bath robe and slippers (from bedside)
 Hemorroids, o Newspaper
 Tenesmus, Procedure:
 Rectal surgery, 1. Check physician’s order for sitz bath
 Anal fissures, patient.
 After proctoscopic or cycloscopic 2. Prepare the materials needed and bring
exams materials at bedside.
 Uterine and renal colic. 3. Introduce self and check patient’s
4. To induce menstruation. identity.
4. Explain procedure and results expected
Indications of Hot Sitz Bath from treatment.
o Hemorrhoids 5. Make patient void before procedure.
o Anal Fissures/Surgery 6. Place bathmat on floor beside tub. You
o Episiotomy may use newspaper if bathmat is not
o Uterine Cramps available.
7. Fill in tub one-fourth full of water –
Contraindications of Hot Sitz Bath temperature 98◦F to 100◦F.
o Hemorrhages 8. Remove patient’s bath robe and place
o Menstrual bleeding on back of chair.
o Prolapses 9. Wrap patient with bath blanket and pin
o Acute lung congestion at back.
o Acute inflammation 10. Remove patient’s gown.
o Painful conditions with spasms or colic 11. Ask and help patient to sit squarely on
o Heart problems tub.
o Pregnant women 12. Prevent blanket (about patient) from
getting wet by arranging it over
Important Considerations shoulders and tucking it at feet and
o Warm water should not be used if sides of tub. Adjust hot water bag about
considerable congestion is already patient’s feet. Bring second blanket up
to knees.
present.
13. Increase temperature of water gradually
o The patient should be observed closely for to 110◦F-120◦F or as hot as patient can
signs of weakness and faintness. tolerate by holding your hand between
patient’s body and stream of water
being poured.
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 Page |2
NCM 109: MCN LAB, RLE
14. Let patient stay in tub for the prescribed
period of time.
15. Assist patient out of tub then dry him
thoroughly with bath towel.
16. Assist patient while he puts on his
gown and bath robe.
17. Take patient back to bed and keep him
warm.
18. Make patient comfortable and give him
something to drink. Place buzzer or
intercom within patient’s reach.
19. Do after care:
 Bring all materials except sitz tub
to utility room. Cleanse
thoroughly and return to their
proper places. Return chair to its
place.
 Wash tub with soap and running
water for non-communicable
cases.
20. Do documentation:
 Type of treatment
 Length of time of application
 Type of heat application
 Comfort of patient
 Signature of nurse.

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