Republic of the Philippines

Province of Negros Occidental

NORTHERN NEGROS STATE COLLEGE OF SCIENCE & TECHNOLOGY
College of Nursing and Allied Health Services
Rizal St., Sagay City, Negros Occidental
(034) 722-4169/ www.nonescost.edu.ph

PERFORMANCE CHECKLIST
Student’s name:
Year
level/Section:
Evaluator:
Instructions for the evaluator:
1. Observe the student performing the procedure.
2. Describe the assessment activity and the date on which it was undertaken.
3. Place a tick in the box to show what corresponds to the student’s performance based on the legend given below.
4. Complete the feedback sections of the form.
Description of Assessment Activity: Return Demonstration
Name of procedure: PERINEAL CARE
Date performed:
Location of evaluation activity: Skills Laboratory
The student… 3 2 1
1. Defines the procedure.
2. Checks care plan.
3. Washes hands.
4. Gathers the necessary supplies.
5. Identifies client using two identifiers.
6. Explains the procedure to the patient.
7. Positions the patient in dorsal recumbent position and loosens the foot part of the top sheet.
8. Places rubber protector against patient’s buttocks.
9. Places the patient on bedpan.
10. Does fan fold of the top sheet towards the knees, to expose the vulva and perineum.
11. Puts a bath towel over the abdomen.
12. Pours sterile water over the vulva.
13. Cleans the vulva and perineum using perineal balls soaked in solution using a downward stroke in the
following sequence:
a. Center of the vulva
b. Farther labia minora
c. Nearer labia minora
d. Farther labia majora
e. Nearer labia majora
f. Center of the vulva, mons veneris/ mons pubis. Uses a fresh perineal ball for each stroke.
(Repeat sequence of cleansing as necessary).
14. Discards used perineal balls into the waste receptacle.
15. Rinses area with warm water. See to it that the solution is completely rinsed off.
16. Dries vulva and perineum with dry perineal balls following the same sequence in cleansing.
17. Removes bed pan and turn patient near you.
18. Dries buttocks and anus using tissue paper.
19. Assists patient to assume a dorsal recumbent position. (Apply medication as ordered and perineal pad, if
necessary).
20. Removes the bed protector.
21. Arranges the beddings and places the patient in a comfortable position.
22. Discards the used materials.
23. Washes hands thoroughly.
24. Documents the nursing procedure, monitors adverse effects, and reports any abnormal findings.
LEGEND: 3- SKILLFULLY DONE- Demonstrated correctly according to standard, has adequate knowledge and exhibited appropriate attitude.
2- NOT SKILLFULLY DONE- Demonstrated, but not according to standard, has minimal knowledge and exhibited appropriate attitude.
1 - NOT DONE- Not demonstrated at any time.
Clinical Instructor’s Remarks
(Strengths/ Improvements needed/ attitude towards the patient and procedure) Total score: (90)

Student’s signature: Date:

Evaluator’s signature: Date:
Step #5 can also be done in the following sequence:
a. Center of the vulva
b. Farther labia minora
c. Farther labia majora
d. Nearer labia minora
e. Nearer labia majora
f. Center of the vulva down to the anus
g. Mons veneris/ mons pubis- use one direction from side to side starting from the lower portion going to the suprapubic area.