COLLEGE OF NURSING

NAME: _________________________________________________ DATE: _______________________

BLOCK: ________________________________________________ SCORE: ______________________
CLINICAL INSTRUCTOR: __________________________________________________________________

ASSISTING ON GOWNING AND GLOVING A TEAM MEMBER

PROCEDURE CHECKLIST

I. Objective/s
- To assist in Cesarean delivery procedure.
- To ensure procedures done are sterile and done aseptically.
- To eliminate inhabitant microbial count to a minimum.
- To provide appropriate and timely maternal and newborn care.
- To work harmoniously with the other members of the operating room team.
Materials/equipment
- OR gown / disposable scrub suit or OR gown (Sterile Pack)
- Sterile gloves
- Sterile towel
II. Procedure Steps. Check Done or Not done. The DONE NOT REMARKS
student is expected to perform the following DONE
1 0

1. If wearing sterile gear, assemble all necessary equipment for the

team member.
A. Assessment
2. Ensure team member hands and forearms are thoroughly dry.
3. Inspect for cuts, wounds, lesions or abrasions on the hands and
forearms of the team member.
4. Check for jewelries or accessories that team member is wearing.

B. Planning
5. At the end of the procedure,
A. Client is assisted comfortably before, during and after
the surgical procedure.
B. Client and newborn are given timely and appreciate
aseptic nursing care.
C. Surgical technique is strongly observed and client is
not exposed on microorganisms.
D. Mother is free from any intrapartal complications
such as infections.
E. Build camaraderie among members of the operating
room.
C. Implementation
6. Prepare surgical gown and gloves packs.
7. Sterile towel can be offered to the team member.
C1. Assist in Gowning a Team Member
8. Opens the hand towel, and lays one end on the freshly scrubbed
Checklist Date Date Prepared and Revised By: Validated and Evaluated by: Approved by:
for:: Effective Revised Ms. Melody S.Yanos, Mrs. Teresita F. Merin, RN, Page 1
RN,MAN MPH Dr. Almira A. Tenorio, RN, of 2
Maternal and 2nd February Ms. Bernice U. Caliwagan, Dr. Johdel Cabaluna, RN, MAN MAN, MAEd
Child Health Semester 2022 RN MAN Ms. Michelle Suguitan, RN, Dean
SY 2020- Faculty MSN
2021 Faculty
 COLLEGE OF NURSING
team member’s hand, being careful not to touch the hand.
9. Ensure that the team member dries hand up to mid-lower arms in a
rotational motion.
10. Dries the hand then the arm and returns to same hand using a
different part of the sterile towel or use a new sterile towel.
11. After drying the hands and arms, check team member’s hands and
arms are away from the main sterile field.
12. Lift the gown and unfold it carefully, with the sterile outside
surface facing he scrub nurse and the unsterile inside surface
facing the person being gowned, holding it open at the shoulders
and neckline by cuffing over the hands.
13. Keep the hands on the sterile side of the gown under a protective
cuff of the neck and shoulder area, offer the inside of the gown for
the team member to don.
14. Carefully not to let the sleeves make contact with unsterile areas.
15. Releases the gown when it is secured by the person being gowned.
C2. Assist in Gloving a Team Member
16. Picks up the right glove, grasping it firmly with the fingers of both
hands under the everted cuff on the sterile side.
17. Holds the palm of the glove toward the person being gloved.
18. Stretches the cuff sufficiently open for the other to introduce the
right hand. Avoid touching the hand by holding the thumbs out
(abducted).
19. Pulls the glove cuff up over the cuff of the right sleeve.
20. Follows the same steps for the left hand.

Evaluator’s name and signature: Score:

_________________________
/20

REFERENCE:
Operating Room Nursing: Perioperative Practice.

Comment/s:
__________________________________________________________________________________________
__________________________________________________________________________________________

Evaluated by: Student Conforme:

_______________________________ _______________________________
Bernice Caliwagan, RN, MAN Student’s full name with signature
Clinical Instructor

_______________________________
Melody S.Yanos,RN,MAN
Clinical Intructor
Checklist Date Date Prepared and Revised By: Validated and Evaluated by: Approved by:
for:: Effective Revised Ms. Melody S.Yanos, Mrs. Teresita F. Merin, RN, Page 2
RN,MAN MPH Dr. Almira A. Tenorio, RN, of 2
Maternal and 2nd February Ms. Bernice U. Caliwagan, Dr. Johdel Cabaluna, RN, MAN MAN, MAEd
Child Health Semester 2022 RN MAN Ms. Michelle Suguitan, RN, Dean
SY 2020- Faculty MSN
2021 Faculty