_____________ PERFORMANCE EVALUATION CRITERIA

SCALE DESCRIPTION INDICATORS

4 Very Good Student performs behaviors/tasks affecting the highest
level of performance: consistent, independent, effective
3 Good Student performs behaviors/tasks reflecting mastery of
performance with minimal supervision
2 Fair Student performs behaviors/tasks reflecting
development and movement toward mastery of
performance: with help or direct supervision in some
aspects
1 Needs Improvement Student performs behaviors/tasks reflecting beginning
level of performance; tasks not done properly majority
of the time but demonstrate understanding of concepts
involved with tasks.

INTRODUCTION

A tepid sponge bath involves the use of lukewarm water to reduce a patient's fever by dilating superficial
blood vessels, thus releasing heat and lowering body temperature. You may also use a tepid sponge bath to
lower systemic temperature when routine fever treatments fail. Guidelines no longer recommend tepid
sponge bath use for children because it may lead to extreme chilling and shock to an immature nervous system
and has little advantage over the use of oral antipyretics.

Equipment’s:

✓ Basin of tepid water, about 80° F to 93° F (26.7° C to 33.9° C)

✓ Bath (utility) thermometer
✓ Bath blanket
✓ Fluid-impermeable pad
✓ Washcloths
✓ Patient thermometer
✓ Towel
✓ Clean hospital gown (for patient)
✓ Vital signs monitoring equipment
✓ Optional: gloves, prescribed antipyretic, ice bag and cover, facility-approved disinfectant

PROCEDURE RATIONALE 4 3 2 1 REMARKS

ASSESSMENT

1. Assess the patient's condition. This information will

be used to assess the
patient's response to
treatment.
2. Obtain the patient's vital signs (temperature, This provides baseline
pulse, respirations, and blood pressure) to data for comparison
serve as baselines for comparison.
PLANNING

1. Inspect all equipment and supplies. If a Ensures that all

product is expired, is defective, or has equipment and
compromised integrity, remove it from supplies are prepared
patient use, label it as expired or defective, to enhance time

and report the expiration or defect as efficiency and are safe

directed by your facility. If needed, prepare to use on clients.
an ice bag and cover; the cover helps
prevents skin irritation and tissue damage.
2. Then place the bath thermometer in a basin The water
 and run water over it until the temperature temperature must be
reaches the high end of the tepid range (93° just right, neither too
F [33.9° C]) because the water will cool cold nor too hot.
during the sponge bath. Immerse the
washcloths in the tepid solution until they're
saturated.
IMPLEMENTATION
1. Verify the practitioner's order. This ensures that the
patient receives the
correct procedure
2. Review the patient's medication record for • Because it
recent administration of an antipyretic. If not does not work
administered recently, administer an immediately,
antipyretic, as ordered, 15 to 20 minutes it must be
before the sponge bath, following safe given sooner.
medication administration practices.
• To lower
temperature.
3. Gather and prepare the necessary Promotes organization
equipment. and efficiency
4. Perform hand hygiene. Stops the spread of
microorganisms
5. Confirm the patient's identity using at least Identify the correct
two patient identifiers. client to ensure an
accurate assessment
6. Provide privacy. This maintains the
client’s privacy and
minimizes
embarrassment.
7. Explain the procedure to the patient and Providing information
family (if appropriate), according to their to the client fosters
individual communication and learning cooperation and
needs. understanding
8. Ensure that the room is warm and free from To ensure that the
drafts. client is comfortable
during the procedure

9. Raise the patient's bed to waist level. To prevent back

strain
10. Perform hand hygiene. Stops the spread of
microorganisms
11. Put on gloves, as needed, to comply with Stops the spread of
standard precautions. microorganisms
12. Place a fluid-impermeable pad under the • To catch any
patient to catch any spills and a bath spills and
blanket on top of the patient for privacy. provide privacy
Then remove the patient's gown. Also • Remove top
remove the top bed linen to avoid getting it linen to avoid
wet. getting it wet
13. Place a covered ice bag on the patient's As the rest of the
head, if needed, to prevent the patient's body cools,
development of headache and nasal this avoids headaches
congestion as the rest of the patient's body and nasal congestion.
cools.
14. Wring out each washcloth before using it so This is to keep the
that the water doesn't drip and cause patient safe and the
patient discomfort. water from leaking.

15. Place moist washcloths over the patient's Accelerates cooling

 major superficial blood vessels in the
axillae, groin, and popliteal areas. Change
the washcloths as they become warm.
16. Bathe each of the patient's extremities To give the client
separately for 5 minutes. Then bathe the security, only the body
chest and abdomen for 5 minutes. Turn the part that will be
patient and then bathe the back and sponged one at a time
buttocks for 5 to 10 minutes. Keep the is exposed.
patient covered, except for the body part
you're sponging.
17. Pat each area dry using a towel after Rubbing increases cell
sponging. Avoid rubbing the patient's skin metabolism and
with the towel. produces heat.
18. Add warm water to the basin, as needed, To maintain the
checking the bath thermometer reading. desired water
temperature.
19. Monitor the patient's temperature, pulse, To ensure that patient
respirations, and blood pressure every 10 is stable.
minutes or as needed. Notify the
practitioner if the patient's temperature
doesn't fall within 30 minutes.
20. Observe the patient for chills, shivering, This must be noted
pallor, mottling, cyanosis of the lips or nail because it could signify
beds, or vital sign changes—especially a an emergency.
rapid, weak, or irregular pulse—because
such signs may indicate an emergency. If
any of these signs occur, discontinue the
bath, cover the patient lightly, and notify
the practitioner.
21. If no adverse effects occur, bathe the Client’s temperature
patient for at least 30 minutes or until the will continue to fall
patient's temperature reaches 1° F to 2° F naturally
(0.6° C to 1° C) above the desired level
because the temperature will continue to
fall naturally. Continue to monitor the
patient's temperature until it stabilizes.
22. After the sponge bath, ensure that the Ensures patient
patient is dry and comfortable. comfortability.
23. Dress the patient in a clean gown. Cover the Allowing your patient
patient lightly. to wear bulky clothes
or an unnecessary
amount of sheet
covering would only
raise his temperature.
24. Return the patient's bed to the lowest To prevent falls and
position. maintain patient safety

25. Discard used supplies in the appropriate Stops the spread of

receptacles. microorganisms
26. Remove and discard your gloves, if worn. Stops the spread of
microorganisms
27. Perform hand hygiene. Stops the spread of
microorganisms
If you'll be repeating the treatment, clean and disinfect the reusable equipment, according to the manufacturer's
instructions to prevent the spread of infection and store the equipment in the patient's room.
1. Perform hand hygiene. Stops the spread of
microorganisms
2. Obtain the patient's temperature, pulse, To determine the
respirations, and blood pressure 30 minutes treatment's
after the sponge bath to determine the effectiveness.
 treatment's effectiveness.
3. Perform hand hygiene. Stops the spread of
microorganisms
4. Document the procedure. To ensure that all data
needed is complete

Special Considerations
1. Consider covering the patient's trunk with a wet towel for 15 minutes to speed cooling. Resaturate the towel, as
needed.
2. Refrain from bathing the breasts of a postpartum patient because the nipples may become overly dry or develop
fissures.
3. Because temperatures can vary greatly among methods and anatomic sites, consistently use the same method
and site throughout the procedure, if possible.

Complications
Accelerated temperature reduction may provoke seizure activity.

DOCUMENTATION
1. Record the date, time, and duration of the To ensure data is
sponge bath; the temperature of the water; correct and complete
the patient's temperature, pulse,
respirations and blood pressure before,
during, and after the procedure; and the
patient's tolerance of the procedure.
2. Note any complications that arise, the To ensure data is
practitioner you notified, interventions you correct and complete
took, and the patient's response to the
interventions. Document teaching you
provided to the patient and family (if
applicable), their understanding of that
teaching, and any need for follow-up
teaching.
TOTAL /148

A (92-100) Student’s Signature: _____________________________

A- (84-91.99) Clinical Instructor’s Signature: _____________________
B (76-83.99)
B- (68-75.99)
C (60-67.99)
F (<60)

Reference:

Lippincott Nursing Procedures https://procedures-

lww-com.library.xu.edu.ph/lnp/home.do