NAME OF STUDENT: ____________________________________________

LEVEL & BLOCK: SCHOOL YEAR & TERM:

_____________________________ ___________________________ OVERALL RATING

MODULE 1. DONNING AND DOFFING OF STERILE GLOVES (OPEN METHOD)

PERFORMANCE EVALUATION CHECKLIST 1

PROCEDURE PERFORMED PERFORMED UNABLE

INDEPENDENTLY WITH TO
ASSISTANCE PERFOR REMARKS
M
4-5 2-3 0-1
ASSESSMENT
1. Consider the type of procedure to be
performed and consult agency policy on
use of sterile gloves.

2. Select correct size and type of gloves and

then examine glove
package to determine if it is dry and intact
with no water stains.

3. Inspect condition of hands for cuts,

hangnails, open lesions, or
abrasions.

4. Assess patient for the risk factors before

applying latex gloves.
PLANNING
5. Expected outcomes following completion
of procedure:
• Patient does not develop signs or
symptoms of infection after
procedure.
• Patient does not develop latex sensitivity
or latex allergy
reaction

IMPLEMENTATION
1. Wash hands.
 2. Remove outer wrapper carefully by
separating and peeling apart sides and
lay it on clean, flat surface.

3. Open inner wrapper and touching only the

outside, secure both flaps in open
position.

4. Identify right and left glove. Each glove

has cuff approximately 5 cm and 2 inches
wide. Glove dominant hand.

5. With thumb and first two fingers of non-

dominant hand, grasp the inner fold of the
cuff. Lift the glove, holding away from the
body. Slip dominant hand touching only
the inner surface of the glove.
6. With gloved dominant hand, slip four
fingers underneath second glove cuff. Lift
the glove away from the body.

7. Carefully pull second glove over

nondominant hand and adjust fingers of
both gloves using gloved hand.

8. After second glove is on, interlock hands

together above waist level. The cuffs
usually fall down after application. Be
sure to touch only sterile sides

9. Grasp outside of one cuff with other

gloved hand, avoid touching the wrists.

10. Pull glove off, turning it inside out.

11. Take fingers of bare hand and tuck inside

remaining glove cuff Peel glove off inside
out and over previously removed glove.
Discard both gloves in receptacle

DOCUMENTATION
12. Record the specific procedure performed
and patient’s response and status.

REMARKS:
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CONFORME: STUDENTS SIGNATURE CLINICAL INSTRUCTOR