OLIVAREZ COLLEGE

Dr. A. Santos Avenue, San Dionisio, Parañaque City

PACUCOA Accredited
COLLEGE OF HEALTH SCIENCES EDUCATION
NURSING DEPARTMENT
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Student Name: ___________________________________________ Score: _________________________

Level and Group No.: ______________________________________ Date: ________________________
Directions: Evaluate each step/task by putting (✔) under the proper heading. A numerical number may also
be assigned and a minimum passing level determined.

Rate the students from 2 - 0, where:

(2) Performed Correctly Students performed the step according to the standard procedure or guidelines

(1) Attempted Not Correctly Students unable to perform the steps/task according to procedure or guidelines

(0) Not Done Students did not do the step/task

(NO Not Observed (NO) Evaluator unable to observe the step/task for various reasons like
) interruptions/inattentiveness,

Checklist on Capillary Blood Glucose Monitoring

ST Perfor Attempt N Not
med ed Not ot Obser
EP
Correctl Correctl D ved
y (2) y (1) on (NO)
e
(0)
1. Verify doctor’s order

2. Prepare equipment

3. Greet the client

4. Explain the procedure to the client

5. Perform handwashing before and after the procedure.

6. Choose the puncture site. For adults and children fingertips can be used. For
infants, the tip of the great toe or heel can be the puncture site.

7. Put on glean gloves

8. Prepare the finger to be lanced by cleaning it with an alcohol wipe. Alcohol

must dry thoroughly before finger is lanced.

9. If glucometer is used, load the strip into the device beforehand.

10. Turn on the glucose meter. Prepare the glucometer by validating the proper
calibration with the strips to be used. (This usually involves matching a code
number on the strip bottle to the code registered on the meter.)

11. The meter will indicate its readiness for testing blood glucose by message or
symbol. Some meters require that the glucose test strip be inserted at this time.

12. To collect a blood sample, position the lancet (pricking needle) at the side of
the site. To minimize pain and patient’s anxiety , pierce the skin sharply and
briefly. This technique also increases blood flow. For better results, some
hospitals are using a lancing device (mechanical blood-letting device) wherein
the lancets are simply loaded in the spring of the equipment. (It’s like using a
spring-loaded pen, once you click the button the spring releases the lancet and
immediately retracts it after piercing the skin). However, be sure to load an
unused lancet before using it to prevent spread of blood-transmitted disease.
 13. Place a small amount of blood carefully to the strip test area (varies by
glucose meter model). Read the result.

14. Place gauze over the punctured area and briefly apply pressure until the
bleeding stops. Ask the parents of a child to do this.

14. Apply an adhesive bandage once the bleeding on the puncture site has
stopped

16. Remove gloves and record the result of glucose level from the digital display.

17. Document in the patient’s chart and endorse to the incoming shift.

Computation for student rating:

Raw score X 60 + 40
Perfect score

Student’s Signature and Date: _____________________________

Signature of Clinical Instructor and Date: ______________________

Remarks:
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