KDM 001

Institute of Health Science

Baptist Hospital Kediri

Type of Skill : Taking of sputum sample

Revision number :0
Student name : Maria Natalia Ponga
Study program / Student ID Number : S1/01.2.17.00614
Level / Semester : Three (3)/Six (6)
Day / The date : ________________/_________________
Place of practice : _________________________________

*Scale
NO COMPONENT
(0, 1, 2, 3)
I Tools preparation :
1 A sterile place to hold the sputum specimen with a lid
2 Clean gloves
3 Crooked (prn)
4 Tissue
5 Tooth brush (client’s property)
6 Label
7 Laboratory examination request form file
8 Plastic specimen
9 Disinfecting liquid
II Pre-interaction stage :
1 Order verification
2 Nurse’s self preparation
3 Prepare a tool
4 Prepare the environment : Protect client privacy and close the blinds
III Orientation Stage :
1 Bring the tools and do identifying patients (calling names, asking names, reading bed cards,
reading patient bracelets)
2 Give a therapeutic greeting
3 Clarification os contracts when awarding positions
4 Explain the purpose and procedure for positioning
5 Give clients the opportunity to ask questions
6 Prepare the tool and then brought to the client
IV Work Stage :
1 Wash your hands with the right steps
2 Wear clean gloves
3 Bring the crooked near the patient
4 Recommend the client for not to touch the inside of the sputum container
5 Do deep breathing techniques and effective cough
6 Ask the client to remove sputum in the specimen reservoir. Do it repeatedly until the amount of
sputum is sufficient or about 2-10cc
7 Close the specimen reservoir
8 Clean with disinfectant liquid if there is sputum on the outside og the specimen reservoir
9 Give the client a tissue to clean if around the dirty mouth
10 Perform oral care (toothbrush) if needed
11 Give the label to the specimen place (client name, date, type of inspection, room name)
12 Save the specimen reservoirs in plastic specimens
13 Tidy up the tools and clients, take off the gloves and wash your hands properly
14 Document and deliver the specimen place to the laboratory with the laboratory examination
request form
V Termination Stage :
1 Evaluation of patient responses
2 Summarize the result of the activity
3 Giving a message
4 Contract time, place, topic or further activities
VI Documentation :
1 The new position of the patient
 *Scale
NO COMPONENT
(0, 1, 2, 3)
2 Time for the position transfer
3 Client response
VII Attitude :
1 Therapeutic communication
2 Maintain work principles
3 Work with the carefully
4 Work systematically
VIII Cognitive
1 The purpose of taking sputum
2 Indication of taking sputum
3 Nurses vigilance

1. Assessment Table
Stage Stage Final score
Value sub
Weight Score Total value x 100
(Weight x Score)
Maximum Score (......)
I Equipment and
1
environmental preparation
II Pre-interaction Stage 1
III Orientation Stage 1
IV Work Stage 3
V Termination Stage 1
VI Documentation 1
VII Attitude 1
VIII Cognitive 1
Total value

2. Value Conversion
A : > 80
AB : 75-79,9
B : 70-74,9
BC : 65-69,9
C : 55-64,9

Result : Pass / Not pass

* Cross the unnecessary ones

Supervisor note :

Kediri, …………………………….
Supervisor/Examiner :

( ________________________)