A Nursing Protocol for Vaginal Ring Pessary Change

July 25, 2013 11:09 am

The intention is for a First Level Registered Community Nurse to be able to t a ring pessary in order to correct a uterine or vaginal prolapse.

Ring pessaries need to be changed after three months, or as advised by a GP or Gynaecologist.

The vagina and cervix should be examined at the same time and their condition evaluated.

Equipment needed

• Prescribed ring pessary
• Non-sterile gloves
• Plastic apron
• Plastic/paper bed protection
• Jug, soap and warm water
• Sizing guide

Action	Rationale
The patient should be given an explanation of the procedure, its aims and be shown the ring pessary.	To enable the patient to understand the procedure and give valid consent, as well as allaying anxiety.
The patient should pass urine and swab the vulval area from front to back with clean water.	To help reduce the risk of introducing infection and promote comfort.
The patient should be asked to remove pants, corsets, stockings, tights and to lie on the couch/bed covered by a modesty sheet.	To allow the patient to position herself correctly for the procedure and to provide maximum dignity.
The nurse should wash her hands and put on an apron and non-sterile gloves.	To help minimise cross infection.
The size of the ring pessary should be checked against the prescription and it should be removed from its sealed packaging.	The nurse has professional responsibility and accountability for fitting the correct ring pessary, even if prescribed by a GP.
If the nurse immerses the PVC pessary in a bowl of warm water to make it more pliable, she should be extremely careful that it has cooled before putting it into the patient s vagina.	To prevent vaginal mucosa tissue damage and discomfort.
The patient should be asked to lie on her back, with her knees drawn up and separated.	Patient comfort and ease of fitting.
To remove the fitted pessary, the nurse should insert the index finger of her dominant hand into the patient s vagina to locate the ring, as it lies under the symphysis pubis. Hook the ring underneath with the same finger and remove gently, using a continual downward traction movement.	To allow easy removal of the ring and reduce the risk of discomfort for the patient.
If inspection of the pessary reveals cracking or other defects, it should not be re-used. If the pessary is in good condition, it may be cleaned with soap and water and be re-used up to three months.	To help reduce the risk of complications arising, such as infection, ulceration of vaginal mucosa and irritation.
To insert the pessary, the nurse should hold the pessary with the thumb and forefinger of the dominant hand, the pessary should be compressed into an oval shape, then a water-based lubricant should be applied.	To allow comfortable, easy access through the vaginal vault.
Using the non-dominant hand, the nurse should part the labia to explore the entrance to the vagina.	To allow comfortable, easy access through the vaginal vault
The nurse should slide the pessary into the posterior part of the vagina, pulling backwards and downwards until it settles in the posterior fornix. The pessary will spring back into its circular shape once inside the vagina, above the pelvic floor.	Correct positioning essential for optimum efficacy and comfort.
When secured posterially the nurse should hook the front portion of pessary into the anterior fornix of the vagina, secured behind the symphsis pubis. The cervix will be seen positioned centrally through the ring.	To gain the correct position to treat prolapse and to prevent incorrect fitting.
The patient should be asked if the pessary feels comfortable. She should sit up, stand and walk around, cough, bear down and ideally have a bowel movement.	To ensure the fit is secure.
The nurse should check that the patient understands about the management of the ring pessary and that she has instructions for her observations.	The patient will be able to identify any complications which may occur and notify the nurse or GP as soon as possible for treatment.
An appointment should be made for a future pessary change and check up. The nurse should give her name and telephone number for the patient to contact if any problems occur.	Fitted pessary and patient health should be monitored and recorded.
The nurse will ensure that the nursing documentation is completed.	To ensure the full plan of care is recorded for patients and carers.
The nurse will ensure that the intervention is entered onto the Community Information System.	To facilitate clinical audit and contribute to the electronic patient record.

This protocol was devised by the community nursing team working in the Newark Region, Nottinghamshire, with assistance from Sandra Moloney in 2002