NCM 103 Checklist Midterms

WESLEYAN UNIVERSITY-PHILIPPINES
COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES
NCM 103 CHECKLIST
PERFORMANCE EVALUATION TOOL

NCM 103 – FUNDAMENTALS OF NURSING PRACTICE
DIRECTIONS:
● The evaluation tool will be discussed by the clinical instructor/s.
● During the discussion, the instructor/s may demonstrate the procedures or may use
video viewing for students’ orientation.
● The students should be given sufficient time to prepare for the return demonstration.
● The students will do the return demonstration based on the checklist given.
● The following rating scale shall be used in grading student’s performance:
2 points - able to perform

Perform the procedure safely and accurately in a very consistent and
independent manner without supportive assistance from the instructors.
Perform a difficult action quickly and skillfully
Spends minimal time on task
Focuses on client while giving care
1 point - able to perform with assistance

Perform the procedure safely and accurately with frequent guidance and
supervision from the instructor.
Demonstrate incomplete skills in some part of the procedure.
Takes longer time to complete the procedure.
0 point - unable to perform

Unable to perform procedure even under close supervision of guidance
Require continuous, supportive and directive cues
Performs in unskilled manner
● At the end of each laboratory session, the instructor/s will give remarks based on the
student’s performance in accordance to the procedures indicated.

NCM 103 CHECKLIST
NAME OF STUDENT: _____________________

BSN I- Block #______
PROCEDURE: HAND HYGIENE
PURPOSE 2 1 0 REMARKS
• To reduce the number of microorganisms on the
hands
• To reduce the risk of transmission of microorganisms
to clients
1 • To reduce the risk of cross contamination among
clients
• To reduce the risk of transmission of infectious
organisms to oneself
PREPARATION
• Soap
1. • Warm running water
• Paper towels
ASSESSMENT
1 For the nurses:
● Nails should Rationale: Short, natural
be kept short. nails are less likely to
harbor microorganisms,
scratch a client, or
puncture gloves.
Rationale: Removal
● Removal of
facilitates proper cleaning
all jewelry is of the hands and arms.
recommende
d.
● Check hands Rationale: A nurse who

for breaks in has open sores may
NCM 103 CHECKLIST
the skin, such require a work assignment

as hangnails with decreased risk for
or cuts. transmission of infectious
organisms due to the
chance of acquiring or
passing on an infection
IMPLEMENTATION RATIONALE 2 1 0 REMARKS
Duration of the entire
procedure: 40-60 seconds
If you are washing your
hands where the client can
observe
you, introduce yourself and
1
explain to the client what
you are
going to do and why it is
necessary.
Turn on the water and Warm water removes less
2 adjust the flow so that the of the protective oil of the
water is warm. skin than hot water.
Apply enough soap to
3
cover all hand surfaces.
Rub hands palm to palm. The circular action creates
friction that helps
4 remove microorganisms
mechanically.
Right palm over left dorsum Interlacing the fingers

5 with interlaced fingers and and thumbs cleans the
vice versa. interdigital spaces.
Palm to palm with fingers
6
interlaced.
Back of fingers to opposing
7 palms with fingers
interlocked.
Rotational rubbing of left
8 thumb clasped in right palm
and vice versa.
9 Rotational rubbing,
NCM 103 CHECKLIST
backwards and forwards

with clasped fingers of right
hand in left palm and vice
versa.
10 Rinse hands with water.
Dry the hands thoroughly
11
with a single use towel.
Use the towel to turn off the This prevents the nurse
faucet. from picking up
12
microorganisms from the
faucet handles
TOTAL: /30
Student’s Signature: _______________ Instructor’ Signature________________

Date: _____ Date: __________
Comments/Suggestions: __________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________

NAME OF STUDENT: _____________________

PROCEDURE: ALCOHOL BASED HAND RUB
1 • To reduce the number of microorganisms on the
hands
• To reduce the risk of transmission of microorganisms
to clients
• To reduce the risk of cross contamination among
NCM 103 CHECKLIST
clients
• To reduce the risk of transmission of infectious
organisms to oneself
PREPARATION
1. • Alcohol
ASSESSMENT
For the nurses:
● Nails should Rationale: Short, natural
be kept short. nails are less likely to
harbor microorganisms,
scratch a client, or
puncture gloves.
Rationale: Removal
● Removal of
facilitates proper cleaning
all jewelry is of the hands and arms.
recommende
1
d.
● Check hands Rationale: A nurse who

for breaks in has open sores may
the skin, such require a work assignment
with decreased risk for
as hangnails
transmission of infectious
or cuts. organisms due to the
chance of acquiring or
passing on an infection
Duration of the entire
procedure: 20-30 seconds
1 If you are doing hand rub
where the client can
observe
you, introduce yourself and
explain to the client what
you are
NCM 103 CHECKLIST
going to do and why it is

necessary.
Apply a palmful of the
2 product in a cupped hand,
covering all surfaces.
3 Rub hands palm to palm.
Right palm over left dorsum
5 with interlaced fingers and
vice versa.
Palm to palm with fingers
6
interlaced.
Back of fingers to opposing
7 palms with fingers
interlocked.
Rotational rubbing of left
8 thumb clasped in right palm
and vice versa.
Rotational rubbing,
backwards and forwards
9 with clasped fingers of right
hand in left palm and vice
versa.
Once dry, your hands are
10
safe.
TOTAL: /26

Date: _____ Date: __________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________
NCM 103 CHECKLIST

NAME OF STUDENT: _____________________

PROCEDURE: SHAMPOOING THE HAIR OF A CLIENT CONFINED TO BED
To stimulate the blood circulation to the scalp.
To distribute hair oils and provide a healthy sheen.
1 To increase the client’s comfort
To assess or monitor hair or scalp problems (e.g.
matted hair or dandruff)
PREPARATION
1. Gather and prepare the necessary materials using the
linear arrangement along the designated side table.
Table must be lined with a paper towel as much as
possible.
● Two Bath Towels
● Washcloth
● Cotton Balls
● Shampoo and Conditioner
● Pair of clean gloves
NCM 103 CHECKLIST
● Comb/Hairbrush
● Hair Dryer
● Face Mirror
Additional Materials for Bed Ridden Patients:
● 2 Basin or 2 pail: 1st basin or pail filled with
water; the second pail or basin is used as a
water receptacle during shampooing
● Kelly Pad
● Pitcher/Dipper
ASSESSMENT
1 Assess for the following:
● Patient’s level of
consciousness
and activity
tolerance
● History of the
following
conditions:
- Recent
chemotherapy,
hypothyroidism,
radiation of the
head,
unexplained hair
loss and
excessive hair
growth.
● Presence of
dandruff/lice
● Condition of the
hair and scalp.
● Usual hair care
practices and
routinely used
NCM 103 CHECKLIST
hair care
products.
Hand hygiene and PPE
prevent the spread of
Perform hand hygiene and
1 microorganisms. PPE is
put on PPE, if indicated.
required based on
transmission precautions.
Introduce yourself and To establish trust and
verify the client’s identity. rapport
Explain to the client what
2 you are going to do, why it
is necessary, if appropriate,
and how the client can
cooperate.
Provide for client privacy by Hygiene is a personal
drawing the curtains matter. This ensures the
3 around the bed or closing patient’s privacy and
the door to the room. lessens the risk for loss of
body heat during the bath.
Raise the bed to a level of Having the bed at the
comfortable working proper height prevents
4
position. Lower the side back and muscle
rails where you will work. strain.
If the client is wearing To secure all patient’s
eyeglasses, gently remove belongings.
5 it and place it safely inside
the client’s cabinet or
bedside table.
Don clean gloves. Gloves prevent
6 transmission of
microorganisms.
Place the client diagonally To remove tangles.
in bed and remove pins
7 from the hair if any. Comb
and brush the hair
thoroughly.
8 Remove the pillow and The trough of the Kelly
place it on a chair. Place pad should be directed to
NCM 103 CHECKLIST
the Kelly pad under the a pail to prevent spillage

head, with the client’s neck of water onto the floor.
hyperextended.
Cover the client’s eyes with To protect the eyes from
9
wash cloth. irritation.
Plug both ears with cotton To prevent entry of water
10 balls. into the external auditory
canal.
Adjust the water To ensure patient comfort.
11 temperature according to
the clients preference.
Wet hair thoroughly and
apply small amount of
12
shampoo and work on a
lather.
Massage scalp using finger to promote blood
13 pads not the finger nails in circulation and relaxation
circular motion. in the scalp.
Rinse the hair thoroughly. Shampoo residue in hair
may cause irritation of the
14
scalp and may cause dry
hair.
Squeeze the end of the
15
hair strands to remove
excess water.
Dry the hair thoroughly with

16 a clean towel or by using
the hair dryer.
Remove the Kelly pad,
17 cotton balls and wash
cloth.
Comb and style hair Avoid juvenile hairstyle if
18 according to patient’s client is an older client.
preferences.
Part the hair and divide it
19
into two main sections.
20 Brush/ comb the hair. Start
at the scalp and brush
NCM 103 CHECKLIST
toward the hair ends.

Offer eye glasses and face For the client to better
21 mirror to the client. view himself/herself.
Assist the patient to a Proper positioning with

comfortable position. raised side rails and
22 proper bed height
provides for patient
comfort and safety.
Place all soiled materials in
a hamper. Rearrange
23
reusable materials to its
proper places
Remove PPE, if used. Removing PPE properly
Perform hand hygiene. reduces the risk for
infection transmission
and contamination of
24
other items. Hand hygiene
prevents
the spread of
microorganisms.
Document procedures and
25 any observations in the
clients chart.
TOTAL: /56

Date: _____ Date: __________
______________________________________________________________________
______________________________________________________________________
_________________________________________________________________

NCM 103 CHECKLIST
NAME OF STUDENT: _____________________

PROCEDURE: BATHING AN ADULT CLIENT
● To remove transient microorganisms, body
secretions and excretions and dead skin cells.
1 ● To stimulate circulation to the skin.
● To promote a sense of well-being.
● To produce relaxation and comfort.
PREPARATION
Gather the following equipment:
● Basin with warm water (between 43-46C)
● Soap and soap dish
● Bath Blanket
● Two Bath Towels
● Washcloth
● Clean Gown or Clothes as needed
1. ● Clean gloves, if appropriate (Presence of body
fluids or open lesions)
● Personal hygiene articles (e.g., deodorant, lotion,
creams)
● Shaving equipment
● Table for bathing equipment
● Laundry bag
ASSESSMENT
1 ● Physical or emotional factors (e.g., fatigue ,
sensitivity to cold, anxiety or fear)
● Condition of the skin (color, texture and turgor,
presence of pigmented spots, temperature, lesions,
excoriations, abrasions, and bruises.)
NCM 103 CHECKLIST
● Assess the sacrum, bony prominences and heels for

possible presence of sores.
● Presence of pain and need for adjunctive measures
(e.g., analgesic) before the bath.
● Range of motion of the joints
Hand hygiene and PPE
prevent the spread of
Perform hand hygiene and
1 microorganisms.
put on PPE, if indicated.
PPE is required based on
transmission precautions.
Introduce self and verify
the client’s identity. Explain
to the client what you are
going to do, why it is
necessary and how he or
2
she can participate.
Discuss with the client their
preferences for bathing and
explain any unfamiliar
procedures.
Provide for client privacy by Hygiene is a personal
drawing the curtains matter. This ensures the
3 around the bed or closing patient’s privacy and
the door to the room. lessens the risk for loss of
body heat during the bath.
Offer the client a bedpan or Warm water and activity
urinal or ask whether the can stimulate the need to
client wishes to use the void. The client will be
4 toilet or commode. more comfortable after
voiding, and voiding
before cleaning the
perineum is advisable.
5 Position the bed at a This avoids undue
comfortable working height. reaching and straining and
Lower the side rail on the promotes good body
side close to you. Keep the mechanics. It also
other side rail up. Assist ensures client safety.
the client to move near
NCM 103 CHECKLIST
you.
Place bath blanket over top
sheet. Remove the top
sheet from under the bath
6 blanket by starting at
client’s shoulders and
moving linen down toward
the client’s feet.
Ask the client to grasp and The bath blanket provides
hold the top of the bath comfort, warmth and
7
blanket while pulling linen privacy.
to the foot of the bed.
Remove the client’s gown
while keeping the client
8 covered with the bath
blanket. Place gown in
linen hamper.
Make a bath mitt with the A bath mitt retains water
washcloth. and heat better than a
cloth loosely held and
9
prevents ends of
washcloth from dragging
across the skin.
Place the towel under the Using separate corners
client’s head. Wash the prevents transmitting
eyes with water only and microorganisms from one
10
dry them well. Use a eye to the other.
separate corner of the
washcloth for each eye.
Wipe from inner to outer This prevents secretions
11 canthus. from entering the
nasolacrimal ducts.
Wash the client’s face. Ask Soap has a drying effect,
whether the client wants and the face, which is
12 soap used on the face. exposed to the air more
than other body parts
tends to be drier.
NCM 103 CHECKLIST
Wash, rinse and dry the

13
client’s face, ears and
neck.
Remove the towel from

14
under the client’s head.
Wash the arms and hands. To protect the bed from
Place a towel lengthwise becoming wet.
15
under the arm away from
you.
Wash, rinse and dry the Firm strokes from distal to
arm by elevating the proximal areas promote
client’s arm and supporting circulation by increasing
16 the client’s wrist and elbow. venous blood return.
Use long firm strokes from
wrist to shoulder, including
the axillary area.
Repeat for hand and arm
nearest you. Exercise
17 caution if an IV infusion is
present, and check its flow
after moving the arm.
Apply deodorant or powder Powder is not
if desired. Special caution recommended for these
18 is needed for clients with clients due to the potential
respiratory alterations. respiratory adverse
effects.
Place bath towel Keeps the client warm
lengthwise over the chest. while preventing
20
Fold bath blanket down to unnecessary exposure to
the client’s pubic area. the chest.
21 Lift the bath towel off the
chest and bathe the chest
and abdomen with your
mitted hand using long firm
strokes. Give special
attention to the skin under
the breasts and any other
skinfolds, particularly if the
NCM 103 CHECKLIST
client is overweight.
22 Rinse and dry well.
Replace the bath blanket
23 when the areas have been
dried.
Expose the leg farthest Covering the perineum
from you by folding the promotes privacy and
bath blanket toward the maintains the client’s
24
other leg, being careful to dignity.
keep the perineum
covered.
Lift leg and place the bath Washing from the distal to
towel lengthwise under the proximal areas promotes
leg. Wash, rinse and dry circulation by stimulating
25
the leg using long, smooth, venous blood flow.
firm strokes from the ankle
to the knee to the thigh.
Reverse the coverings and
26
repeat to the other leg.
Wash the feet by placing
27
them in the basin of water.
Dry each foot. Pay
particular attention to the
spaces between the toes. If
28
preferred, wash one foot
after that leg before
washing the other leg.
Obtain fresh, warm Water may become dirty
bathwater now or when or cold. Because surface
29
necessary. skin cells are removed
with washing.
Lower the bed and raise This ensures the safety of
30 the side rails when refilling the client.
the basin.
31 Assist the client into prone This provides warmth and
or side-lying position facing prevents undue exposure.
away from you. Place bath
towel lengthwise alongside
the back and buttocks
NCM 103 CHECKLIST
while keeping the client

covered with the bath
blanket as much as
possible.
Wash and dry the client’s
back, moving from the
shoulders to the buttocks,
32
and upper thighs paying
attention to the gluteal
folds.
Remove and discard
33
gloves if used.
Perform a back massage
34 now or after the completion
of bath.
Assist the client to the
supine position and
determine whether the
client can wash the
35
perineal area
independently. If the client
cannot do so, drape the
client and wash the area.
Assist the client with
grooming aids such as
36
powder, lotion or
deodorant.
Put on a clean gown, This provides for the
37 pajamas or clothes to the patient’s warmth and
patient. comfort.
Place the patient in a Proper positioning with
comfortable position and raised side rails and
38 secure the side rail. proper bed height
provides for patient
comfort and safety.
Remove and dispose
39
equipment appropriately.
40 Remove PPE, if used. Removing PPE properly
Perform hand hygiene. reduces the risk for
NCM 103 CHECKLIST
infection transmission
and contamination of
other items. Hand hygiene
prevents
the spread of
microorganisms.
Document the following:
● Type of bath given
(Complete, partial, self-
help)
● Skin assessment
● Ability of the client to
41 assist or participate with
bathing.
● Client strength. Note
range of motion and
circulation, movement
and sensation of all
extremities.
TOTAL: /88

Date: _____ Date: __________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________
REFERENCE: KOZIER AND ERB’S FUNDAMENTALS OF NURSING CONCEPTS, PROCESS

AND PRACTICE 10TH EDITION

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WESLEYAN UNIVERSITY-PHILIPPINES

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

NCM 103 CHECKLIST

PERFORMANCE EVALUATION TOOL

2 points - able to perform

1 point - able to perform with assistance

0 point - unable to perform

PERFORMANCE EVALUATION TOOL

NCM 103 CHECKLIST

NAME OF STUDENT: _____________________

PROCEDURE: HAND HYGIENE

● Check hands Rationale: A nurse who

NCM 103 CHECKLIST

the skin, such require a work assignment

Right palm over left dorsum Interlacing the fingers

NCM 103 CHECKLIST

backwards and forwards

Student’s Signature: _______________ Instructor’ Signature________________

PERFORMANCE EVALUATION TOOL

NAME OF STUDENT: _____________________

PROCEDURE: ALCOHOL BASED HAND RUB

NCM 103 CHECKLIST

● Check hands Rationale: A nurse who

NCM 103 CHECKLIST

going to do and why it is

Student’s Signature: _______________ Instructor’ Signature________________

NCM 103 CHECKLIST

PERFORMANCE EVALUATION TOOL

NAME OF STUDENT: _____________________

PROCEDURE: SHAMPOOING THE HAIR OF A CLIENT CONFINED TO BED

NCM 103 CHECKLIST

NCM 103 CHECKLIST

NCM 103 CHECKLIST

the Kelly pad under the a pail to prevent spillage

Dry the hair thoroughly with

NCM 103 CHECKLIST

toward the hair ends.

Assist the patient to a Proper positioning with

Student’s Signature: _______________ Instructor’ Signature________________

PERFORMANCE EVALUATION TOOL

NCM 103 CHECKLIST

NAME OF STUDENT: _____________________

PROCEDURE: BATHING AN ADULT CLIENT

NCM 103 CHECKLIST

● Assess the sacrum, bony prominences and heels for

NCM 103 CHECKLIST

NCM 103 CHECKLIST

Wash, rinse and dry the

Remove the towel from

NCM 103 CHECKLIST

NCM 103 CHECKLIST

while keeping the client

NCM 103 CHECKLIST

Student’s Signature: _______________ Instructor’ Signature________________

REFERENCE: KOZIER AND ERB’S FUNDAMENTALS OF NURSING CONCEPTS, PROCESS

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