JOSE RIZAL UNIVERSITY

College of Nursing and Health Sciences

Performance Checklist
Donning and Removing Sterile Gloves (Open Method)

Name of Student: ___________________________ Date: ___________

Year/Section/Group No.: ________________ Grade: __________

Rate the student’s performance by checking the appropriate box using the following criteria:

5- Excellent Carries out procedure efficiently and systematically

4- Very Satisfactory Carries out procedure efficiently or systematically, requires minimal guidance and supervision
3- Satisfactory Carries out procedure efficiently or systematically, requires moderate guidance and supervision
2- Fair Carries out procedure with close guidance and supervision
1- Poor Unable to perform the procedure

CRITERIA 5 4 3 2 1
A. KNOWLEDGE – 30%
1. Assess client for latex allergies.
2. Assemble equipment and supplies:
 Sterile gloves
3. Ensure sterility of the package of gloves.
B. SKILLS – 60%
1. Explain to the client what you are going to do, why it is necessary, and how he can
cooperate.
2. Wash hands and observe other appropriate infection control procedures.
3. Provide for client privacy.
4. Open the package of sterile gloves.
 Place the package of gloves on a clean dry surface.
 If the gloves are packed in both an inner and an outer package, open the
outer package without contaminating the gloves or the inner package.
 Remove the inner package from the outer package.
 Place the package in the center of the work area so that the top flap of the
wrapper opens away from you.
 Reaching around the package (not over it), pinch the first flap on the outside
of the wrapper between the thumb and index finger. Pull the flap open, laying
it flat on the far surface.
 Repeat for the side flaps, opening the top one first. Use the right hand for the
right flap, and the left hand for the left flap.
 Pull the fourth flap toward you by grasping the corner that is turned down.
Make sure that the flap does not touch any object.
5. Put the first glove on the dominant hand.
 If the gloves are packaged so that they lie side by side, grasp the glove for
the dominant hand by its folded cuff edge (on the palmar side) with the thumb
and first finger of the non-dominant hand. Touch only the inside of the cuff;
or,
 if the gloves are packaged one on top of the other, grasp the cuff of the top
glove as above, using the opposite hand.
 Insert the dominant hand into the glove and pull the glove on. Keep the thumb
of the inserted hand against the palm of the hand during insertion.
 Leave the cuff turned down.
6. Put the second glove on the non-dominant hand.
 Pick up the other glove with the sterile-gloved hand, inserting the gloved
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fingers under the cuff and holding the gloved thumb close to the gloved palm.
 Pull on the second glove carefully. Hold the thumb of the gloved first hand as
far as possible from the palm.
 Adjust each glove so that it fits smoothly, and carefully pull the cuffs up by
sliding the fingers under the cuffs.
7. Remove and dispose of used gloves.
 There is no special technique for removing sterile gloves. If they are soiled
with secretions, remove them by turning them inside out.
8. Document that sterile technique was used in the performance of the procedure.
C. ATTITUDE – 10%
1. Show responsibility by having a complete set of equipment needed in the activity and
shows interest in doing the procedure.
2. Display courtesy and consideration in acknowledging criticisms and suggestions by the
Clinical Instructor.
3. Demonstrate integrity by doing the skill honestly, competently and completely.
TOTAL

A. Knowledge - Total score / Total no of items x 60 + 40 = _____x .3= ______

B. Skills - Total score / Total no of items x 60 + 40 = _____x .6= ______

C. Attitude - Total score / Total no of items x 60 + 40 = _____x .1= _____

Total grade = _______

Clinical Instructor’s Comments / Suggestions:

______________________________________________________________________________________________________
______________________________________________________.

Students’ Comments / Suggestions:

______________________________________________________________________________________________________
_______________________________________________________.

_______________________ ____________________________

Student’s Signature C.I’s Name / Signature