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Learning outcomesThe intended learning outcomes for teaching the.pelvic examination is for the student todemonstrate ability to 1 Interact with the patient in a way that elicitsconfidence and cooperation and assures thepatient s comfort .2 Perform the complete examination in a sensitive3 Use appropriate medical terminology andcommunication skills when performing the examand to communicate the results and educate the 3 parts of the pelvic exam.1 The visual exam is a way to look for any signs ofinfection on the outside of the woman s genitals2 The speculum exam is a way to see inside thewoman s vagina and to test the health of her cervix Youuse a tool called a speculum to do the speculum exam .3 The bimanual exam 2 hand exam is a way to checkthe health of a woman s womb and ovaries or to checkthe size of the womb in pregnancy To do a bimanual exam you feel the womb with the fingers of one hand inside awoman s vagina and the other hand on her belly at the. Indications for pelvic exam include Vulvar or vaginal complaints Abdominal pain in a woman Exposure to sexually transmitted infection Pregnancy known or proven . Health maintenance to perform pap smear Before the exam Help the woman relaxRemind the woman to take deep breaths andto let her body relax. Some women are afraid to have pelvic exams suchas women who have never had pelvic exams and womenwho have had exams that were painful When you do a pelvic exam you are examining a woman sgenitals and vagina Many women are embarrassed or.ashamed about these parts of their bodies Preparation Wash hands Introduce yourself to the patient using full Make sure that you have privacy . Ensure that the room is sufficiently worm Prepare all the tools you will need for the Exam best performed when patient hasempty bladder Preparation. Make sure the nurse has all of the necessary materialsfor the exam Speculum GYN cotton tipped appropriate sizeplastic or metal over head. Preparation Make sure the nurse has all of the necessary materialsfor the exam Lubricant Pap material cytobrush spatula cervical broom .Slide and fixative orliquid media Positioning Privacy Buttocks just off. Good Lighting Standby Before the exam Ask the woman to urinate beforethe exam This will make the exam.more comfortable for her a fullbladder will obstruct the view ofthe cervix Ask her to lie on her back with herknees up and her buttocks at the.end of the exam table or bed If she is not down far enough inserting the speculum can bemore difficult and uncomfortable Before the exam. Appropriate draping should beused to help make the patientmore comfortable Good lighting is important and isoften accomplished with a.goose neck lamp Wash your hands with cleanwater and soap Your fingernailsshould be short and clean Put clean plastic gloves on your. Inspection Inspect the client s external Perineal area must be wellilluminated Both hands are gloved to.prevent the spread of Mons pubis note quantityand distribution of hair Labia usually plump andwell formed in adult female. Inspection Perineum slightlydarker than the skin ofthe rest of the body Mucous membranes.appear dark pink and Inspection Separate the labia and inspect the labia Labia minora Clitoris. Urethral orifice Vaginal orifice Inspection Note the following Discharge. Inflammation Ulceration Lesions Prolapse Stress incontinence. Sequence of a Pelvic Examination Note abnormalities Bulges and swellingof vulva and vagina Enlarged clitoris. Syphilitic chancres Sebaceous cystPrimary Syphilis Skene s glands examination Skene s glands. Near the urethra Suspect inflammation check for urethral Skene s glands examinationSkene s glands. Insert index finger with palmfacing you into the vagina up tothe 2d joint Apply pressure upwards andmilk the Skene s gland by.moving your fingers outward Do this on both sides and noteany discharge Obtain specimen for culture Change glove if discharge is. Bartholin s glands examination If there is history or appearance oflabial swelling check Bartholin s Insert index finger up to first With your index finger and.thumb palpate theposterolateral area of the labiamajora noting any Swelling Tenderness. Masses Heat or discharge Bartholin s glands examination Bartholin s glands CONT A painful abscess is.pus filled and usuallystaphylococcal orgonococcal in originand should be incisedand drained . Assess the support of the vaginal outlet With the labia separatedby middle and index Ask patient to strain Note any bulging of the.vaginal walls cystoceleand rectocele Inspection Inspect the anus atthis time note.presence of lesionsand hemorrhoids Speculum Examination of Internal Select a speculum ofappropriate size lubricate.and warm with warm Small not sexually active Medium sexually active Large women who havehad children. Medium to largespeculum may be used iffemale has had children Appropriate SpeculumGrave s speculum.Width 20 38 mm Pederson speculumLength 75 115 mm Width 13 25 mmLength 75 120 mm Metal speculae side view A small Plastic speculae side view A Pedersen B medium Graves C large small Pedersen B medium.Graves Pedersen C large Pedersen Angle of insertionAngle of insertion at entry and B Angle at full insertion Speculum Examination of Internal Hold speculum in right hand. Place two fingers just inside or atthe introitus and gently pressdown this will help guide thespeculum into the vaginaopening Angle at full insertion. The speculum has to be closed Insert closed speculum obliquelyinto vagina at a 45 degree anglerotating 50 degreescounterclockwise. Warm waterNot too hotLubricates speculumSpread labiaKeep labia apart.Blades remain closed until fully inserted Speculum Examination of Internal Genitalia Avoid trauma to the urethra Care is taken to avoid pullingpubic hair or pinching the. Maintaining downwardpressure open blades slowlyafter full insertion and Open speculum cuppingposition the speculum so thatthe cervix can be visualized. When the cervix is in full view the blades are locked in theopen position Examination Collection Specimen of the Cervix Inspect the cervix. Nulliparous smallround oval Parous multiparous linear irregular stellate Inspect the cervix.Ectropion DysplasiaColor should be uniformly pink Inspect the cervix Pale anemia Bluish Chadwick s.sign presumptive signof pregnancy Physiologicaldischarge odorless Erythema around cervixcolorless Culture any. Ayers Spatula Concave end to fit the Convex end forvaginal wall andvaginal pool scrapings. Sample Cervix Use concave end Rotate 360 degrees Don t use too muchforce bleeding pain . Don t use too littleforce inadequate Cytobrush Insert 2 cm untilbrush is fully inside. Rotate only 180degrees otherwise willcause bleeding Make Pap Smear As thin as possible. Properly labeled Spray with Fixative Within 10 15 Allow to fully drybefore packaging. Cytologic Fixative hairspray worksacceptably also Inspection of the Vagina Withdraw the speculum slowly while.observing the vaginal wall Close blades as the speculum emergesfrom the introitus Inspect vaginal mucosa as thespeculum is withdrawn. 3 Perform a Bimanual Examination From a standingposition introduce theindex finger and middlefinger of your gloved.hand into the vagina Exert pressureposteriorly Your thumb should beadducted with the ring.finger and little fingerinto your palm to avoidtouching the clitoris Perform a Bimanual Examination Palpate the vaginal walls as you insert.your fingers for tenderness cysts nodules masses or growths Identify the cervix noting thefollowing Position anterior or posterior. Shape pear shaped Consistency firm or soft uterine enlargement suggestspregnancy benign or malignant The uterus should be 5 5 8 0 cm long. Identify the Uterus Noting the Following should be mobile in the antero postero plane deviation to the left or right isindicative of adhesions pelvic.masses of pregnancy Tenderness suggests PIDprocess or ruptured tubal Masses Perform a Bimanual Examination. Palpate the fornix around the The os should admit yourfingertip 0 5 cm Place your free hand on thepatient s abdomen midway.between the umbilicus andsymphysis pubis and pressdownward toward the pelvic Bimanual ExaminationIdentify Right Ovary.and Masses in the Place your abdominalhand on the right lower Place your pelvic hand inthe right lateral fornix. Maneuver your abdominalhand downward Use your pelvic hand forpalpation Bimanual Examination.Identify Right Ovary and Masses in the Felt with the vaginal hand The ovary has the size andconsistency of a shelled oyster Note the size shape consistency mobility and tendernessof any palpable organs or masses. Repeat the procedure on the left side The normal ovary is somewhat tender when palpated Withdraw Fingers from Vagina and Change Gloves PELVIC EXAM VIDEO http www youtube com watch v S... .UZAY feature related http www medicalvideos us play... http www youtube com watch v k... PELVIC EXAM Inspect Externally. Palpate Skene s Glands Palpate Bartholin s Glands Assess Outlet Speculum Exam Bimanual Exam. Vagina Cervix Uterus Adnexa Reference Bates guide to physical examination historytaking Ninth edition Lynn S Bickley and PeterG Szilagyi Lippincott Williams Wilkins 2007 . Textbook of physical diagnosis history andexamination Fourth edition Mark H Swartz W B Saunders Company Edelman A Anderson J Lai S Braner DAV Tegtmeyer K Pelvic examination NEJM.2007 356 e26 3 parts of the pelvic exam. 1. The visual exam is a way to look for any signs of infection on the outside of the womanâ€™s genitals. 2. The speculum exam . is a way to see inside the womanâ€™s vagina and . to test the health of her cervix.