PHINMA-Cagayan de Oro College
Max Suniel St., Carmen, Cagayan de Oro
COLLEGE OF ALLIED HEALTH & SCIENCES
STUDENT NAME: Date:
Section: Clinical Instructor:
ASSESSING FEMALE GENITOURINARY SYSTEM
Purpose/s:
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Principle/s:
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PATIENTS BIOGRAPHIC DATA
Patients Name: Sarena Jasmin B. Rendon
Age: 19
Gender:F
Religion: Catholic
Marital Status: Single
Height: 5’0
Weight: 45kg
Assessing the Female Genitourinary System
Area/Physical Assessment Assessment Normal Findings Students Findings
Skill Developmental/Cultural Variations
INSPECTION Position: Lithotomy. Maintain
standard precautions, wear
gloves
External genitalia Have patient void before exam
Labia Majora Note color, hair distribution, External genitalia intact, pink, and E
Labia minora condition of skin, swelling, moist; color depends on patients’
Clitoris lesions, polyps, discharge, odor, pigmentation. Hair distribution depends
Urethra prolapsed, or pubic pediculosis. on age and development of the patient.
Vaginal Orifice
Skene’s glands No lesions, edema, discharge,
odor, or prolapse
(bladder, uterus, or rectum)
Bartholin’s glands Normal cervical discharge
depends on the menstrual cycle;
Perineum clear and stretchy before
ovulation, white and opaque after
ovulation, bloody during
menstruation.
Rectal area Note condition of skin, Rectal area intact, no inflammation,
inflammation, rashes, excoriation, lesions, prolapsed, hemorrhoids,
rectal prolapsed, external discharge, or bleeding.
hemorrhoids, polyps, lesions,
fissures, bleeding, and discharge.
PELVIC EXAM WITH Use warm speculum. Cervix round, midline, pink, no lesions
SPECULUM Note color, lesions, discharge, or discharge, os is slit in parous female,
bleeding, position, size, shape, round and closed in nulliparous female.
Cervix and symmetry, shape and Bluish color seen with pregnancy, paler
patency of os. color seen in post menopausal women.
Vaginal walls
Obtain specimens as indicated. Vaginal walls pink with rugae, no
Inspect vaginal walls while lesions.
withdrawing speculum.
PALPATION Lubricate index and middle
fingers of gloved hand. Perform
vaginal exam first, then
speculum exam, bimanual exam,
and rectovaginal exam.
Skene’s gland, Usually performed before Area smooth; no swelling, masses or
speculum insertion. tenderness.
Bartholin’s glands Insert index finger into vagina
with finger pad upward, and milk
urethra and Skene’s gland.
Note any masses, swelling,
discharge, or tenderness
Vaginal walls Note texture, swelling, lesions, or Vaginal wall rugae: no swelling, lesions,
tenderness nodules, or tenderness. Less rugae in
post menopausal women.
Cervix Note size, shape, consistency, Cervix round, smooth, firm, midline,
position, mobility, or tenderness. mobile and non tender.
Cervix smaller in older women
Cervix softer and enlarged during
pregnancy
Uterus Notesize, shape, consistency, Uterus midline, maybe anteflexed or
position, mobility, or tenderness. anteverted, midplane, retroflexed, or
retroverted. Pearshaped, size increases
with pregnancy, firm, mobile, slightly
tender. No masses.
Ovaries Note size, shape, symmetry, or Ovaries are usually nonpalpable; if
tenderness. palpable, almond shaped, firm, smooth,
about 3 x 2 x 1 cm, mobile, sensitive to
palpation. Ovaries not palpable in
postmenopausal women or prepubertal
girls.
Anus and rectum Change gloves before the Positive sphincter tone; nontender; no
rectovaginal exam to prevent masses, polyps, lesions, hemorrhoids,
cross-contamination. or bleeding.
Perform rectal exam and note
sphincter tone, pain, tenderness, Stool brown, negative for occult blood.
nodules, lesions, masses,
hemorrhoids, polyps, or bleeding.
Note color of stool; test for occult
blood.
Assessing the Female Genitourinary System
Pertinent Health History Findings:
Pertinent Physical Findings:
Nursing Diagnoses (Actual or Potential) with clustered Data:
II. DOCUMENTATION
