TEPID SPONGE BATH

Materials:
Bath basin Wash cloth Bath blanket
Water (40⁰C) Bath thermometer Pt thermometer

CHECKLIST 1 2 3 4 5
1. Explain/inform the patient/family about the procedure.
2. Gather the necessary materials needed.
3. Provide privacy & make sure the room is warm & free from drafts.
4. Do hand hygiene.
5. Position the patient comfortably on bed.
6. Assess the patient's condition to measure patient's tolerance/ capability
to undergo procedure
7. Fill the basin with water.
8. Drape the patient properly & expose only the body part to be sponged to
prevent patient from shivering
9. Don clean gloves
10. Immerse the face towel in the water until saturated & wring out the face
towel before sponging the patient to avoid excessive wetness
11. Apply wet cloths to axilla & groin.
12. Pat patient's face gently with the face towel.
13. Sponge patient's face down to the extremities.
14. Bathe each extremity separately.
15. Sponge the chest & abdomen.
16. Turn the patient to the side & sponge his lower back & buttocks.
17. Pat each area to dry after sponging & avoid rubbing with the towel.
18. Put on a clean, fresh laundered hospital gown & cover him/her lightly.
19. Make sure the patient is dry & comfortable.
20. Dispose liquids & clean/discard soiled materials according to Waste
21. Management Protocol.
22. Do hand hygiene.
23. Reassess patient's condition 30 minutes after the bath & refer
accordingly to determine the effectiveness of the procedure
24. Document the date, time & duration of the bath & the patient's response
to the procedure.

TOTAL SCORE = ______ = ______ %

24
 HANDWASHING (WHO)

Materials:
Liquid hand soap paper towel Yellow trash bag

CHECKLIST 1 2 3 4 5
1. Gather the necessary supplies. Stand in front of the sink. Do not allow your
clothing to touch the sink during the washing procedure.
2. Remove jewelry, if possible, & secure in a safe place. A plain wedding
band may remain in place.
3. Turn on water & adjust force. Regulate the temperature until the water is
warm.
4. Wet the hands & wrist area. Keep hands lower than elbows to allow water
to flow toward fingertips.
5. Use about 1 teaspoon liquid soap from dispenser & lather thoroughly.
Cover all areas of hands with the soap product.
6. Rub hands Palm to palm
7. Right palm over left dorsum with interlaced fingers and vice versa.
8. Rub palm with fingers interlaced.
9. Rub back of fingers to opposite palms with finger interlocked
10. Rotational rubbing of left thumb clasped in right palm and vice versa
11. Rotational rubbing backwards and forwards with clasped fingers of right
hand in left palm and vice versa
12. Rinse hands with water thoroughly with water flowing toward fingertips.
13. Pat hands dry with a paper towel, beginning with the fingers & moving
upward toward forearms, & discard it immediately.
14. Use another clean towel to turn off the faucet. Discard towel immediately
without touching other clean hand.

TOTAL SCORE = ______ = ______ %

14
 ASSESSING TEMPERATURE (AXILLA)

Materials:
Thermometer dry tissue clean gloves cotton ball with alcohol Yellow trash bag

CHECKLIST 1 2 3 4 5
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection
prevention procedures.
5. Provided for client privacy.
6. Placed the client in the appropriate position.
7. Wear gloves.
8. Expose axilla and pat dry if very moist.
9. Wipe the thermometer using cotton moistened with alcohol from the tip to
base and discard the cotton ball in the appropriate receptacle.
10. Placed the tip of the thermometer in the center of the axilla.
11. Waited the appropriate amount of time.
12. Removed the thermometer and wiped with a cotton moistened with alcohol
from the base to tip and discard the cotton ball in the appropriate receptacle.
13. If gloves were applied, removed and discarded gloves. Performed hand
hygiene.
14. Read the temperature and recorded it on a worksheet.
15. Washed the thermometer if necessary and returned it to storage location
16. Document the temperature in the client record.

TOTAL SCORE = ______ = ______ %

16
 ASSESSING PULSE RATE (RADIAL PULSE)

Materials:
watch with second hand

CHECKLIST 1 2 3 4 5
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be used.
3. Performed hand hygiene and observed other appropriate infection
prevention procedures.
4. Provided for client privacy.
5. Selected pulse point.
6. Assisted client to a comfortable resting position. When the radial pulse is
assessed, with the palm facing downward, the client’s arm can rest
alongside the body or the forearm can rest at a 90-degree angle across the
chest. For the client who can sit, the forearm can rest across the thigh, with
the palm of the hand facing downward or inward.
7. Palpated and counted the pulse. Placed two or three middle fingertips lightly
and squarely over pulse point. Count for 15 seconds and multiply by 4.
Record the pulse in beats per minute on your worksheet. If taking a client’s
pulse for the first time, when obtaining baseline data, or if the pulse is
irregular, count for a full minute. If an irregular pulse is found, also take the
apical pulse.
8. Assessed pulse rhythm and volume.
9. Document the pulse rate, rhythm, and volume and your actions in the client
record.
TOTAL SCORE = ______ = ______ %
9
 ASSESSING RESPIRATORY RATE

Materials:
watch with second hand

CHECKLIST 1 2 3 4 5
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection
prevention procedures.
5. Provided for client privacy.
6. Observed or palpated and counted respiratory rate. Count the respiratory
rate for 30 seconds if the respirations are regular. Count for 60 seconds if
they are irregular. An inhalation and an exhalation count as one respiration.
7. Observed depth, rhythm, and character of respirations.
8. Document the respiratory rate, depth, rhythm, and character on the
appropriate record.
TOTAL SCORE = ______ = ______ %
8
 ASSESSING BLOOD PRESSURE
Materials:
Sphygmomanometer stethoscope cotton balls with alcohol (antiseptic wipe) Yellow trash bag

CHECKLIST 1 2 3 4 5
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection
prevention procedures.
5. Provided for client privacy.
6. Positioned the client appropriately.
7. Wrapped the deflated cuff evenly around the upper arm. Applied the center
of the bladder directly over the brachial artery.
8. Performed a preliminary palpatory determination of systolic pressure, if
client’s initial examination.
a. Palpated the brachial artery with the fingertips.
b. Pumped up the cuff until brachial pulse was no longer felt.
c. Released the pressure completely in the cuff, and waited 1 to 2 minutes
before making further measurements.
9. Positioned stethoscope appropriately.
a. Cleanse the earpieces with antiseptic wipe.
b. Inserted the ear attachments of the stethoscope in ears so that they
tilted slightly forward.
c. Ensured that the stethoscope hung freely from the ears to the
diaphragm.
d. Placed the bell side of the amplifier of the stethoscope over the brachial
pulse site.
e. Placed the stethoscope directly on the skin, not on clothing over the site.
10. Auscultated client’s blood pressure.
a. Pumped up the cuff until the sphygmomanometer read 30 mm Hg
above the point where the brachial pulse disappeared.
b. Released the valve cuff carefully so that the pressure decreased at rate
of 2 to 3 mm Hg per second.
c. Identified the manometer reading at Korotkoff phases 1, 4, and 5 as
pressure fell.
d. Deflated the cuff rapidly and completely.
e. Waited 1 to 2 minutes before making further determinations.
f. Repeated above steps to confirm the accuracy of the reading.
11. Removed the cuff from the client’s arm.
12. Wiped the cuff with an approved disinfectant.
13. Document and report pertinent assessment data according to agency policy.

TOTAL SCORE = ______ = ______ %

13
 PREPARING STERILE FIELD
Materials:
Sterile wrap (2 pcs) kidney basin betadine 10cc syringe Sterile Gauze 4inx4in Yellow trash bag

CHECKLIST 1 2 3 4 5
PLANNING
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection
prevention procedures.
5. Provided for client privacy if appropriate.
TO OPEN A WRAPPED PACKAGE ON A SURFACE:
6. Placed the package in the work area so that the top flap opened away from
self.
7. Reached around the package and pinched the top of the flap on the outside
of the wrapper between the thumb and index finger. Pull the flap open,
laying it flat on the far surface.
8. Repeated for side flaps using right hand for right flap and left hand for left
flap.
9. Pulled the fourth flap towards self by grasping the corner that was turned
down.
ESTABLISHED A STERILE FIELD BY USING A DRAPE.
10. Opened package containing drape as described above.
11. Plucked corner of the drape that is folded back on the top with one hand.
12. Lifted drape out of its cover and allowed it to open freely without touching
any objects.
13. Picked up another corner of the drape, holding it away from body, and
touching only the same side of the drape as the first hand
14. Laid drape on a clean and dry surface placing the bottom furthest from self.
ADDED COMMERCIALLY PACKAGED SUPPLIES TO A STERILE FIELD.
15. Opened each package as previously described.
16. Held package 15 cm above field, and allow contents to drop on the field,
avoiding the 2.5 cm edge.
ADDED SOLUTION TO A STERILE BOWL.
17. Obtained exact amount of solution if possible.
18. Read the label three times to ensure it was the correct solution and
concentration. Wiped outside of the bottle with a damp towel to remove any
large particles that could have fallen into the bowl or field.
19. Removed lid or cap from bottle and inverted lid before placing it on surface
that was not sterile.
20. Held bottle so label was against palm of the hand.
21. Held bottle of fluid at a height of 10 to 15 cm over the bowl and to the side of
the sterile field.
22. Poured solution gently to avoid splashing liquid.
23. Tilted neck of bottle back to vertical quickly when done pouring.
24. Replaced the lid securely and wrote the date and time of opening on the
label if the bottle was going to be used again.

TOTAL SCORE = ______ = ______ %

24
 DONNING AND REMOVING STERILE GLOVES (OPEN GLOVING)

Materials:
sterile gloves Yellow trash bag

CHECKLIST 1 2 3 4 5
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection
prevention
procedures.
5. Provided for client privacy if appropriate.
6. Opened the package of sterile gloves.
7. Put the first glove on the dominant hand.
8. Grasped the glove for the dominant hand by the folded cuff edge with the
thumb and first finger of the nondominant hand.
9. Inserted the dominant hand keeping the thumb of the inserted hand against
the palm.
10. Put the second glove on the nondominant hand.
11. Picked up the second glove with the sterile gloved hand, inserting the
gloved fingers under the cuff and holding the gloved thumb close to the gloved
palm.
12. Pulled on the second glove holding the thumb of the first gloved hand as far
as possible from the palm.
13. Adjusted the gloves, pulling up by sliding fingers under the cuffs.
14. Removed soiled gloves inside out.

15. Performed hand hygiene

TOTAL SCORE = ______ = ______ %

15
 FEMALE CATHETERIZATION (Indwelling)

Materials:
Cherry balls soaked in Betadine Sharps bin Sterile water
Picking forceps Clean Gloves 10 cc syringe
Lubricating jelly Sterile Gloves Plaster
Waterproof drape Foley Catheter Bandage scissors
Urobag Yellow trash bag

CHECKLIST 1 2 3 4 5
1. Introduced self and verified the client’s identity.
2. Explained procedure to client and discussed how results will be used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observe other appropriate infection control
procedures.
5. Provided for client privacy.
Prepared equipment:
6. Opened 10cc syringe and filled with 10cc sterile water
7. Opened drainage bag package and placed end of tubing within reach.
8. Opened Sterile Catheter:
a. Opened outer package of sterile catheter half way.
b. Opened top part of inner package and exposed the balloon and urine drainage
tube, making sure not to touch with unsterile hand the part of inner package
with the catheter tube.
9. Pretested the balloon applying agency policy and/or manufacturer
recommendations.
a. Attached syringe.
If using needle-access catheter:
i. Held inflation valve between two fingers of nondominant hand.
ii. Using dominant hand, insert needle parallel to the balloon tube,
making sure not to injure self.
b. Injected 10cc of sterile water.
c. Observed for leaks or any damages in the balloon.
d. If none, aspirated sterile water.
e. Removed syringe and recap.
If using syringe with needle,
i. Recap safely using one-hand scoop method. Do not use other hand to
hold cap in the process.
f. Placed syringe within reach.
10. Attach end of tubing of the drainage bag at the urine drainage port of the catheter
11. Prepare Sterile field using the inner package of sterile gloves:
a. Opened sterile gloves.
b. Poured lubricating jelly
Prepared client:
12. Placed client in appropriate position: supine with knees flexed, feet about 2 feet
apart, and hips slightly, externally rotated.
13. Draped all areas except perineum.
14. Established adequate lighting
 15. Stood on client’s right if nurse was right-handed and on left if nurse was
left-handed
16. Placed a waterproof drape under the buttocks without contaminating the center
of the drape.
17. Open container of cherry balls soaked in betadine
18. Don Clean Gloves
19. Cleansed the meatus.
a. With thumb and one finger of nondominant hand, spread labia and identified
meatus. Did not allow the labia to close over cleaned meatus.
b. Use the dominant hand to handle picking forceps.
c. Pick up a cherry ball using picking forceps.
d. Cleansed in anteroposterior direction using one cherry ball for each wipe.
a. Wipe the farther labia and discard cherry ball.
b. Wipe the nearer labia and discard cherry ball.
c. Last wipe over the meatus and discard cherry ball
2. Remove clean gloves
Inserted catheter:
20. Don Sterile gloves
21. Inserted the catheter.
a. Removed catheter from package holding the sterile catheter tube.
b. Grasped catheter firmly 2 to 3 in. from tip.
c. Lubricated the tip (1-2 inches)
d. Asked client to take a slow deep breath and inserted catheter approximately
2 to 3 in. as client exhaled.
e. After urine begins to flow through it, advanced catheter another 2-3 in.
farther.
f. If catheter became contaminated by touching labia or other tissue before
entering meatus, performed catheterization with a new sterile catheter.
g. Held catheter with nondominant hand.
22. Inflated retention balloon with designated volume.
a. Without releasing catheter, held inflation valve between two fingers of
nondominant hand while nurse inflated with dominant hand.
b. If patient complains pain, it could indicate the catheter is not in the bladder.
Deflate the balloon and insert the catheter further into the bladder. ALWAYS
ensure urine is flowing before inflating the balloon.
c. Pulled gently on catheter until resistance was felt.
23. Secured an indwelling catheter to client’s inner thigh.
24. Secured collecting tubing and hung bag below bladder level.
25. Wiped the perineal area of any remaining antiseptic or lubricant
26. Returned client to comfortable position. Instructed client on positioning and
moving with catheter in place.
27. Discarded all used supplies in appropriate receptacles.
28. Removed and discarded gloves.
29. Performed hand hygiene.
30. Documented procedure and all relevant information

TOTAL SCORE = ______ = ______ %

30
 MALE CATHETERIZATION (Indwelling)

Materials:
Cherry balls soaked in Betadine Sharps bin Sterile water
Picking forceps Clean Gloves 10 cc syringe
Lubricating jelly Sterile Gloves Plaster
Waterproof drape Foley Catheter Bandage scissors
Urobag Yellow trash bag

CHECKLIST 1 2 3 4 5
1. Introduced self and verified the client’s identity.
2. Explained procedure to client and discussed how results will be used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observe other appropriate infection control
procedures.
5. Provided for client privacy.
Prepared equipment:
6. Opened 10cc syringe and filled with 10cc sterile water
7. Opened drainage bag package and placed end of tubing within reach.
8. Opened Sterile Catheter:
a. Opened outer package of sterile catheter half way.
b. Opened top part of inner package and exposed the balloon and urine drainage
tube, making sure not to touch with unsterile hand the part of inner package
with the catheter tube.
9. Pretested the balloon applying agency policy and/or manufacturer
recommendations.
a. Attached syringe.
If using needle-access catheter:
i. Held inflation valve between two fingers of nondominant hand.
ii. Using dominant hand, insert needle parallel to the balloon tube,
making sure not to injure self.
c. Injected 10cc of sterile water.
d. Observed for leaks or any damages in the balloon.
e. If none, aspirated sterile water.
f. Removed syringe and recap.
If using syringe with needle,
i. Recap safely using one-hand scoop method. Do not use other hand to
hold cap in the process.
g. Placed syringe within reach.
10. Attach end of tubing of the drainage bag at the urine drainage port of the catheter
11. Prepare Sterile field using the inner package of sterile gloves:
h. Opened sterile gloves.
i. Poured lubricating jelly
Prepared client:
12. Placed client in appropriate position: supine, thighs slightly abducted or apart
13. Draped all areas except perineum.
14. Established adequate lighting
15. Stood on client’s right if nurse was right-handed and on left if nurse was
left-handed
16. Placed a waterproof drape under the penis without contaminating the center of
the drape.
17. Applied sterile gloves.
18. Cleansed the meatus.
a. Grasped penis just below glans with nondominant hand. Retracted foreskin if
necessary.
b. Using dominant hand, picked up a cherry ball. Cleansed in circular moving from
the meatus down the glans of the penis. Used a new cherry ball each time for
three more wipes.
c. Discarded each cherry ball after one use.
Inserted catheter:
19. Inserted the catheter.
a. Removed catheter from package holding the sterile catheter tube.
b. Lubricated the tip (6-7 inches)
c. Held catheter an inch or two from the tip.
d. Ask the patient to take deep breaths.
e. Advance the catheter to the bifurcation or “Y” level of the ports. Do not use
force to introduce the catheter.
f. If the catheter resists entry, ask patient to breathe deeply and rotate catheter
slightly.
g. Hold the catheter securely at the meatus with your nondominant hand
20. Inflated retention balloon with designated volume.
a. Without releasing catheter, held inflation valve between two fingers of
nondominant hand while nurse inflated with dominant hand. (ALWAYS ensure
urine is flowing before inflating the balloon.)
b. Replace foreskin over catheter
c. Lower penis.
d. Pulled gently on catheter until resistance was felt.
21. Secured an indwelling catheter to client’s abdomen or anterior thigh.
22. Secured collecting tubing and hung bag below bladder level.
23. Wiped the perineal area of any remaining antiseptic or lubricant. Replaced
foreskin if retracted earlier.
24. Returned client to comfortable position. Instructed client on positioning and
moving with catheter in place.
25. Discarded all used supplies in appropriate receptacles.
26. Removed and discarded gloves.
27. Performed hand hygiene.
28. Documented procedure and all relevant information

TOTAL SCORE = ______ = ______ %

28
 ONE-HAND SCOOP TECHNIQUE

Materials:
Syringe with Needle Sharps bin Kelly Forceps Clean gloves (worn prior to procedure)
Yellow trash bag

CHECKLIST 1 2 3 4 5
One-Hand Scoop to recap needle:
1. Leave the needle cap on the surface
2. Keep non-dominant hand at the side.
3. Using Dominant hand, hold the barrel of the syringe
4. Guide the sharp used needle tip into the cap using only one hand
(dominant hand)
5. Recap the bulk of the length of the needle by moving the syringe forward -
this allows the needle to enter the cap in a scooping movement
6. Lift the needle and syringe vertically
7. Once the tip is covered:
1. use the other hand to affix the cap into place, or
2. use a hard surface to snap the cap into place without using the other
hand
8. Discard the needle into a sharps bin following the facility policy.
9. Removed and discarded gloves.
10. Performed hand hygiene.

TOTAL SCORE = ______ = ______ %

10
 ADMINISTERING INTRADERMAL INJECTION
Materials:
Cotton balls in container Sterile Water Clean gloves Bandage scissors
Alcohol Tuberculin syringe Plaster Withdrawal Needle
Ampule (Vit. C or PCM) Medication Tray
Yellow trash bag

CHECKLIST 1 2 3 4 5
1. Check physicians order.
2. Assemble equipment
3. Perform hand hygiene.
4. Prepare medication. If necessary, withdraw medication from ampule or vial.
5. Introduce yourself.
6. Identify the patient carefully. There are three ways to do this:
a. Check the name of the patient’s identification badge.
b. Ask the patient his or her name.
c. Verify the patient’s identification with the staff member who knows the patient.
7. Explain procedure to patient.
8. Locate site of choice. Ensure that area is not tender and is free of lumps or nodules.
a. Select area on inner aspect of forearm that is not heavily pigmented or covered with
hair.
b. Upper chest or upper back beneath the scapulae are also sites for intradermal
injections.
9. Don disposable gloves.
10. Clean area around injection site. Use a firm circular motion while moving outward from
the injection site. Allow area to dry.
11. Remove needle cap with non-dominant hand by pulling it straight off.
12. Use non-dominant hand to spread skin taut over injection site.
13. Place needle almost flat against patient’s skin, bevel side up. Insert needle into skin so
that point of the needle can be seen through skin. Insert needle only about 1/8 inch with
the entire bevel under the skin.
14. Slowly inject agent while watching for a small wheal or blister to appear. If none appears,
withdraw needle to ensure bevel is intradermal tissue.
15. Once the agent has been injected, withdraw needle quickly at the same angle it was
inserted.
16. Do not massage area after removing needle. Tell the patient not to rub or scratch the
side.
17. Do not recap used needle. Discard needle and syringe in appropriate receptacle.
18. Assist patient to a position of comfort.
19. Remove gloves, and dispose of them properly.
20. Do after care.
21. Perform hand hygiene.
22. Evaluate patient response to medication within an appropriate time frame.
23. Chart administration of medication, including the site of administration and if there are
any reactions (usually at 24 to 72 hours periods).
24. Observe the area for signs of a reaction at ordered intervals,
TOTAL SCORE = ______ = ______ %
24
 ADMINISTERING SUBCUTANEOUS INJECTION
Materials:
Cotton balls in Medication Tray Syringe 3cc Plaster Withdrawal Needle
container Sterile Water Clean gloves Bandage scissors
Alcohol Yellow trash bag

CHECKLIST 1 2 3 4 5
1. Check physicians order.
2. Assemble equipment
3. Perform hand hygiene.
4. Prepare medication. If necessary, withdraw medication from ampule or vial.
5. Introduce yourself.
6. Identify the patient carefully. There are three ways to do this:
a. Check the name of the patient’s identification badge.
b. Ask the patient his or her name.
c. Verify the patient’s identification with the staff member who knows the patient.
7. Explain procedure to patient.
8. Locate site of choice. Ensure that area is not tender and is free of lumps or nodules.
9. Have patient assume a position appropriate for the most commonly used sites.
a. Outer aspects of upper arm- Patients arm should be relaxed and at side of the body.
b. Anterior thighs- Patient may sit or lie with leg relax.
c. Abdomen- Patient may lie in a semi recumbent position.
10. Don disposable gloves.
11. Clean area around injection site with an antimicrobial swab. Use a firm circular motion
while moving outward from the injection site. Allow area to dry.
12. Remove needle cap with non-dominant hand, pulling it straight off.
13. Grasp and bunch area surrounding injection site or spread skin at site.
14. Hold syringe in dominant hand between thumb and forefinger. Inject needle quickly at an
angle of 45 to 90 degrees, depending on amount and turgor of tissue and length of
needle.
15. After needle is in place, release tissue. If you have a large skin fold pinched up, ensure that
the needle stays in place as the skin is released. Immediately move your non-dominant
hand to steady the lower end of the syringe. Slide your dominant hand to the tip of the
barrel.
16. Aspirate, if recommended, by pulling back gently of syringe plunger to determine whether
needle is in blood vessel. (According to the CDC (2009) this procedure is not required).
17. If blood appears, the needle should be withdrawn, the medication syringe and needle
discarded, and a new syringe with medication prepared. Do not aspirate when giving
insulin or heparin.
18. If no blood appears, inject solution slowly.
19. Withdraw needle quickly at the same angle at which it was inserted.
20. Apply gentle pressure. Do not massage the site. Apply a small bandage if needed.
21. Do not recap used needle. Discard needle and syringe in appropriate receptacle.
22. Assist patient to a position of comfort.
23. Remove gloves, and dispose of them properly.
24. Do after care.
25. Perform hand hygiene.
26. Evaluate patient response to medication within an appropriate time frame.
27. Chart administration of medication, including the site of administration and if there are
any reactions.
TOTAL SCORE = ______ = ______ %
27
 ADMINISTERING INTRAMUSCULAR INJECTION
Materials:
Cotton balls in Medication Tray Syringe 3cc Plaster Withdrawal Needle
container Sterile Water Clean gloves Bandage scissors
Alcohol Yellow trash bag

CHECKLIST 1 2 3 4 5
1. Check physicians order.
2. Assemble equipment
3. Perform hand hygiene.
4. Prepare medication. If necessary, withdraw medication from ampule or vial.
5. Introduce yourself.
6. Identify the patient carefully. There are three ways to do this:
a. Check the name of the patient’s identification badge.
b. Ask the patient his or her name.
c. Verify the patient’s identification with the staff member who knows the patient.
7. Explain procedure to patient.
8. Locate site of choice. Ensure that area is not tender and is free of lumps or nodules.
9. Have patient assume a position appropriate for the most commonly used sites.
a. Ventrogluteal- Patient may lie on back or side with hip and knee flexed.
b. Vastuslateralis- Patient may lie on the back or may assume a sitting position.
c. Deltoid- patient may sit or lie with arm relaxed.
d. Dorsogluteal- Patient may lie prone with toes pointing inward or on side with upper
leg flexed and place in front of lower leg.
10. Don disposable gloves.
11. Clean area around injection site with an antimicrobial swab. Use a firm circular motion
while moving outward from the injection site. Allow area to dry.
12. Remove needle cap with non-dominant hand, pulling it straight off.
13. Displace skin in a Z-track manner by pulling to one side or spread skin at the site using
your non-dominant hand.
14. Hold syringe in your dominant hand between thumb and forefinger. Quickly dart needle
into the tissue at the 90-degree angle.
15. As soon as needle is in place, move your non-dominant hand to hold lower end of
syringe. Slide your dominant hand to tip of barrel.
16. Aspirate, if recommended, by pulling back gently of syringe plunger to determine
whether needle is in blood vessel. (According to the CDC (2009) this procedure is not
required).
17. If blood appears, the needle should be withdrawn, the medication syringe and needle
discarded, and a new syringe with medication prepared. Do not aspirate when giving
insulin or heparin.
18. If no blood appears, inject solution slowly.
19. Withdraw needle quickly at the same angle at which it was inserted
20. Replace displace tissue if Z-track technique was use.
21. Apply gentle pressure. Do not massage the site. Apply a small bandage if needed.
22. Do not recap used needle. Discard needle and syringe in appropriate receptacle.
23. Assist patient to a position of comfort.
24. Remove gloves and dispose of them properly.
25. Do after care.
26. Perform hand hygiene.
27. Evaluate patient response to medication within an appropriate time frame.
28. Chart administration of medication, including the site of administration and if there are
any reactions.
TOTAL SCORE = ______ = ______ %

28
 WOUND CARE
Materials:
Yellow trash PNSS cherry balls sterile pack Forceps plaster
bag cherry balls soaked in old wound kidney basin sterile gloves 5 pcs gauze
clean gloves betadine dressing

CHECKLIST 1 2 3 4 5
1. Review the medical orders for wound care or the nursing plan of care related to
wound care.
2. Gather the necessary supplies and bring to the bedside stand or overbed table.
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around bed and close door to room if possible.
6. Explain what you are going to do and why you are going to do it to the patient.
7. Assess the patient for possible need for nonpharmacologic pain-reducing
interventions or analgesic medication before wound care dressing change.
Administer appropriate prescribed analgesic. Allow enough time for analgesic to
achieve its effectiveness.
8. Place a waste receptacle or bag at a convenient location for use during the
procedure.
9. Adjust bed to comfortable working height, usually elbow height of the caregiver
10. Assist the patient to a comfortable position that provides easy access to the wound
area. Use the bath blanket to cover any exposed area other than the wound. Place a
waterproof pad under the wound site.
11. Check the position of drains, tubes, or other adjuncts before removing the dressing
12. Put on clean, disposable gloves
13. Loosen tape on the old dressings. If necessary, use an adhesive remover or normal
saline to help get the tape off.
14. Carefully remove the soiled dressings. If any part of the dressing sticks to the
underlying skin, use small amounts of sterile saline to help loosen and remove
15. After removing the dressing, note the presence, amount, type, color, and odor of
any drainage on the dressings.
16. Place soiled dressings in the appropriate waste receptacle.
17. Remove your gloves and dispose of them in an appropriate waste receptacle
18. Inspect the wound site for size, appearance, and drainage. Assess if any pain is
present. Check the status of sutures, adhesive closure strips, staples, and drains or
tubes, if present. Note any problems to include in your documentation.
19. Using sterile technique, prepare a sterile work area and open the needed supplies
20. Open the sterile cleaning solution. Depending on the amount of cleaning needed,
the solution might be poured directly over gauze sponges over a container for small
cleaning jobs, or into a basin for more complex or larger cleaning.
21. Put on sterile gloves
22. Clean the wound with gauze dampened with normal saline.
a. Clean the wound from top to bottom and from the center to the outside. Following
this pattern, use new gauze for each wipe, placing the used gauze in the waste
receptacle.
b. If a drain is in use at the wound location, clean around the drain from center to
outside
23. Once the wound is cleaned, dry the area using a gauze sponge in the same manner.
24. Apply betadine, ointment or antiseptic medications, as ordered, in the same
manner.
25. Apply a layers of dry, sterile dressing over the wound. Forceps may be used to apply
the dressing.
a. 1st layer serves as a wick for drainage
b. 2nd layer is for increased absorption of drainage
c. 3rd layer act as additional protection for the wound against microorganism
26. Remove and discard gloves.
27. Apply tape
28. After securing the dressing, label dressing with date and time.
29. Remove all remaining equipment; place the patient in a comfortable position, with
side rails up and bed in the lowest position.
30. Perform hand hygiene.
31. Check all wound dressings every shift. More frequent checks may be needed if the
wound is more complex or dressings become saturated quickly.
TOTAL SCORE = ______ = ______ %
31
 DONNING AND REMOVING STERILE GLOVES (OPEN GLOVING)

Materials:
Sterile gloves Yellow trash bag

CHECKLIST 1 2 3 4 5
DONNING STERILE GLOVES
1. Perform hand hygiene.
2. Identify the patient. Explain the procedure to the patient.
3. Check that the sterile glove package is dry and unopened. Also note expiration date,
making sure that the date is still valid.
4. Place sterile glove package on clean, dry surface at or above your waist.
5. Open the outside wrapper by carefully peeling the top layer back. Remove inner
package, handling only the outside of it.
6. Place the inner package on the work surface with the side labeled ‘cuff end’ closest to
the body.
7. Carefully open the inner package. Fold open the top flap, then the bottom and sides.
Take care not to touch the inner surface of the package or the gloves.
8. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the
glove for the dominant hand, touching only the exposed inside of the glove.
9. Keeping the hands above the waistline, lift and hold the glove up and off the inner
package with fingers down. Be careful it does not touch any unsterile object.
10. Carefully insert dominant hand palm up into glove and pull glove on. Leave the cuff
folded until the opposite hand is gloved.
11. Hold the thumb of the gloved hand outward. Place the fingers of the gloved hand inside
the cuff of the remaining glove. Lift it from the wrapper, taking care not to touch
anything with the gloves or hands.
12. Carefully insert nondominant hand into glove. Pull the glove on, taking care that the
skin does not touch any of the outer surfaces of the gloves.
13. Slide the fingers of one hand under the cuff of the other and fully extend the cuff down
the arm, touching only the sterile outside of the glove. Repeat for the remaining hand.
14. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile
areas
15. Continue with procedure as indicated
REMOVING SOILED GLOVES
16. Use dominant hand to grasp the opposite glove near cuff end on the outside exposed
area. Remove it by pulling it off, inverting it as it is pulled, keeping the contaminated
area on the inside. Hold the removed glove in the remaining gloved hand
17. Slide fingers of ungloved hand inside the remaining glove cuff. Take care to avoid
touching the outside surface of the glove. Remove it by pulling it off, inverting it as it is
pulled, keeping the contaminated area on the inside, and securing the first glove inside
the second.
18. Discard gloves in appropriate container. Remove additional PPE, if used. Perform hand
hygiene
TOTAL SCORE = ______ = ______ %
18
 BLOOD TRANSFUSION

Materials:
Blood bag blood set Yellow trash bag IV Main line PNSS clean gloves

CHECKLIST 1 2 3 4 5
1. Performed pre administration protocol:
1.1. Obtained blood component following agency protocol.
1.2. Checked blood bag for signs of contamination and presence of leaks.
1.3. Compared verbally; correctly verified patient, blood product, and type
with another qualified person before initiating transfusion.
1.3.1. identifies patient using at least two identifiers.
1.3.2. Matched transfusion record number and patient’s ID number.
1.3.3. Ensured patient name is correct on all documents
1.3.4. Checked unit number on blood bag with blood bank, checked
expiration date and time.
1.3.5. Ensure blood type matches transfusion record and blood bag
1.3.6. Checked that patient’s blood type and Rh type are compatible with
donor’s
1.3.7. Checked expiration date and time on unit of blood.
1.3.8. Check patient’s ID information with blood unit label, did not
administer if patient has no ID bracelet.
1.3.9. Verified patient and unit identification record process properly.
1.4. Reviewed purpose of transfusion, asked patient to report any changes he
or she may feel during the transfusion.
1.5. Had patient empty urine drainage collection container or applied gloves
and emptied for him or her
2. Administered transfusion:
2.1. Performed hand hygiene, applied gloves, re-inspected blood product for
leakage or unusual appearance.
2.2. Opened Y-tubing blood administration set, used multiset if needed.
2.3. Set all clamps to off position.
2.4. Spiked normal saline IV bag with spike, hung bag on pole, primed tubing,
opened upper clamp on saline side of tubing, squeezed drip chamber
until fluid covered filter and appropriate amount of drip chamber.
2.5. Maintained clamp on blood product side of tubing in off position, opened
common tubing clamp, closed clamp when tubing was filled with saline,
maintained protective sterile cap on tubing connector.
2.6. Prepared blood component for administration, agitated blood unit bag,
removed covering from access port, spiked unit with other Y connection,
closed saline clamp, opened blood unit clamp, primed tubing with blood,
ensured residual air was removed.
2.7. Maintained asepsis, attached primed tubing to patient’s VAD, connected
primed blood administration tubing to patient’s VAD.
 2.8. Opened tubing clamp, regulated blood flow properly.
2.9. Monitored patient’s vital signs at the appropriate times.
2.10. Regulated rate appropriately if there was no transfusion reaction, checked
drop factor for the blood tubing.
2.11. Cleared IV line with saline, discarded blood bag appropriately, maintained
patency when consecutive units were ordered.
2.12. Disposed of all supplies appropriately, removed gloves, performed hand
hygiene.
3. Evaluate for transfusion reaction. If no blood transfusion reaction,
increase the rate to 25-30 drops or according to hospital policy
TOTAL SCORE = ______ = ______ %
28
 ESSENTIAL NEWBORN CARE
Materials: Yellow trash bag
eye ointment BCG vaccine 0.05 ml extra linen newborn clothes kidney basin
vit K 01. Ml rectal thermometer bonnet mittens and booties cord clamp
hepatitis B 0.5 ml tape measure newborn diaper ID Badge Kelly forcep

CHECKLIST 1 2 3 4 5
PREPARING FOR DELIVERY
1. Checked temperature in DR area to be 25-28 °Celsius; eliminated air draft.
2. Removed all jewelry then washed hands thoroughly
3. Prepared newborn resuscitation area and checked that resuscitation equipment are
clean and functional
4. Prepared materials for routine newborn procedures
CROWNING
5. Don 2 sterile gloves.
FIRST 30 SECONDS AFTER DELIVERY
6. Perform thorough drying and continued for 30 seconds, starting from the face and head,
going down to the trunk and extremities while performing a quick check for breathing.
1 - 3 MINUTES
7. Removed the wet cloth and replace with clean dry linen
8. Placed baby in skin-to-skin contact on the mother’s abdomen or chest.
9. Covered baby’s head with a bonnet.
10. Remove 1st gloves
11. Palpated umbilical cord to check for pulsations.
12. Once palpation has ceased, clamped cord using the plastic clamp 2 cm from the base.
13. With dominant hand, hold cord clamp and with non-dominant hand, milk cord away
from base.
14. Using dominant hand, clamp Kelly forceps 5 cm from base
15. Cut cord close to cord clamp, in between cord clamp and Kelly forceps
16. Advised mother to observe for feeding cues and cited examples of feeding cues,
instructed her on positioning and attachment.
17. Apply ID Badge
AFTER 60 - 90 MINUTES SKIN-SKIN CONTACT
18. Weigh baby fast and accurately
19. Check rectal temperature
20. Obtain Head Circumference, Chest Circumference, Abdominal Circumference and
Mid-Arm circumference
21. Apply newborn diaper
22. Apply newborn clothes (do not close front for skin-to-skin contact)
23. Apply mittens and booties
24. Apply eye ointment from inner to outer canthus starting from farther eye
25. Apply injections: BCG (Right deltoid ID), Hep B (Right Vastus lateralis IM), Vit K (Left
Vastus lateralis IM)
26. Position of comfort
27. Observe for unusuality
28. Document
TOTAL SCORE = ______ = ______ %
28
 ASSESSING THE RESPIRATORY SYSTEM
Materials: Yellow trash bag
Gloves Stethoscope Light source Mask Skin marker Metric ruler

CHECKLIST 1 2 3 4 5
1. Gather all equipment.
2. Perform Hand hygiene and explain procedure to patient
3. Provide privacy and expose only the part to be examined.
INSPECTION
4. Anterior/Posterior/Lateral. Compare side to side. Work apex to base
5. Assess respiratory rate and rhythm, depth, symmetry for chest movement
6. Assess AP ratio, costal angle, spinal deformities muscles for breathing and condition of
skin
PALPATION
7. Anterior/Posterior/Lateral. Compare side to side. Work apex to base
8. Palpate the trachea.
9. Palpate chest for tenderness and sensation.
10. Palpate the chest for crepitus and other abnormalities.
Crepitus- Use your fingers and follow the appropriate sequence when palpating. Note
if there is a crackling sensation (like bones or hairs rubbing against each other) as you
palpate.
11. Assess for tactile fremitus. Use the ball or ulnar edge of one hand to assess for
fremitus. As you move your hand to each area, ask the client to say “ninety-nine.”
Assess all areas for symmetry and intensity of vibration.
12. Assess for chest expansion. Place your hands on the posterior chest wall with your
thumbs at the level of T9 or T10 and pressing together a small skin fold. As the client
takes a deep breath, observe the movement of your thumbs
PERCUSSION
13. Percuss Anterior/Posterior/Lateral portion of chest.
14. Note general percussion sound of chest.
15. Percuss for diaphragmatic chest excursion.
● Ask the client to exhale forcefully and hold the breath. Beginning at the scapular line
(T7), percuss the intercostal spaces of the right posterior chest wall.
● Percuss downward until the tone changes from resonance to dullness. Mark this level
and allow the client to breathe.
● Next ask the client to inhale deeply and hold it. Percuss the intercostal spaces from
the mark downward until resonance changes to dullness.
● Mark the level and allow the client to breathe. Measure the distance between the two
marks.
AUSCULTATION
16. Use diaphragm of stethoscope. Have patient take slow, deep breaths through mouth.
17. Assess Anterior/Posterior/Lateral. Compare side to side, apex to base.
18. Assess breath sounds (bronchial, bronchovesicular, vesicular)
● Bronchial- heard over the trachea and thorax.
● Bronchovesicular- heard over the major bronchi—posterior: between the
scapulae; anterior: around the upper sternum in the first and second intercostal
spaces.
● Vesicular- heard over the peripheral lung fields.
19. Assess for voice sounds.
● Bronchophony: Ask the client to repeat the phrase “ninety-nine” while you
auscultate the chest wall.
● Egophony: Ask the client to repeat the letter “E” while you listen over the chest
wall.
 ● Whispered pectoriloquy: Ask the client to whisper the phrase “one–two–three”
while you auscultate the chest wall.
20. After the assessment, make the patient comfortable and perform hand hygiene. Do
after care.
21. Document the data.
TOTAL SCORE = ______ = ______ %
21
 ASSESSING THE ABDOMEN

Materials: Yellow trash bag

Gloves Stethoscope Light source Mask Skin marker Metric ruler

CHECKLIST 1 2 3 4 5
1. Gather all equipment
2. Perform Hand hygiene and explain procedure to patient
INSPECTION
3. Have patient void before exam. Inspect from side and foot of bed.
4. Assess the abdomen. Note size, shape and symmetry and condition of skin
5. Note abdominal movements: respiratory, pulsations and peristalsis
6. Note position, contour, color and herniation of umbilicus
AUSCULTATION
7. Auscultate for bowel sounds in each quadrant.
8. Auscultate for bruits over aorta, renal, iliac, and femoral arteries.
9. Use scratch test to locate inferior edge of liver.
● Place the diaphragm of your stethoscope at the second to last intercostal
space, MCL.
● Use one finger to very lightly stroke the skin horizontally, starting at the
umbilicus. Continue to stroke the skin, moving toward the lower costal
margin.
● The sound will suddenly be transmitted through the stethoscope and
increase in intensity. This indicates the lower border of the liver.
PERCUSSION
10. Percuss the tone of the abdomen in each quadrant.
11. Note areas of tympany, dullness or tenderness.
12. Percuss the span or height of the liver by determining its lower and upper borders.
● To assess the lower border, begin in the RLQ at the mid-clavicular line
(MCL) and percuss upward.
● Note the change from tympany to dullness. Mark this point: It is the lower
border of liver dullness.
● To assess the upper border, percuss over the upper right chest at the MCL
and percuss downward, noting the change from lung resonance to liver
dullness.
● Mark this point: It is the upper border of liver dullness.
● Measure the distance between the two marks: this is the span of the liver.
13. Percuss the spleen.
● Begin posterior to the left mid-axillary line (MAL), and percuss downward,
noting the change from lung resonance to splenic dullness.
14. Blunt percussion for costovertebral angle
- Place non-dominant hand over organ
 - Make fist with dominant hand
- Note any tenderness
15. If indicated, use blunt percussion to assess for organ (liver or gallbladder)
tenderness.
16. Percuss the urinary bladder.
PALPATION
17. Palpate all four quadrants beginning with a light palpation, then do deep,
bimanual palpation
18. Note for masses, bulges, or swelling around the umbilicus.
19. Test abdominal reflexes by lightly stroking each quadrant toward the umbilicus.
20. Assess the pulsation of the abdominal aorta.
21. Palpate the liver. (Bimanual and Hooking techniques)
● Bimanual Technique
o Stand at the client’s right side and place your left hand under the
client’s back at the level of the eleventh to twelfth ribs.
o Lay your right hand parallel to the right costal margin (your fingertips
should point toward the client’s head).
o Ask the client to inhale, then compress upward and inward with your
fingers.
o Have the client exhale and hold your hand in place as the client
inhales a second time.
o With deep inhalation the edge of the liver is more easily palpated.
● Hooking Technique
o To palpate by hooking, stand to the right of the client’s chest.
o Curl (hook) the fingers of both hands over the edge of the right costal
margin.
o Ask the client to take a deep breath and gently but firmly pull inward
and upward with your fingers.
22. Palpate the spleen, kidneys, urinary bladder.
23. Palpate for inguinal lymph nodes. Use light palpation; palpate horizontal and
vertical inguinal nodes. Note size, shape, consistency, tenderness, and mobility.
24. TEST FOR ASCITES: Test for shifting dullness and perform the fluid wave test.
25. TEST FOR APPENDICITIS: If indicated, assess for rebound tenderness at
McBurney’s point, referred rebound tenderness, the iliopsoas test, and the
Obturator test.
26. TEST FOR CHOLECYSTITIS: Press your fingertips under the liver border at the right
costal margin and ask the client to inhale deeply.
27. After the assessment, make the patient comfortable and perform hand hygiene.
Do after care.
28. Document the data.
TOTAL SCORE = ______ = ______ %
28
 OBTAINING A SAMPLE FOR CAPILLARY BLOOD GLUCOSE
Materials: Yellow trash bag
Blood Glucose meter Sterile lancet Cotton balls Testing strips Clean gloves Sharps Bin

CHECKLIST 1 2 3 4 5
1. Check the patient’s medical record or nursing plan of care for monitoring schedule.

2. Gather equipment.

3. Perform Hand hygiene and explain procedure to patient

4. Identify the patient.
5. Explain the procedure to the patient and instruct the patient about the need for
monitoring blood glucose.
6. Close curtains around bed and close the door to the room, if possible
7. Turn on the glucose monitor device.
8. Put on nonsterile gloves.
9. Prepare lancet using aseptic technique.
10. Remove test strip from the vial. Recap container immediately.
11. Check that the code number for the strip matches code number on the monitor
screen.
12. Insert the strip into the meter according to directions for that specific device.
13. For adult, massage side of finger toward puncture site.
In infants and young children, use the heel to obtain the blood specimen. In an
infant, use the outer aspect of the heel. If the heel is cool, place a warm compress
on the foot.
14. Cleanse the skin with an alcohol swab. Allow skin to dry completely.
15. Hold lancet perpendicular to skin and pierce site with lancet
16. Wipe away first drop of blood with cotton ball.
17. Encourage bleeding by lowering the hand, making use of gravity. Lightly stroke the
finger, if necessary, until sufficient amount of blood has formed to cover the
sample area on the strip, based on monitor requirements. Take care not to
squeeze the finger, not to squeeze at puncture site, or not to touch puncture site
or blood.
18. Gently touch a drop of blood to pad to the test strip without smearing it
19. Press time button if directed by manufacturer.
20. Apply pressure to puncture site with a cotton ball or dry gauze. Do not use alcohol
wipe.
21. Read blood glucose results and document appropriately at bedside. Inform patient
of test result.
22. Turn off meter, remove test strip, and dispose of supplies appropriately. Place
lancet in sharps container.
23. Remove gloves and any other PPE, if used. Perform hand hygiene.
24. Document result in the chart.
TOTAL SCORE = ______ = ______ %
24
 INTRAVENOUS THERAPY: PRIMING
Materials: Yellow trash bag
IV Bottle IV Tag IV Tubing/ line IV Pole Clean gloves Alcohol Cotton balls Plaster Bandage Scissors

CHECKLIST 1 2 3 4 5
1. Verify the IV solution order on the chart. Clarify any inconsistencies. Check the
patient’s chart for allergies.

2. Gather all equipment and bring to the bedside.

3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around bed and close the door to the room, if possible.
6. Explain what you are going to do and why you are going to do it to the
patient.
7. Ask the patient about allergies to medications, as appropriate.
8. Remove IV bag from outer wrapper, if indicated.
9. Check expiration dates.
10. Compare on patient identification band with the chart.
11. Label the solution container with the patient’s name, solution type,
additives, date, and time.
12. Maintain aseptic technique when opening sterile packages and IV solution.
13. Remove administration set from package
14. Close the roller clamp or slide clamp on the IV administration set
15. Invert the IV solution container and remove the cap on the entry site, taking
care not to touch the exposed entry site.
16. Remove the cap from the spike on the administration set.
17. Using a twisting and pushing motion, insert the administration set spike into
the entry site of the IV container
18. Hang the IV container on the IV pole.
19. Squeeze the drip chamber and fill at least halfway
20. Open the IV tubing clamp, and allow fluid to move through tubing. Some
brands of tubing may require removal of the cap at the end of the IV tubing
to allow fluid to flow.
21. Allow fluid to flow until all air bubbles have disappeared and the entire
length of the tubing is primed (filled) with IV solution
22. Close the clamp.
23. Maintain its sterility. After fluid has filled the tubing, recap the end of the
tubing.
24. Attach end of tubing to Roller clamp.
TOTAL SCORE = ______ = ______ %
24
 INTRAVENOUS THERAPY: CHANGING IV SOLUTION

Materials: Yellow trash bag

IV Bottle IV Tag IV Tubing/ line IV Pole Clean gloves Alcohol Cotton balls Plaster Bandage Scissors

CHECKLIST 1 2 3 4 5
1. Verify the IV solution order on the chart. Clarify any inconsistencies. Check the
patient’s chart for allergies.

2. Gather all equipment and bring to the bedside.

3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around bed and close the door to the room, if possible.
6. Explain what you are going to do and why you are going to do it to the
patient.
7. Ask the patient about allergies to medications, as appropriate.
8. Remove IV bag from outer wrapper, if indicated.
9. Check expiration dates.
10. Compare on patient identification band with the chart.
11. Label the solution container with the patient’s name, solution type,
additives, date, and time.
12. Maintain aseptic technique when opening sterile packages and IV solution.
13. Remove administration set from package
14. Close the roller clamp or slide clamp on the IV administration set
15. Invert the new IV solution container and remove the cap on the entry site,
taking care not to touch the exposed entry site.
16. Remove the cap from the spike on the administration set.
17. Lift empty old container off IV pole and invert it.
18. Quickly remove the spike from the old IV container, being careful not to
contaminate it.
19. Discard old IV container.
20. Using a twisting and pushing motion, insert the administration set spike into
the entry site of the new IV container
21. Hang the new IV container on the IV pole.
22. Slowly open the roller clamp on the administration set and adjust the drops
according to doctor’s order.
23. Evaluate patient reaction.
24. Document procedure and patient reaction.
TOTAL SCORE = ______ = ______ %
24
 INTRAVENOUS THERAPY: IV TERMINATION

Materials: Yellow trash bag

Clean gloves Cotton balls Plaster Bandage Scissors

CHECKLIST 1 2 3 4 5
1. Verify medical order for removal and facility policy and procedure.

2. Gather equipment and bring to bedside.

3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around bed and close the door to the room, if possible.
6. Explain what you are going to do and why you are going to do it to the
patient.
7. Adjust bed to comfortable working height, usually elbow height of the
caregiver
8. Put on gloves.
9. Stabilize hub with your nondominant hand.
10. Carefully remove all the tape that is securing the cannula in place.
11. With your nondominant hand, apply cotton ball on the insertion site.
12. Using dominant hand, remove the cannula slowly keeping it parallel to the
skin.
13. After removal, apply pressure to the site until hemostasis is achieved
(minimum 1 minute).
14. Then apply a small sterile dressing or plaster to the site.
15. Dispose of cannula and IV tubing according to facility policy.
16. Remove gloves.
17. Ensure patient’s comfort.
18. Lower bed, if not in lowest position.
19. Remove additional PPE, if used. Perform hand hygiene.
20. Document procedure and patient reaction.
TOTAL SCORE = ______ = ______ %
20
 DRAWING-UP MEDICATION FROM VIAL (OR/DR)
(2 nurses: Non-Sterile / Sterile)

STERILE

Materials: Yellow trash bag

Sterile Gloves Sterile Field Sterile Syringe Sterile Needle sterile water

CHECKLIST 1 2 3 4 5
1. Repeat Doctor’s order and select the proper medication from the patient’s
medication drawer or unit stock.
2. Read label and expiry date out loud.
3. Show label to sterile at his eye level at appropriate distance.
4. Read the label and expiry date out loud.
5. Remove the metal or plastic cap on the vial that protects the rubber stopper.
6. Swab the rubber top with the antimicrobial swab and allow to dry.
7. Invert and position vial diagonally where rubber top is visible and accessible to the
sterile person. Make sure arm is not close to the vial.
8. Remove the cap from the needle or blunt cannula by pulling it straight off.
9. Touch the plunger at the knob only.
10. Draw back an amount of air into the syringe that is equal to the specific dose of
medication to be withdrawn.
11. Pierce the rubber stopper in the center with the needle tip and inject the
measured air into the space above the solution. Do not inject air into the solution.
12. Reposition vial vertically and down at sterile person’s eye level.
13. Keep the tip of the needle or blunt cannula below the fluid level
14. Touch the plunger at the knob only. Draw up the prescribed amount of medication
while holding the syringe vertically and at eye level
15. If any air bubbles accumulate in the syringe, tap the barrel of the syringe sharply
and move the needle past the fluid into the air space to re-inject the air bubble
into the vial. Return the needle tip to the solution and continue withdrawal of the
medication.
16. After the correct dose is withdrawn, remove the needle from the vial and carefully
replace the cap over the needle (scoop method).
17. Discard vial to appropriate container. If a multidose vial is being used, label the
vial with the date and time opened, and store the vial containing the remaining
medication according to facility policy.
18. Some facilities require changing the needle before administering the medication.
TOTAL SCORE = ______ = ______ %
18
 DRAWING-UP MEDICATION FROM VIAL (OR/DR)
(2 nurses: Non-Sterile / Sterile)

Non-STERILE

Materials:
Anesthesia

CHECKLIST 1 2 3 4 5
1. Repeat Doctor’s order and select the proper medication from the patient’s
medication drawer or unit stock.
2. Read label and expiry date out loud.
3. Show label to sterile at his eye level at appropriate distance.
4. Read the label and expiry date out loud.
5. Remove the metal or plastic cap on the vial that protects the rubber stopper.
6. Swab the rubber top with the antimicrobial swab and allow to dry.
7. Invert and position vial diagonally where rubber top is visible and accessible to the
sterile person. Make sure arm is not close to the vial.
8. Remove the cap from the needle or blunt cannula by pulling it straight off.
9. Touch the plunger at the knob only.
10. Draw back an amount of air into the syringe that is equal to the specific dose of
medication to be withdrawn.
11. Pierce the rubber stopper in the center with the needle tip and inject the
measured air into the space above the solution. Do not inject air into the solution.
12. Reposition vial vertically and down at sterile person’s eye level.
13. Keep the tip of the needle or blunt cannula below the fluid level
14. Touch the plunger at the knob only. Draw up the prescribed amount of medication
while holding the syringe vertically and at eye level
15. If any air bubbles accumulate in the syringe, tap the barrel of the syringe sharply
and move the needle past the fluid into the air space to re-inject the air bubble
into the vial. Return the needle tip to the solution and continue withdrawal of the
medication.
16. After the correct dose is withdrawn, remove the needle from the vial and carefully
replace the cap over the needle (scoop method).
17. Discard vial to appropriate container. If a multidose vial is being used, label the
vial with the date and time opened, and store the vial containing the remaining
medication according to facility policy.
18. Some facilities require changing the needle before administering the medication.
TOTAL SCORE = ______ = ______ %
18
 BED SHAMPOO

Materials:

CHECKLIST 1 2 3 4 5
1. Introduce self and verify the client’s identity using agency protocol. Explain to the
client what you are going to do, why it is necessary, and how he or she can
participate.
2. Perform hand hygiene and observe other appropriate infection control
procedures. Gloves may be worn.
3. Provide client privacy.
4. Gather equipment and place at bedside.
5. Lower head of bed. Position and prepare the client appropriately. Assist the client
to the side of the bed from which you will work.
6. Remove pins and ribbons from the hair (if present) and brush or comb it to
remove any tangles.
7. Arrange the equipment and place protective pad/plastic sheet under patient’s
head and shoulders
8. Remove pillow from under the patient’s head and place it under the shoulders
unless there is an underlying condition.
9. Tuck the bath towel around the patient’s shoulders.
10. Place the shampoo basin/Kelly pad under the patient’s head, putting a folded
washcloth for the client’s neck resting on the edge of the basin.
11. Cover the upper part of the client with a bath blanket. Fanfold the top bedding
down to the waist.
12. Place receiving receptacle or pail on floor underneath the drain of the Kelly pad.

13. Protect the client’s eyes. Place a damp washcloth over the patient’s eyes and put
cottonballs on both ears.
14. Feel the pitcher with warm water (40.5°C to 46°C or 105°F to 115°F)
15. Pour pitcher of warm water slowly over patient’s head making sure that all hair is
saturated. Refill pitcher, if needed.
16. Apply a small amount of shampoo. Make a good lather and massage hair deep
into scalp avoiding any cuts or sore spots.
17. Rinse with warm water briefly.
18. Apply shampoo again and make a good lather. Massage scalp.
19. Rinse with warm water thoroughly this time until all conditioner is out of hair.
20. Remove the Kelly pad and wrap a towel around the patient’s head to dry the hair
and ensure they do not feel cold.
21. Dry the surrounding skin, paying particular attention to skin folds in the neck.
22. Gently brush hair removing tangles as needed. Blow dry hair on a cool setting if
allowed and if patient wishes.
23. Remove protective pad and change patient’s gown if necessary.
24. Assist the patient into a comfortable position. Place back the pillow.
25. Remove gloves. Perform hand hygiene.
 26. Document that hair was washed and any cuts or lesions found.

TOTAL SCORE = ______ = ______ %

26

UNOCCUPIED BED MAKING

Materials:

CHECKLIST 1 2 3 4 5
1. If the client is in bed, prior to performing the procedure, introduce self and
verify the client’s identity using agency protocol. Explain to the client what you
are going to do, why it is necessary, and how he or she can participate.
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide for client privacy.
4. Assemble equipment and place the fresh linen on the client’s chair or overbed
table in the order in which items will be used; do not use another client’s bed.
5. Adjust the bed to a comfortable working height, usually elbow height of the
caregiver. Drop the side rails and make sure wheels are locked.
6. Apply clean gloves if linens and equipment have been soiled with secretions
and/or excretions.
7. Strip the bed.
● Check bed linens for any items belonging to the client, and detach the call bell
or any drainage tubes from the bed linen.
● Loosen all bedding systematically, starting at the head of the bed on the far side
and moving around the bed up to the head of the bed on the near side.
● Remove the pillowcases, if soiled, and place the pillows on the bedside chair
near the foot of the bed.
● Roll all soiled linen inside the bottom sheet, hold it away from your uniform,
and place it directly in the linen hamper, not on the floor.
● Remove and discard gloves if used. Perform hand hygiene.
8. Place the bottom sheet starting from the foot of the bed, with its center fold
placed in the center. Make sure the sheet is hem side down. Open the sheet
and spread it out over the mattress, and allow a sufficient amount of sheet at
the top to tuck under the mattress. Fan-fold sheet to the center.
9. Miter the sheet at the top corner on the near side and tuck the sheet under the
mattress, working from the head of the bed to the foot.
10. Place drawsheet over the bottom sheet so that the center fold is at the
centerline of the bed and the top and bottom edges extend from the middle of
where the client’s back would be on the bed to the area where the midthigh or
knee would be. Fanfold the uppermost half of the folded drawsheet at the
center or far edge of the bed.
11. Place protective pad over the drawsheet with centerfold in the center of the
bed and fanfold to the center of the mattress. Tuck the rest of the sheet and
protective pad.
12. Place the top sheet, hem side up, on the bed so that its center fold is at the
center of the bed and the top edge is even with the top edge of the mattress.
Unfold the sheet over the bed.
13. Follow the same procedure for the blanket, but place the top edges about 15
cm (6 in.) from the head of the bed to allow a cuff of sheet to be folded over
them.
14. Tuck in the top sheet and blanket at the foot of the bed, and miter the bottom
corner.
15. Move to the other side of the bed to secure bottom linens. Pull the bottom
sheet tightly and secure over the corners at the head and foot of the mattress.
Pull the drawsheet tightly and tuck it securely under the mattress and miter the
corner.
16. Tuck the top sheet and blanket under the foot of the bed on the near side.
Miter the corners.
17. Fold the upper 6 inches of the top sheet down over the blanket and make a cuff.
18. Put clean pillowcases on the pillows as required.
● Grasp the closed end of the pillowcase at the center with one hand.
● Gather up the sides of the pillowcase and place them over the hand grasping
the case. Then grasp the center of one short side of the pillow through the
pillowcase.
● With the free hand, pull the pillowcase over the pillow.
● Adjust the pillowcase so that the pillow fits into the corners of the case and the
seams are straight.
● Place the pillows appropriately at the head of the bed with the opening facing
away from the door covered by the top sheet.
19. OPEN BED: If the bed is currently being used by a client, either fold back the top
covers at one side or fanfold them down to the center of the bed.
20. Provide for client comfort and safety. Raise side rail and lower bed.
21. Document and report pertinent data.
● Record any nursing assessments, such as the client’s physical status and pulse
and respiratory rates before and after being out of bed, as indicated.
VARIATION: SURGICAL BED
1. Strip the bed
2. Place and leave the pillows on the bedside chair
3. Apply the bottom linens as for an unoccupied bed. Place a bath blanket on the
foundation of the bed if this is agency practice
4. Place the top covers (sheet, blanket, and bedspread) on the bed as you would
for an unoccupied bed. Do not tuck them in, miter the corners, or make a toe
pleat.
5. Make a cuff at the top of the bed as you would for an unoccupied bed. Fold the
top linens up from the bottom.
6. On the side of the bed where the client will be transferred, fold up the two
outer corners of the top linens so they meet in the middle of the bed forming a
triangle
7. Pick up the apex of the triangle and fanfold the top linens lengthwise to the
other side of the bed
8. Leave the bed in high position with the side rails down
9. Lock the wheels of the bed if the bed is not to be moved

TOTAL SCORE = ______ = ______ %

30
 OCCUPIED BED MAKING

Materials:

CHECKLIST 1 2 3 4 5
1. If the client is in bed, prior to performing the procedure, introduce self and verify the
client’s identity using agency protocol. Explain to the client what you are going to do,
why it is necessary, and how he or she can participate.
2. Perform hand hygiene and observe other appropriate infection control procedures.
3. Provide for client privacy.
4. Remove any equipment attached to the bed linen, such as a signal light.
5. Replace top sheet with a bath blanket. Spread the bath blanket over the top
sheet.
6. Ask the client to hold the top edge of the blanket.
7. Reaching under the blanket from the side, grasp the top edge of the sheet and
draw it down to the foot of the bed, leaving the blanket in place.
8. Remove the sheet from the bed and place it in the soiled linen hamper.
9. Raise the side rail that the client will turn toward.
10. Assist the client to turn on the side away from the nurse and toward the raised
side rail.
11. Loosen the bottom linens on the side of the bed near the nurse
12. Fanfold the dirty linen (i.e., drawsheet and the bottom sheet) toward the center
of the bed as close to and under the client as possible.
13. Place the new bottom sheet on the bed and vertically fanfold the half to be
used on the far side of the bed as close to the client as possible.
14. Tuck the bottom sheet under the near half of the bed and miter the corner.
15. Place the clean drawsheet on the bed with the center fold at the center of the
bed. Fanfold the uppermost half vertically at the center of the bed and tuck the
near side edge under the side of the mattress.
16. Assist the client to roll over toward you, over the fanfolded bed linens at the
center of the bed, onto the clean side of the bed.
17. Move the pillows to the clean side for the client’s use.
18. Raise the side rail before leaving the side of the bed.
19. Move to the other side of the bed and lower the side rail.
20. Remove the used linen and place it in the portable hamper.
21. Unfold the fanfolded bottom sheet from the center of the bed.
22. Facing the side of the bed, use both hands to pull the bottom sheet so that it is
smooth and tuck the excess under the side of the mattress.
23. Unfold the drawsheet fanfolded at the center of the bed and pull it tightly with
both hands. Tuck the excess drawsheet under the side of the mattress.
24. Reposition the pillows at the center of the bed.
25. Assist the client to the center of the bed. Determine what position the client
requires or prefers and assist the client to that position.
26. Spread the top sheet over the client and either ask the client to hold the top
edge of the sheet or tuck it under the shoulders. The sheet should remain over
the client when the bath blanket or used sheet is removed.
27. Place the bath blanket in the linen hamper.
28. Raise the side rails.
29. Place the signal cord/light within the client’s reach. Put items used by the client
within easy reach.
30. Place the bed in the low position before leaving the bedside.
TOTAL SCORE = ______ = ______ %
30
 BED BATH

Materials:

CHECKLIST 1 2 3 4 5
1. Introduce yourself and verify the client’s identity.
2. After explaining the procedure, put on clean gloves and follow infection
control procedures to clean all surfaces you will be using.
3. Provide for client privacy by drawing the curtains around the bed or closing
the door to the room, if needed.
4. Remove your gloves, perform hand hygiene, and gather the appropriate
equipment.
5. Use two basins of comfortably warm water (43°C to 46°C or 110°F to 115°F) so
that there is always one for the clean rinse water.
6. Place a waterproof pad behind the client’s head. Prepare the client and
his/her environment.
7. You may offer the client a bedpan or urinal if the client asks.
8. Raise the bed to the appropriate working height.
9. Lower the side rail closest to yourself and assist patient to side of bed where
you will work. Have patient lie on his or her back.
10. Place a bath blanket over the top sheet and bedspread. Remove the linen from
under the bath blanket by starting at the client’s shoulders and moving the
linen down toward the client’s feet.
11. If linen is to be reused, fold it over at chair. Place soiled linen at the laundry
bag.
12. Remove the client’s gown while keeping the client covered with the bath
blanket. If patient has an IV line and is not wearing a gown with snap sleeve
remove gown from the other arm first. lower the IV container and pass down
over the tubing and the container. Rehang the container and check the drip
rate.
13. Take a washcloth and make it into a bath mitt folded around the hand.
14. With no soap on the washcloth, wipe one eye from the inner part of the eye,
near the nose, to the outer part.
15. Rinse or turn the cloth before washing the other eye.
16. Wash the other parts of client’s face. Ask whether the client wants soap used
on his/her face, ears or neck.
17. Use a clean/separate towel to dry off the face, ears, and neck.
18. Remove the pad from behind the client’s head.
19. Place a towel lengthwise under one arm.
20. Open and wet a bar of soap and use it to wash the arm.
21. Use long, firm strokes from wrist to shoulder, including the axillary area.
22. Rinse and dry the hand and arm. Rinse the washcloth in a separate basin. You
may apply deodorant or powder if desired.
23. To wash the chest and abdomen, first place a bath towel lengthwise over the
client’s chest. Fold the bath blanket down, as needed.
24. Lift the bath towel off the chest and bathe the chest and abdomen with a
mitted hand.
25. To wash the legs and feet, expose one leg by folding the bath blanket toward
the other leg.
26. Lift the exposed leg and place a bath towel lengthwise under the leg.
27. Wash, rinse, and dry the leg using long, firm strokes from ankle to knee to
thigh.
28. You may wash the feet by placing them in a basin or using your mitted hand.
29. Dry each foot, paying particular attention to the spaces between the toes.
30. Remove the bath towel beneath the leg and cover the client.
31. Return the side railing and the bed to the original position.
32. Obtain fresh, warm bathwater before continuing to the other side of the body.
Remove your gloves and wash your hands before rinsing out each basin.
33. Put on clean gloves and return with the refilled basins to the client.
34. Cleanse the other side of the body in the same manner as the first side.
35. When you are done with the arms and legs, remove the bath blanket and
cover the client. If the client requests, help him/her with grooming aids such
as powder, lotion, or deodorant.
36. Remove all items that you used for the procedure. Rinse and refill the basins
using proper hand hygiene.
37. Return with towels to wash the client’s back and clean blankets.
38. Move the bed’s position as needed and help the client turn to a side-lying or
prone position.
39. Place a towel under the area to be bathed.
40. Wash, rinse, and dry the client’s back, moving from the shoulders to the
buttocks.
41. Remove the towel from under the client and help the client onto his/her back.
42. Complete perineal care at this time. Assist the client to the supine position
and determine whether the client can wash the perineal area independently. If
the client cannot do so, drape the client and wash the area.
43. Remove your gloves and dispose of them. Perform hand hygiene.
44. Assist the client to dress in a clean hospital gown. Tie the clean gown at the
neck for the client.
45. Remove the old gown and blanket that was placed on the client.
46. Return blankets, sheets, bed, and side rails to the original position.
47. When you are done, clean and store the bath equipment. Dispose of the dirty
linen according to facility guidelines.
TOTAL SCORE = ______ = ______ %
47
 ADMINISTERING NGT FEEDING
Materials:
Clean gloves Stethoscope Osterized Feeding Water Yellow trash bin

CHECKLIST 1 2 3 4 5

1. Introduce yourself and verify the client's identity.

2. Explain procedure to client and discuss how he or she can participate.

3. Gather appropriate equipment.

4. Perform hand hygiene and observe other appropriate infection prevention procedures.

5. Provide for client privacy if the client desires it.

6. Assist the client to Fowler’s position in bed or a sitting position in a chair. If a sitting position
was contraindicated, place the client slightly elevated right side-lying.

7. Assess tube placement.

8. Assess residual feeding contents.

9. Administer the feeding.
a. Remove plunger from syringe and connected syringe to a pinched or clamped nasogastric
tube.

b. Add feeding to the syringe barrel.

c. Permit feeding to flow in slowly at prescribed rate. Raised or lowered syringe to adjust flow
as needed. Pinched or clamped tubing to stop flow for a minute if the client experienced
discomfort.

10. Clamp feeding tube before all water was instilled.

11. Ensure client comfort and safety.

a. Secure tubing to client’s gown.

b. Ask the client to remain in sitting upright in Fowler’s position or in a slightly elevated right
lateral position for at least 30 minutes.

d. Remove and discard gloves. Perform hand hygiene.

12. Dispose of equipment appropriately.

13. Document the data.
TOTAL SCORE = ______ = ______ %
13
 TRACHEOSTOMY CARE AND SUCTIONING

Materials:

CHECKLIST 1 2 3 4 5

1. Explain the procedure to the client; reassure him that you will interrupt procedure if the
client indicates respiratory distress

2. Gather equipment

3. Provide privacy for client

4. Assist client to a semi-Fowler’s or Fowler’s position, if conscious

5. Wash your hands

6. Turn suction to appropriate pressure

7. Place clean towel across client’s chest

8. Open sterile drape, set-up equipment and prepare suction

9. Place sterile drape, if available, across client’s chest

10. Pour sterile saline into one sterile bowl and hydrogen peroxide on another bowl

11. Add three 4x4 gauze packages and cotton tipped swab packages

12. Don sterile gloves on dominant hand and clean gloves on non-dominant hand

13. Connect sterile suction catheter to suction tubing that is held with unsterile gloved hand

14. Remove oxygen source and then inner cannula with non-dominant hand. Drop inner
cannula into the bowl with hydrogen peroxide

15. Moisten the catheter by dipping it into the container of sterile saline

16. Using sterile gloved hand, gently and quickly insert catheter into the trachea. Advance
about 10-12.5 cm (4-5 inches) or until client coughs. Do not occlude Y-port while inserting the
catheter.

17. Apply intermittent suction by occluding Y-port with thumb of unsterile gloved hand.
Gently rotate catheter as catheter is being withdrawn. Suction secretions for 8-10 seconds

18. Flush the catheter with saline and repeat suctioning as needed and according to client’s
tolerance of the procedure. Allow client to rest and deep breath between suctioning.

19. When procedure is complete, turn off suction machine and disconnect catheter from
suction tubing.

20. Clean the inner cannula and using pipe cleaner or gauze. Rinse with normal saline.
21. Replace the inner cannula and lock. Reapply the oxygen sources.

22. Using cotton-tipped swab soaked with hydrogen peroxide, clean exposed outer cannula
surfaces & rinse with cotton tipped swab soaked in normal saline.

23. Replace tie PRN with knot tied at the side of the neck

24. Insert fresh tracheostomy dressing under clean ties; cover mouth of tube with gauze
moistened with normal saline if no oxygen source is attached.

25. Remove gloves & discard in appropriate receptacle with soiled ties. Wash hands.

26. Position client comfortably and assess respiratory status.

TOTAL SCORE = ______ = ______ %

26
 DELIVERY ROOM INSTRUMENTATION

Materials:
Sterile Gloves

CHECKLIST Y N
1. 10cc Syringe

2. Allis Forceps

3. Cord Clamp

4. Curved Kelly Forceps

5. Foley Catheter

6. Kidney Basin

7. Needle Holder

8. Ovum Forceps

9. Scissors

10. Sharp Uterine Curette

11. Straight Kelly Forceps

12. Suture

13. Tissue/Thumb Forceps (with teeth)

14. Tissue/Thumb Forceps (without teeth)

15. Uterine Sound

16. Vaginal Speculum

TOTAL SCORE = ______ = ______ %

16
DELIVERY ROOM INSTRUMENTATION