Pelvic_and_Breast_Exam_Statement_of_work.doc

03/24/2016

STATEMENT OF WORK

The Integrated Clinical Skills (ICS) Course includes direct student – “patient” physical examination encounters. To provide the initial training in the female pelvic examination, we require the participation of trained teaching associates. These individuals serve as both the subject of the examination and the instructor as to technique and overall approach. Teaching associates must have appropriate training/experience in both examination and educational techniques to convey the required curriculum materials. All sessions are conducted at the Simulation Center located on the Walter Reed Annex in Silver Spring, Maryland; therefore, the contractor must be able to provide an onsite monitor and personnel transportation to that facility on the agreed upon dates and times.

Female Breast and Pelvic Examination (ICS Course) – Module 6, Class 2019 Services include:

1. Student to teaching associate of no more than (model) 2:1 (except on noted dates, see below).

2. Model demonstration of the pelvic examination of both external and internal genitalia, including the speculum and bimanual examination.

3. Individual student practicum on pelvic examination.

4. Model demonstration of breast examination with emphasis on the general approach, inspection, palpation, and lymph node and axillary examination.

5. Emphasis on teaching patients breast self-examination.

6.

Provide an on-site monitor/administrator for each session.

7.

Provide necessary supplies for each session (note: there is no capacity for on-site storage of supplies)

8.

Provide services within the time limit specified (session times cannot be extended, awardee must supply adequate staffing to complete the session within the presented timeframe.

9. Provide additional training sessions at no additional expense should students have insufficient time to practice all designated skills due to contractor or teaching associate error, or failure to follow the prescribed time guidelines in the statement of work.

10. Contractor will inform teaching associates that a valid drivers license and proof of insurance is required to drive a vehicle onto the Forest Glen military installation. Contractor will also inform teaching associates that all vehicles entering the installation are subject to random vehicle inspections.

PELVIC EXAM AND ULTRASOUND DATES Summer 2016 – Graduate School of Nursing

· DURATION OF EXERCISE: 1:00 – 4:10 PM

· # OF SESSIONS: 1 Daytime session

· # OF STUDENTS: approximately 20 students per session; 2 students/TA (except where noted on schedule)

· SESSION DURATION: 90 min. per student pair for the pelvic exam and 45 minutes for the ultrasound

· SESSION TIMES:

12:00 – 1:30 PM: Pelvic Teaching Only (10 students)

1:30 – 2:00 PM: Prescreening of FGTAs with faculty

2:15 – 3:00 PM: Ultrasound (All students)

3:10 – 4:40 PM: Pelvic Teaching Only (10 students)

DATE

BREAST and PELVIC EXAM DATES Summer 2016 – Class of 2019 (Graduate School of Nursing)

· DURATION OF EXERCISE: 1:00 – 4:10 PM

· # OF SESSIONS: 2 Evening sessions

· # OF STUDENTS: approximately 24 students per session; 2 students/TA (except where noted on schedule)

· SESSION DURATION: 90 min. per student pair

1:00 – 2:30 PM

2:40 – 4:10 PM

12 Students: 2:40 – 4:10 PM (2 st/TA)

12 Students: 2:40 – 4:10 PM (2 st/TA)

BREAST and PELVIC EXAM DATES Fall 2016 – Class of 2019 (School of Medicine)

· DURATION OF EXERCISE: 6:00-9:45 PM

· # OF SESSIONS: 8 Evening sessions

· # OF STUDENTS: approximately 24 students per session; 2 students/TA (except where noted on schedule)

· SESSION DURATION: 90 min. per student pair

6:00 –7:30 PM

7:45 – 9:15/9:45 PM (depending on student #)

12 Students: 7:45 – 9:15 PM

12 Students: 7:45 – 9:15 PM

12 Students: 7:45 – 9:15 PM

12 Students: 7:45 – 9:15 PM

12 Students: 7:45 – 9:15 PM

12 Students: 7:45 – 9:15 PM

12 Students: 7:45 – 9:15 PM

6 Students: 7:45 – 9:15 PM

Breast & PELVIC Examination Sequence

DURATION OF EXERCISE:

90 min/student pair

Patient is in room, gowned

Sexual history has been taken

Exam will proceed in context of a complete physical

Students should be instructed in performing the following sequence:

Breast Examination Preparation (2 min/pair):

1.

Knocks and waits for recognition, introduces self to patient and addresses patient by surname.

2.

Explains purpose and main steps of the examination.

3.

Invites patient to ask questions now or at any time during the examination.

4.

Checks all articles and equipment for examination including drape (gloves may be needed for lactating patient).

5.

Uses universal precautions and washes hands in presence of patient before beginning examination.

6.

Asks patient whether they perform regular breast self-examination and discusses it's importance in early detection of cancer. Advises patient that they will be showing them ways to do the techniques at home that are being done today. Discuss when is the best time of the month to do the breast self-exam and current recommendation for age and periodicity of mammogram.

Visual Examination (3 min/pair):

Student instructed to look for symmetry, masses, lesions, skin changes, dimpling, peau d' orange, scars, bruises, etc.

7.

Exposes both breasts completely (shoulders at the same level). (Advises patient to use wall mirror at home for items 7‑9 and 11)

8.

Visually inspects both breasts in seated position.

9.

Visually inspects both breasts with hands on hips and asks patient to raise shoulders and squeeze shoulder and chest muscles.

10.

Visually inspects both breasts with patient leaning forward. (Advises patient that hand mirror can be used at home.)

11.

Visually inspects both breasts with arms above head.

Breast Examination (15 min/pair):

Palpates patient's right axilla in seated position:

12.

Examiner uses left hand to examine patient's right axilla and palpates: deep central axillary area, lateral lymph nodes, medial axillary area, pectoral lymph nodes, and subscapular lymph nodes.

Palpates patient's left axilla in seated position:

13.

Uses right hand to examine patient's left axilla and palpates: deep central axillary area, lateral lymph nodes, medial axillary area, pectoral lymph nodes, and subscapular lymph nodes.

Palpates patient's right and left breast in lying position:

14.

Explains and demonstrates technique while examining patient. Teaches patient breast self-examination including regular, monthly use of hand and wall mirror for visual inspection and prone palpation techniques performed by the clinician with emphasis on importance of baseline knowledge of their own anatomy.

15.

Repeats thorough examination of entire right breast using three degrees of pressure and methodical path with patient supine. Note: In patients, B cup and larger, left side lying position moving both shoulders on table or a pillow can be used to bring breast tissue toward the midline for examination of the lateral aspect. Supine position required for examining medial aspect.

16.

If discharge has been noted in seated exam or reported by patient, attempt to locate source of discharge by palpation/stripping of quadrants of areola then breast.

17.

Reiterates importance of regular breast self-exam, clinical exam, and mammogram as appropriate. Establishes date of next self-exam and clinical exams with patient.

Pelvic Examination (External Genital Examination):

1.

Assists patient in positioning herself (lithotomy position) and encourages and assists patient.

2.

Inquires that the patient is comfortable.

3.

Washes hands and puts on clean gloves (double gloves on dominant hand).

4.

Faces patient's perineum, while sitting on chair, illuminates perineum with light source.

5.

Alerts patient verbally that the examination is about to begin (examiner must establish tactile signal with hand as well).

6.

Visually examines and palpates mons pubis/area of hairline and pubic area. Note pattern of hair growth.

7.

Visually examines and palpates labia majora/outer folds and labia minora/inner folds.

8.

Retracts prepuce/covering and visually examines clitoris.

9.

Visually examines urethral meatus/opening to urethra, and introitus/opening to vagina, followed by palpation of Skene's glands, Bartholin's glands, perineum.

Speculum Examination 10.

Washes hands and re-gloves if necessary.

11.

Chooses the appropriate speculum, checks it (both mechanically and to make sure that it is not too cold) and shows it to the patient.

12.

Alerts patient that speculum examination is about to begin.

13.

Separates labia minora with forefinger and thumb of one gloved hand.

14.

Holds speculum, at a 45 degree angle, with other hand and introduces it into vaginal introitus keeping it away from urethral meatus area.

15.

Inserts speculum slowly into vagina along posterior vaginal wall, depressing perineal body, and rotates it to a flat position.

16.

Opens speculum after inserting it fully; exposes cervix and tightens screw on speculum.

17.

Cervical inspection: observes cervical size, color and outer os configuration and notes any erosion, cyst, polyp, tumor, eversion, etc. (Note: Pap smear protocol would take place here).

18.

Releases screws while holding bills open; removes speculum slightly until free of cervix and closes speculum partially.

19.

Vaginal inspection: rotates speculum while removing to observe anterior and posterior vaginal walls, noting vaginal rugae, bleeding, ulcer and/or tumor; also noting discharge including amount, character and color, if any.

20.

Allows speculum to close completely as it is removed.

Bimanual Vaginoabdominal Examination 21.

Applies lubricant to fore and middle finger of gloved hand.

22.

Alerts patient that bimanual examination is about to begin.

23.

Introduces distal segment of middle and fore fingers (with palm facing sideways) into vagina, uses pubococcygeal relaxation technique by pressing down on the perineal body.

24.

Inserts both fingers slightly into vagina and turns hand to palm up position; hyperextends thumb and flexes fourth and fifth fingers towards the palm.

25.

Palpates vaginal rugae; checks for depth, deformity, scarring, cyst, etc.

26.

Palpates cervical size, direction, configuration, consistency and tenderness.

27.

Asks patient to take a deep breath and then relax her abdominal muscles with other hand on abdomen placed below umbilicus.

28.

Palpates uterine body between vaginal hand and abdominal hand; notes uterine position, size, configuration, mobility, consistency, and sensitivity.

29.

Moves vaginal fingers into fornix and abdominal hand to lower quadrants of abdomen. Attempts to palpate both ovaries and parametrial tissues. Notes thickness of parametrial tissues and whether there are any pelvic masses.

Bimanual Rectrovaginal Examination:

30.

Withdraws middle finger from vagina, re-gloves and applies lubricant to fore and middle fingers.

31.

Alerts patient that examination is about to begin.

32.

Introduces middle finger into rectum and fore finger into vagina.

33.

Uses anal sphincter relaxation technique by asking patient to bear down as finder is inserted.

34.

Repeats the palpation and characterization of the cervix, uterus, ovaries and parametrial tissues from the posterior position.

35.

Palpates posterior pelvic wall with rectal finger.

36.

Palpates rectovaginal septum between fingers while removing internal hand.

37.

Removes fingers smoothly.

38.

Asks patient to meet in office or exam room after dressing to discuss the examination findings.

39.

In meeting, reiterates importance of regular breast self-exam, clinical exam, mammogram, pelvic exam and pap smear.

Note: Be prepared to explain that flatulence, discharge, involuntary urination, bleeding or fecal matter may occur after exam.