Gribador, Jayne Feline J.
April 18, 2023
N1B NCM101 RLE
MALE GENITALIA
PROCEDURE RATIONALE
Gather equipment (gloves, stool, gown, For a productive and seamless
penlight) procedure
Explain procedure to client To raise consciousness and encourage
collaboration
Ask client to put on own To uphold and protect patient privacy
PENIS
Inspect the base of penis and pubic hair There are no lesions at the penis' base.
for growth pattern and excoriation, There are no infestations or erythema in
erythema, or infestation (Client is the pubic hair, which is coarser than scalp
standing while you sit hair.
Inspect the skin of the shaft for rashes, The shaft is cylindrical and free of tumors,
lesions, or lumps lesions, or rashes.
Palpate the shaft for hardened areas or There are no tender or hard spots on the
areas of tenderness shaft.
Inspect the foreskin (if present) for color, The foreskin is situated in the head or tip
location, and integrity of the penis and is brownish or reddish in
color.
Inspect the glans for size, shape, lesions Examine the size, form, lesions, redness,
or redness, and location of the urinary and placement of the urinary means on
means on the glans (If uncircumcised, the glans (if the patient is not circumcised,
ask him to retract his foreskin to allow for request that he retract his foreskin so that
observation) you may observe).
Palpate for urethral discharge by gently When the penis is palpated, there is no
squeezing the glans between the index discomfort or tenderness. The urethral
finger and thumb discharge is often transparent.
SCROTUM
Inspect the size, shape, and position Below the penis, the scrotum is oval-
(Penis is held out of the way) shaped and ranges in length from 4.5 to
5.1 cm.
Observe for swelling, lumps, or bulges There are no bumps, bulges, or swells in
the scrotum.
Inspect the skin for color, integrity, and Skin on the scrotum is thin and brownish
the presence of lesions or rashes (Spread in color. hue, typically without hair
out the scrotal folds of skin to perform an existence of sores or rashes.
accurate inspection. Lift the sac to inspect
the posterior skin)
Palpate the scrotal contents (testes and The epididymis should be felt as a ridge
epididymis) between your thumb and first posterior to the oval, smooth, and firm
two fingers. Note size, shape, testes.
consistency, and presence of tenderness all testicles. Tenderness or swelling are
or nodules. Palpate each spermatic cord not present.
and vas deferens, noting nodules,
swelling or tenderness
Transilluminate the scrotal contents (if a The use of transillumination to detect
mass or swelling was noted). Look for a anomalies in a bodily cavity or organ.
red glow Cystic mass if light can pass through. If
the mass blocks light, it is solid.
INGUINAL AREA
Inspect for inguinal and femoral hernia, While femoral hernia is a protrusion at the
watching for bulges while the client bears slightly lateral region of the groin area,
down inguinal hernia is a bulge in the more
superior section of the groin area.
Palpate for inguinal hernia, observing for Hernias are detectable by a palpable
bulges or masses. Have the client shift protrusion in the inguinal region, which is
weight to the left to palpate the right the upper groin area.
inguinal canal. Place index finger into the
right scrotum and press upward to the
slit-like opening of the external inguinal
ring. With a finger in the canal or external
inguinal ring, ask him to bear down or
cough. Repeat for left side
Palpate for femoral hernia on the front of Hernias are indicated by a palpable
the thigh in the femoral canal area. Ask protrusion in the lateral section of the
him to bear down or cough while feeling groin area, or femoral area.
bulges. Repeat on the other side
Inspect and palpate for scrotal hernia (if a Pressure from activities like lifting and
mass was detected during inspection or straining during bowel movements is a
palpation of the scrotum). Ask the client common cause of scrotal hernia. This
to lie down, and note whether the bulge pressure pushes a portion of the intestine
disappears. If it remains, auscultate it for past the abdominal wall's weak point and
bowel sounds. Then, gently palpate the toward the groin.
mass, and try to push it up into the
abdomen unless it is too render
ANALYSIS OF DATA
Formulate nursing diagnoses (wellness, Helps nurses see the patient in a holistic
risk, actual) perspective, which facilitates the decision
of specific nursing interventions
Formulate collaborative problems Allows the nurses with the physician and
other healthcare professionals to monitor,
plan, and implement patient’s care
Make necessary referrals To ensure that clients are seeing the
correct healthcare providers for further
diagnosis
FEMALE GENITALIA
PROCEDURE RATIONALE
Gather equipment: stool, light, speculum, for being effective and fluid
emesis basin filled with warm tap water, procedure
Surgilube, cotton-tipped applicators,
Chlamydia culture tube, culturette, test
tube with water, sterile gloves, Ayre
spatula (wood stick), and feminine
napkins
Explain procedure to client to raise consciousness and encourage
collaboration
Ask client to gown to uphold and protect patient privacy
EXTERNAL GENITALIA
Inspect the mons pubis. Note pubic hair Normal hair distribution is shaped like an
distribution, signs of infestation inverted triangle with the mons pubis in
the middle.
Inspect the labia majora and perineum. either a long or short labia majora
Note lesions, swelling, excoriation short, smooth or wrinkled, black or light,
and free of lesions, swelling, or
excoriation
Inspect the labia minora, clitoris, urethral The hue of the labia minora ranges from
meatus, and vaginal opening. Note pale pink to brownish black. The clitoris
lesions, excoriation, swelling, discharge measures about 1-1.5 cm on average,
though it might change between people.
Between the clitoris and the urethral
meatus
and the vaginal slit. They don't have any
swelling, lesions, or excoriations.
Discharge from the vagina can be
transparent, milky-white, or off-white.
Palpate the Bartholin’s gland (if history of In the vulvar vestibule, on either side of
swelling or current swelling noted). Note the vagina's exterior entrance, are the
swelling, tenderness, discharge Bartholin glands. It has neither swell nor
softness. Vaginal discharge is
accompanied by its secretion.
Palpate the urethra (if client complains of There is no pain or discharge from the
urethral symptoms or urethritis, or urethra.
inflammation of Skene’s glands is
suspected) by inserting gloved index
finger into the superior portion of the
vagina and milking the urethra from the
inside, pushing up and out. Observe for
drainage
INTERNAL GENITALIA
Inspect the size of the vaginal opening The vaginal canal is 3 to 6 inches long on
and the angle of the vagina by average.
moisturizing gloves index finger with
warm water and gently inserting the finger
into the vagina
Assess the vaginal musculature by The affected person can "squeeze"
keeping the index finger inserted in the close to the finger. There is none
vaginal opening and asking the client to masses or bulges
squeeze around your finger. Using middle
and index fingers to separate the labia
minora, ask the client to bear down.
Observe for bulging or discharge of urine
a. Inspect the cervix for color, size, The cervix is smooth, firm, and pinkish in
position surface, os, discharge, or lesions appearance. It is about the size of a tiny
orange. Although its os is small and
circular (nulliparous), it can appear to
have a slit after giving birth.
b. Obtain specimens for the Pap smear In addition to checking for STDs, a Pap
and, if indicated, cultures to test for STDs smear also checks for cell abnormalities
that could indicate cervical cancer.
c. Inspect the vagina, unlocking the In addition to checking for STDs, a Pap
speculum and inspecting the vagina as smear also checks for cell abnormalities
the partially open speculum is slowly that could indicate cervical cancer.
rotated and removed. Note color, surface,
consistency and discharge
Perform the bimanual examination by To determine the fornix's position, size,
placing a nondominant hand on lower shape, surface properties, consistency,
abdomen and inserting gloved lubricated and mobility, a bimanual examination is
index and middle fingers into the vaginal performed. uterus; and the dimensions,
opening, applying pressure to the contours, and shapes of each ovary.
posterior wall, and waiting for the opening Women who are stressed out or obese
to relax. Palpate the ovaries by sliding may feel their ovaries physically. Post-
your intravaginal fingers to the right menopausal women shouldn't feel them
lateral fornix and attempting to palpate while they're palpable.
the left and then right ovaries. Note size,
shape, consistency, mobility, and
tenderness. Observe for secretions as
fingers are withdrawn
Perform rectovaginal examination by The purpose of the rectovaginal
changing gloves on the dominant hand examination is to evaluate the rectal wall,
and lubricating index and middle fingers. sphincter tone, and muscle of the rectal
Ask the client to bear down. Insert index area. In the uterus additionally evaluated
finger into the vagina and middle finger were its mass, softness, form, and size.
into the rectum. While pushing down on Intactness of the rectovaginal septum
the abdominal wall with the other hand, smooth and elastic. Additionally, if stool
palpate the internal reproductive structure testing for occult blood is mandated, the
through the anterior rectal wall, with test can be used.
attention to the area behind the cervix,
the rectovaginal septum, the cul-de-sac,
and the posterior uterine wall
ANALYSIS OF DATA
Formulate nursing diagnoses (wellness, Helps nurses see the patient in a holistic
risk, actual) perspective, which facilitates the decision
of specific nursing interventions
Formulate collaborative problems Allows the nurses with the physician and
other healthcare professionals to monitor,
plan, and implement patient’s care
Make necessary referrals To ensure that clients are seeing the
correct healthcare providers for further
diagnosis
ANUS, RECTUM, AND PROSTATE
PROCEDURE RATIONALE
Gather equipment (gloves, lubricating gel) For an efficient and smooth procedure
Explain procedure to client To provide awareness and promote
cooperation
Ask client to gown To respect and maintain patient privacy
ANUS AND PERIANAL AREA
Inspect for lumps, ulcers, lesions, rashes, The anus has no lumps, ulcers, lesions,
redness (note size, shape, location, rashes or redness. A healthy anus looks
distribution, and configuration) like a circular set of “puckered lips” and is
located the end of the rectum
Inspect sacrococcygeal area for swelling, The sacrococcygeal area has no swelling
redness, dimpling, or presence of hair in or redness. The pilonidal area usually
pilonidal area contains hair and skin debris
Inspect for rectal prolapse with Valsalva Rectal prolapse occur when the rectum,
maneuver and even part of the large intestine slips
down the anus
Palpate for anal sphincter tone, The anal sphincter has a sufficient tone
tenderness, nodules, or hardness and has no tenderness or nodules
RECTUM AND PROSTATE
Palpate rectal mucosa for tenderness, The walls of the mucosa are smooth and
irregularities, nodules, and hardness has no tenderness or nodules
For males, palpate the prostate gland for The normal size of the prostate when
tenderness, size, shape, texture, or palpated in the rectum is about 1 cm. It is
irregularities usually rubbery and firm with a smooth
surface and should not be tender
Inspect the feces for blood, and perform A fecal occult blood test is commonly
occult blood test used as a screening test to help find
colorectal cancer. It can also be done
when there is concern about bleeding in
the digestive tract from other conditions
ANALYSIS OF DATA
Formulate nursing diagnoses (wellness, Helps nurses see the patient in a holistic
risk, actual) perspective, which facilitates the decision
of specific nursing interventions
Formulate collaborative problems Allows the nurses with the physician and
other healthcare professionals to monitor,
plan, and implement patient’s care
Make necessary referrals To ensure that clients are seeing the
correct healthcare providers for further
diagnosis.
