PERFORMANCE CHECKLIST

USE OF BED PAN

PROCEDURE

DONE

1. Gather materials needed. (gloves, toilet paper,

2.
3.
4.
5.
6.

rubber sheet, bed pan, wash cloth, towel)

Lower the head of the bed, raise side rails, if any.
Inform the patient about the procedure.
Provide privacy.
Wear gloves.
Place the rubber sheet on the bed & expose the

buttocks.
7. Assist client to side-lying position.
8. Place bedpan under the buttocks
9. Help the patient roll on her back or help the

SCORE

NOT
DONE

3
3
3
5
4
4
4
4

parient raise her hips & slide the pan in place.

10. Check placement of bedpan, if indicated, elevate
head of bed at 45 degree angle.
11. When patient is done, place patient in supine

4
4

position.
12. Support the bed pan & assist the patient to roll to
4
side & remove the bedpan.
13. Assist the patient with cleaning or wiping.
14. Measure urine output. Empty, clean & store

3
3

bedpan in proper place.

15. Remove soiled gloves & wash hands.
16. Document the urine output, color and turbidity.
TOTAL

3
3
50

Name: ____________________

Score: _______________

Section: ___________________

Date: _______________

Instructor:__________________