PAMANTASAN NG LUNGSOD NG

MAYNILA COLLEGE OF NURSING

Medical- Surgical Nursing 1

SKILLS LABORATORY CHECKLIST

Procedure: DONNING STERILE GOWN

(for surgical procedure)

Name: _Date:
Year Level and Block: Clinical Instructor:
Rating scale:
3 Performed correctly, systematically according to standard with correct rationale.
2 Performed correctly, with correct rationale but not systematic.
1 Performed correctly, but not systematic and with inadequate rationale.
0 Performed incorrectly.
I.
Performance
Procedure Rationale Remarks
3 2 1 0
1. Do surgical scrubbing (surgical -

handwashing) prior to entering the

OR/ theater.

2. Once at the OR, dry hands with -

sterile towel (following the steps sited

at the surgical handwashing checklist)

3. The circulating nurse standing at -

the opposite side of the table will
assist the scrub nurse in opening the
wrapper of the sterile gown.
- The circulating nurse should only
be touching the folds of the
wrapper.
- After the wrap was opened the
circulating nurse moves back away
from the area, then the scrub
nurse approach the table.
Picking up the Gown
3. With one hand, pick up the entire -
folded gown from the wrapper by
grasping the gown through all layers,
being careful to touch only the inside
top layer which is exposed.
2. Once your hands are securely -
pinching the gown. Hold the gown
near the gown's neck and
allow it to unfold.
3. Step back from the shelf and allow -
the gown to drop. Make sure the
gown does not touch any surrounding
unsterile objects.
4. Grasp the inside shoulder seams
and open the gown with the armholes
facing you.
Inserting your arms into the sleeves of the gown
5. Carefully insert your arms part way -
into the gown one at a time, keeping
hands at shoulder level away from the
body.
6. Slide the arms further into the gown -
sleeves and when the fingertips are
level with the proximal edge of the cuff,
grasp the inside seam at the cuff hem
using thumb and index finger. Be careful
that no part of the hand protrudes from
the sleeve cuff.
Fastening the gown
7. A theatre assistant/ circulating nurse -
will fasten the gown behind you,
positioning it over the shoulders by
grasping the inside surface of the gown
at the shoulder seam. The theatre
assistant’s hands should only ever be in
contact with the inside surface of the
gown.
8. The theatre assistant/ circulating
nurse then prepares to secure the gown
at the neck and upper back. Gowns
differ in how they are secured, but most
with have either ties, buttons or Velcro
tabs.
9. The circulating person then ties the
gown at waist level at the back.
Note: before the final tie of the gown
the scrub nurse must first perform the
sterile close gloving procedure.

10. The scrub person will take hold of -

the belt tab which is securing the belt
ties. Keeping hold of the left side tie
with the left hand pull the tab with the
right-hand ties still secured and hand
the tab to the circulating person.
Variation: in the absence of the belt tab, -
the scrub nurse may use a sterile
forceps to hold the tip of the belt. The
forceps will then be handed to the
circulating nurse. The circulating nurse
must only
hold on to the forceps, careful not to
touch any part of the tie.
11. The circulating person will take hold -
of the tab/ forceps being very careful
not to touch the tie and will move to the
side or behind the scrub person. The
scrub person will then turn if necessary,
to enable them to reach and retrieve the
tie.
12. When the scrub person is properly -
positioned they will then take hold of
the belt tie only being careful not to
touch the tab or forceps and pull on the
tie leaving the circulating person with
 only the tab/ forceps in their hand The
circulating person must hold on tightly
to the tab/ or release clamp of the
forceps so that when the scrub person
pulls on the tie the tab/ forceps doesn't
come with it and contaminate them.
13. Finally the scrub practitioner will -
secure the ties on left side.

Signature over Printed Name of Student

Evaluated By:

Signature over Printed Name

Clinical Instructor

References :