FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL ...

Fundamental of Nursing Procedure Manual
Care Action Rationale
Female client: (Fig.21)
①Use a separate portion of the sponge towel for
each stroke
②Change sponge towel as necessary.
③Separate the labia and cleanse downward from
the pubic to anal area.
④Wash between the labia including the urethral
meatus and vaginal area.
⑤Rinse well and pat dry.
Male Client: (Fig.22)
①Gently grasp the client’s penis.
②Cleanse in a circular motion moving from the
tip of the penis backwards toward the pubic area
③In an uncircumcised male, carefully retract the
foreskin prior to washing the penis.
④Return the foreskin to its former position.
⑤Wash, rinse, and dry the scrotum carefully.
8. Assist the client to turn on the side. Separate the
client's buttocks and use toilet paper, if necessary,
to remove fecal materials.
9.Cleanse the anal area, rinse thoroughly, and dry
with a towel. Change sponge towel as necessary.
10.Apply skin care products to the area according
to need or doctor's order.
Cleanse from the pubis toward the anus to wash
from a clean to a dirty area. Prevent
contaminating the vaginal area and urinary
meatus with organisms from the anus.
Cleanse from the tip of the client's penis
backward to prevent transferring organisms from
the anus to the urethra.
Secretions that collect under the foreskin can
cause irritation and odor. Return the foreskin to
its normal position to prevent injury to the tissue.
Removing fecal material provides for easier
cleaning.
Keep the anal area clean to minimize the risk of
skin irritation and breakdown.
Lotions may be prescribed to treat skin irritation.
11. Return the client to a comfortable position. To provide for comfort and safety.
12. Remove gloves and perform hand hygiene. To prevent the spread of infection
13. Document the procedure, describing the client's
skin condition. Sign the chart.
(from Caroline Bunker Rosdabl: Textbook of Basic Nursing, 1999, p.591)
To provide continuity of care
Giving signature maintains professional
accountability
Fig.21 Female client Fig. 22 Male client
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