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Comprehensive Gynecological Examination Guide, Lecture notes of Health sciences

De La Salle University (DLSU)Health sciences

A detailed overview of the equipment, procedures, and findings associated with a comprehensive gynecological examination. It covers the external genitalia inspection, internal genitalia examination, bimanual examination, rectovaginal examination, and documentation of the examination. Designed to serve as a comprehensive guide for healthcare professionals conducting gynecological examinations, ensuring thorough and accurate assessments. It covers normal and abnormal findings, enabling practitioners to identify potential issues and provide appropriate care. The level of detail and comprehensive nature of the information make this document a valuable resource for medical students, nursing students, and healthcare professionals involved in women's health.

Typology: Lecture notes

2022/2023

Available from 10/27/2024

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PHYSICAL ASSESSMENT OF THE FEMALE
GENITALIA, ANUS AND RECTUM
Review of the Female Reproductive System
External Genitalia
Internal Genitalia
Anus and Rectum
KEY POINTS
a. Respect the client’s privacy.
b. Perform the examination professionally and
preserve the client’s modesty.
c. Prepare the client thoroughly for the physical
examination to put the client
at the greatest ease.
d. Have a chaperone in the room with you when
examining the female
genitalia, rectum, and anus.
e. Wash hands, wear gloves, and make sure
equipment is between room
temperature and body temperature.
f. Inspect and palpate female external and internal
structures correctly.
g. Understand the structures and functions of the
anorectal region.
h. Use examination and laboratory equipment
properly.
i. Understand the difference between common
variations and abnormal
findings.
EQUIPMENT
• Stool
• Light
• Vaginal speculum
• Water-soluble lubricant
• Large swabs for vaginal examination
• Specimen container
• Gloves (non-sterile)
• pH paper
• Feminine napkins
• Hand held mirror
BEFORE THE PHYSICAL EXAMINATION
1. Prior to performing the procedure, introduce
self and verify the
client’s identity using agency protocol.
2. Explain to the client what you are going to do,
why it is
necessary, and how she can participate.
3. Perform hand hygiene, apply gloves, and
observe other
appropriate infection prevention procedures.
4. Provide for client privacy.
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PHYSICAL ASSESSMENT OF THE FEMALE

GENITALIA, ANUS AND RECTUM

Review of the Female Reproductive System External Genitalia Internal Genitalia Anus and Rectum KEY POINTS a. Respect the client’s privacy. b. Perform the examination professionally and preserve the client’s modesty. c. Prepare the client thoroughly for the physical examination to put the client at the greatest ease. d. Have a chaperone in the room with you when examining the female genitalia, rectum, and anus. e. Wash hands, wear gloves, and make sure equipment is between room temperature and body temperature. f. Inspect and palpate female external and internal structures correctly. g. Understand the structures and functions of the anorectal region. h. Use examination and laboratory equipment properly. i. Understand the difference between common variations and abnormal findings. EQUIPMENT

  • Stool
  • Light
  • Vaginal speculum
  • Water-soluble lubricant
  • Large swabs for vaginal examination
  • Specimen container
  • Gloves (non-sterile)
  • pH paper
  • Feminine napkins
  • Hand held mirror BEFORE THE PHYSICAL EXAMINATION
  1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol.
  2. Explain to the client what you are going to do, why it is necessary, and how she can participate.
  3. Perform hand hygiene, apply gloves, and observe other appropriate infection prevention procedures.
  4. Provide for client privacy.

COLLECTING OBJECTIVE DATA

Preparing the Client

  1. Tell the client ahead of time not to douche for 48 hours before a gynecologic examination.
  2. Ask the client to urinate before the examination.
  3. Ask the client to remove her underwear and to put on a gown with the opening in the back.
  4. Assist the client in a lithotomy position.
  5. Ask the client not to put her hands over her head because this tightens the abdominal muscles.
  6. Allow the nurse to maintain eye contact with the client during examination and enables the client to see what the nurse is doing or offer the client a mirror so she can view the examination. PHYSICAL EXAMINATION External Genitalia Inspect the Mons Pubis: Note the distribution of pubic hair and be alert for signs of infestation. Normal Findings:  Pubic hair is distributed in an inverted triangular pattern and there are no signs of infestation. Abnormal Findings:  Presence of lice or nits (eggs) at the base of the pubic hairs indicate infestation with pediculosis pubis. Observe and Palpate Inguinal lymph nodes Normal Findings:  There should be no enlargement or swelling of the lymph nodes. Abnormal Findings:  Enlarged inguinal nodes may indicate a vaginal infection or may be the result of irritation from shaving pubic hairs. Inspect the labia majora and perineum. Observe the labia majora and perineum for lesions, swelling, and excoriation Normal Findings:  The labia majora are equal in size and free of lesions, swelling, and excoriation.  The perineum should be smooth. Abnormal Findings:  Lesions may be from an infectious disease, such as herpes or syphilis  Excoriation and swelling may be from scratching or self-treatment of the lesions. Inspect the labia minora, clitoris, urethral meatus, and vaginal opening. Use your gloved hand to separate the labia majora and inspect for lesions, excoriation, swelling, and/or discharge. Normal Findings:  (^) The labia minora appear symmetric, dark pink, and moist.  The clitoris is sensitive to touch and size varies.  The urethral meatus is small and slit-like.  The vaginal opening size depends on sexual activity or vaginal delivery. Abnormal Findings:  Asymmetric labia may indicate abscess.  Lesions, swelling, bulging in the vaginal opening, and discharges. Palpate Bartholin’s glands. Place your index finger in the vaginal opening and your thumb on the labia majora with a gentle pinching motion. Normal Findings:  Bartholin’s glands are usually soft, non tender, and drainage free.

stirrups with her knees resting in an open, relaxed fashion.

  1. Place two fingers of your non dominant hand against the posterior vaginal wall and wait for relaxation to occur.
  2. Insert the finger of your dominant hand about 2.5cm into the vagina and spread them slightly while pushing them down against the posterior vagina.
  3. Lubricate the blades of the speculum with vaginal secretions from the client.
  4. Hold the speculum with two fingers around the blades and the thumb under the screw or lock.
  5. Insert the speculum between your fingers into the posterior portion of the vaginal orifice at a 45- degree angle downward. When the blades pass your fingers inside the vagina, rotate the closed speculum so that the blades are in a horizontal position. (Figure B)
  6. Continue inserting the speculum until the base touches the fingertips inside the vagina.
  7. Remove the fingers of your gloved non dominant hand from the client’s posterior vagina.
  8. Press handles together (Figure C) to open blades and allow visualization of the cervix.
  9. Secure the speculum in place by tightening the thumbscrew or locking the plastic clip (Figure D). Inspect the cervix. With the speculum inserted in position to visualize the cervix, observe cervical color, size, and position. Normal Findings:  The surface of the cervix is normally smooth, pink, and even.  (^) Normally, it is midline in position and projects 1 – 3 cm into the vagina.  Cervical secretions are normally clear or white and without unpleasant odor Abnormal Findings:  In a non pregnant woman, a bluish cervix may indicate cyanosis  In a non menopausal woman, a pale cervix may indicate anemia.  Redness may be from inflammation.  Asymmetric, reddened areas, strawberry spots, and white patches.  Cervical lesions.  Colored, malodorous, or irritating discharge. Inspect the vagina. Unlock the speculum and slowly rotate and remove it. Inspect thevagina as you remove the speculum. Note the vaginal color, surface, consistency, and any discharge. Normal Findings:  The vagina should appear pink, moist, smooth, and free of lesions and irritation.  It should also be free of any colored or malodorous discharge. Abnormal Findings:  Reddened areas, lesions, and colored,malodorous discharge are abnormal andmay indicate vaginal infections, STIs, or cancer. BIMANUAL EXAMINATION Palpate the vaginal wall Normal Findings:  (^) The vaginal wall should feel smooth, and the client should not report any tenderness. Abnormal Findings:  Tenderness or lesions may indicate infection. Palpate the cervix Normal Findings:  The cervix should feel firm and soft (like the tip of your nose). It is rounded, and can be moved somewhat from side to side without eliciting tenderness. Abnormal Findings:  A hard, immobile cervix may indicate cancer.

 (^) Pain with movement of the cervix may indicate infection (Chandelier’s sign). Palpate the Uterus Normal Findings:  The fundus, the large, upper end of the uterus, is normally round, firm, and smooth.  The normal uterus moves freely and is not tender. Abnormal Findings:  An enlarged uterus above the level of the pubis is abnormal.  An irregular shape suggests abnormalities such as myomas (fibroid tumors) or endometriosis.  A fixed or tender uterus may indicate fibroids, infection, or masses COMMON VARIATIONS IN THE POSITION OF THE UTERUS Anteverted Uterus ● Most typical position of the uterus. ● The cervix is pointed posteriorly, and the body of the uterus is at the level of the pubis over the bladder Midposition ● This is a normal variation. ● The cervix is pointed slightly more anteriorly, and the body of the uterus is positioned more posteriorly than the anteverted position, midway between the bladder and the rectum. ● It may be difficult to palpate the body through the abdominal and rectal walls with the uterus is this position. Anteflexed ● Anteflexion is a normal variation that consists of the uterine body flexed anteriorly in relation to the cervix. ● The position of the cervix remains normal. Retroverted Uterus ● A normal variation that consists of the cervix and body of the uterus tilting backward. ● The uterine wall may not be palpable through the abdominal wall or the rectal wall in moderate retrovertion. Retroflexed Uterus ● A normal variation that consists of the uterine body being flexed posteriorly in relation to the cervix. ● The position of the cervix remains normal. ● The body of the uterus may be felt through the posterior fornix or the rectal wall. Palpate the ovaries Normal Findings:  (^) Ovaries are approximately 3 × 2 × 1 cm (or the size of a walnut) and almond-shaped.  Ovaries are firm, smooth, mobile, and tender on palpation.  A clear, minimal amount of drainage appearing on the glove from the vagina is normal. Abnormal Findings:  Enlarged size, masses, immobility, and extreme tenderness.  Large amounts of colorful, frothy, or malodorous secretions are abnormal.  Ovaries that are palpable 3 – 5 years after menopause are also abnormal.

Palpate the rectum Note tenderness, irregularities, nodules and hardness Normal Findings:  The rectal mucosa is normally soft, smooth, non tender, and free of nodules. Abnormal Findings:  Hardness and irregularities may be from scarring or cancer.  Nodules may indicate polyps or cancer. Palpate the cervix through the anterior rectal wall. Normal Findings:  Cervix palpated as small round mass.  May also palpate tampon or retroverted uterus.  Should not have any bright red blood when gloved finger is removed. Abnormal Findings:  Bright red blood on gloved finger when removed. Large mass palpated. Check stool Inspect stool Normal Findings:  Stool is normally semi-solid, brown, and free of blood. Abnormal Findings:Black stool may indicate upper gastrointestinal bleeding.  Gray or tan stool results from the lack of bile pigment.  Yellow stool suggests steatorrhea (increased fat content).  (^) Blood detected in the stool may indicate cancer of the rectum or colon. AFTER THE PHYSICAL EXAMINATION

  1. Remove and discard gloves.
  2. Perform hand hygiene.
  3. Document findings in the client record using printed or electronic forms or checklists supplemented by narrative notes when appropriate. DOCUMENTATION Sample Objective Data:
    • Visual inspection discloses normal hair distribution of the mons pubis, with lesions present as vesicles, ulcerations noted as well.
    • Labia majora with mild erythema and vesicular lesions along with mild excoriation.
    • Labia minora dark pink, moist, and free of lesions or excoriation. Vesicles and ulcerations extend into the perianal area.
    • Visual inspection of the anus reveals multiple vesicular lesions noted around the anal opening.
    • Upon palpation of the inguinal area and external genitalia, no masses or edema were noted to the inguinal lymph nodes bilaterally.
    • Mild edema noted to the labia majora.
    • Labia minora free from edema and discharge.
    • Bartholin’s glands soft, nontender, and free from discharge.
    • No bulging at vaginal orifice.
    • No discharge from urethral opening.
    • Routine Pap smear performed.
    • Vaginal walls smooth and pink.
    • Cervix slightly anterior, pink, smooth in appearance, slit-like os, without lesions or discharge present.
    • Bimanual examination indicates cervix mobile, nontender, and firm, with no masses or nodules detected.
    • Firm fundus located anteriorly at level of symphysis pubis, without tenderness, lesions, or nodules.
    • Smooth, firm, almond-shaped, mobile ovaries approximately 3 cm in size palpated bilaterally, no excessive tenderness or masses noted.
    • No malodorous, colored vaginal discharge on gloved fingers.
    • Firm, smooth, nontender, movable posterior uterine wall and firm, smooth, thin, movable rectovaginal septum palpated during rectovaginal examination.
    • Good sphincter tone noted with the anus, noted to be smooth, nontender, and free of nodules and hardness.
    • Fecal matter on gloved finger reveals semi-soft, brown stool.

NURSING DIAGNOSIS

Wellness Diagnosis

  • Readiness for enhanced self-health management: Requests information on external genitalia examination.
  • Readiness for enhanced self-health management: Requests information on ways to prevent sexually transmitted diseases infections.
  • Readiness for enhanced self-health management: Requests information on ways to prevent yeast infections.
  • Readiness for enhanced self-health management: Requests information on birth control.
  • Readiness for enhanced self-health management: Requests information on cessation of menses and hormone replacement therapy.
  • Readiness for enhanced self-health management: Requests information on purpose and need for colorectal examination.
  • Readiness for enhanced bowel elimination pattern. Risk Diagnosis
  • Risk of Ineffective Therapeutic Regimen Management (monthly external genitalia examination) related to lack of knowledge of the importance of the examination.
  • Risk for Infection related to unprotected sexual intercourse.
  • Risk for Disturbed Body Image related to perceived effects on feminine role and sexuality.
  • Risk for Ineffective Health Maintenance related to lack of knowledge of need for recommended colorectal examination.
  • Risk for Impaired Skin Integrity in rectal area related to chronic irritation secondary to diarrhea. Actual Diagnosis
  • Fear of ovarian cancer related to high incidence of risk factors.
  • Ineffective Sexuality Pattern related to decreased libido.
  • Ineffective Therapeutic Regimen Management related to lack of knowledge of external genitalia self-examination.
  • Acute Pain: Dysuria related to infection.
  • Anticipatory Grieving related to impending loss of reproductive organs secondary to gynecologic surgery.
    • Ineffective Sexuality Pattern related to perceptions of effects of surgery on sexual functioning and attractiveness.
    • Acute Pain related to surgical incision.
    • Acute Pain: Dyspareunia (painful intercourse) related to inadequate vaginal lubrication.
    • Acute Pain: Rectal.
    • Diarrhea related to chronic inflammatory bowel disease.
    • Ineffective Sexuality Patterns related to feelings of loss of femininity/masculinity and sexual attractiveness secondary to chronic diarrhea or pain.
    • Situational Low Self-Esteem related to loss of control over bowel elimination.
    • Bowel Incontinence related to chronic diarrhea.
    • Constipation related to low intake of high fiber foods.