Student_________________________________________________ Date______________________

Instructor_______________________________________________ Date______________________

PERFORMANCE CHECKLIST SKILL 9.2 PREPARING A STERILE FIELD

S U NP Comments

ASSESSMENT

1. Identified patient using two identifiers, compared

2. identifiers with information in MAR. ____ ____ _____ ______________

3. Verified that procedure requires surgical aseptic

technique. ____ ____ _____ ______________
4. Assessed patient’s comfort, oxygen requirements,

5. and elimination needs before preparation. ____ ____ _____ ______________

6. Instructed patient not to touch work surface or, ____ ____ _____ ______________
equipment during the procedure.

7. Assessed for latex allergies. ____ ____ _____ ______________

8. Checked sterile package integrity or for ____ ____ _____ ______________

sterilization indicator.

9. Anticipated number and variety of supplies ____ ____ _____ ______________

needed for procedure.

PLANNING

1. Identified expected outcomes ____ ____ _____ _____________

1. Completed all other nursing interventions ____ ____ _____ _____________

before procedure.
2. Asked visitors to step out, discouraged ____ ____ _____ _____________

movement by assisting staff.

3. Prepared equipment at bedside. ____ ____ _____ ____________

4. Positioned patient comfortably and ____ ____ _____ ____________
appropriately with assistance of NAP if necessary.
5. Explained purpose of procedure and ____ ____ _____ ____________
importance of sterile technique.
IMPLEMENTATION

1. Applied PPE as needed. ____ ____ _____ _____________

2. Selected an appropriate workspace above ____ ____ _____ _____________

waist level.
3. Performed hand hygiene. ____ ____ _____ _____________

4. Prepared sterile work surface. ____ ____ _____ ____________

a. Used sterile commercial kit or pack.
1) Placed kit or pack on workspace. ____ ____ _____ ____________
2) Opened outside cover, remove package ____ ____ _____ ____________
age and placed on surface.
3) Grasped outer surface or tip of outer- ____ ____ _____ ____________
most flap.

4) Opened outermost flap away from body ____ ____ _____ ___________

and sterile field.

5) Grasped outer surface of edge of first ____ ____ _____ ____________

side flap.
6) Opened side flap, allowed it to lie flat ____ ____ _____ ____________
on table, kept arm away from sterile surface.
7) Repeated for second flap. ____ ____ _____ ____________
8) Grasped outside boarder of last flap, ____ ____ _____ ___________

stood away from package, folded flap

back, allowed it to fall on the table.

b. Opened a sterile linen-wrapped package.

1) Placed package on workspace. ____ ____ _____ ____________

2) Removed seal, unwrapped both layers,

following same steps as with sterile kit. ____ ____ _____ ____________

3) Used open package wrapper as sterile ____ ____ _____ ____________

Field.

c. Prepared sterile drape.

1) Placed pack containing drape on work-

space and opened following same steps
as with sterile kit. ____ ____ _____ ____________
2) Applied sterile gloves. ____ ____ _____ ____________
3) Picked up folded top edge drape with
fingertips of one hand, lifted without
touching any object, discarded wrapper
 with other hand. ____ ____ _____ ____________

4) Kept drape above waist and work

surface and away from body as unfolded,

discarded wrapper with other hand. ____ ____ _____ ___________

5) Held drape, positioned bottom half

over top half of intended work surface. ____ ____ _____ ____________
6) Allowed top half of drape to be placed
over bottom half of work surface. ____ ____ _____ ____________
5. Added sterile items to sterile field:
a. Opened sterile item while holding outside
wrapper in nondominant hand. ____ ____ _____ ____________
b. Carefully peeled wrapper over nondominant
hand.
c. Placed item on field at an angle, ensured
wrapper and arm were not over sterile field. ____ ____ _____ ____________
d. Disposed of outer wrapper. ____ ____ _____ ____________

6. Poured sterile solution:

a. Verified contents and expiration date of

solution. ____ ____ _____ ____________

b. Ensured receptacle was located near

work-space edge. ____ ____ _____ ____________
c. Removed sterile seal and cap properly. ____ ____ _____ ____________

d. Poured needed amount of solution properly

into container. ____ ____ _____ ____________

EVALUATION

1. Observe for break in sterile technique. ____ ____ _____ ____________

2. Identified unexpected outcomes. ____ ____ _____ ____________