■ Avoids intercourse, douching, or use of vaginal suppositories for 24 to 48 hours before examination
■ Empties bladder before examination
■ Lies supine, with head and shoulders slightly elevated, arms at sides or folded across chest to reduce tightening of abdominal muscles
Explains each step of the examination in advance
Drapes patient from mid-abdomen to knees;
depresses drape between knees to provide eye contact with patient
Avoids unexpected or sudden movements
Warms speculum with tap water
Monitors comfort of the examination by watching the patient's face
Uses excellent but gentle technique, especially when inserting the speculum (see p._).
Be sure always to wear gloves, both during the examination and when handling equipment and specimens. Plan ahead, so that any needed equipment or culture media are readily at hand.
Helping the patient to relax is essential for an adequate examination. Be sensitive to her feelings. Adopting the tips above will help ensure the patient's comfort.
Choosing Equipment. You should have within reach a good light, a vaginal speculum of appropriate size, water-soluble lubricant, and equipment for taking Papanicolaou smears, bacteriologic cultures, or other diagnostic tests. Review the supplies and procedures of your own facility before taking cultures and other samples.
Specula are made of metal or plastic, and come in two basic shapes, named for Pedersen and Graves. Both are available in small, medium, and large sizes. The medium Pedersen speculum is usually most comfortable for sexually active women. The narrow-bladed Pedersen speculum is best for e patient with a relatively small in-roitus, such as a virgin or an elderly oman. The Graves specula are best suited for parous women with vaginal prolapse.
Before using a speculum, become thoroughly familiar with how to open and close its blades, lock the blades in an open position, and release them again. Although the instructions in this chapter refer to a metal speculum, you can easily adapt them to a plastic one by handling the speculum before using it.
Plastic specula typically make a loud click or may pinch when locked or released. Forewarning the patient helps to avoid unnecessary surprise.
Male examiners should be accompanied by female assistants. Female examiners should also be assisted if the patient is physically or emotionally disturbed.
Positioning the Patient. Drape the patient appropriately and then assist her into the lithotomy position. Help her to place first one heel and then the other into the stirrups. She may be more comfortable with shoes on than with bare feet. Then ask her to slide all the way down the examining table until her buttocks extend slightly beyond the edge. Her thighs should be flexed, abducted, and externally rotated at the hips. A pillow should support her head.
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