Rle 101 103 Checklist 2023

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HANDWASHING (WHO)
Materials:
Liquid hand soap paper towel
CHECKLIST 1 2 3 4 5
1. Gather the necessary supplies. Stand in front of the sink. Do not allow your
clothing to touch the sink during the washing procedure.
2. Remove jewelry, if possible, & secure in a safe place. A plain wedding

band may remain in place.
3. Turn on water & adjust force. Regulate the temperature until the water is
warm.
4. Wet the hands & wrist area. Keep hands lower than elbows to allow water
to flow toward fingertips.
5. Use about 1 teaspoon liquid soap from dispenser & lather thoroughly.
Cover all areas of hands with the soap product.
6. Rub hands Palm to palm
7. Right palm over left dorsum with interlaced fingers and vice versa.
8. Rub palm with fingers interlaced.
9. Rub back of fingers to opposite palms with finger interlocked
10. Rotational rubbing of left thumb clasped in right palm and vice versa
11. Rotational rubbing backwards and forwards with clasped fingers of right
hand in left palm and vice versa
12. Rinse hands with water thoroughly with water flowing toward fingertips.
13. Pat hands dry with a paper towel, beginning with the fingers & moving
upward toward forearms, & discard it immediately.
14. Use another clean towel to turn off the faucet. Discard towel immediately
without touching other clean hand.
SKILLS:
TOTAL SCORE = = %
14
KNOWLEDGE: %
ASSESSING TEMPERATURE (AXILLA)
Materials:
Thermometer dry tissue clean gloves cotton ball with alcohol
CHECKLIST 1 2 3 4 5
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection

prevention procedures.
5. Provided for client privacy.
6. Placed the client in the appropriate position.
7. Wear gloves.
8. Expose the axilla and pat dry if very moist.
9. Wipe the thermometer using cotton moistened with alcohol from the tip to
base and discard the cotton ball in the appropriate receptacle.
10. Placed the tip of the thermometer in the center of the axilla.
11. Waited the appropriate amount of time.
12. Removed the thermometer and wiped with a cotton moistened with alcohol
from the base to tip and discard the cotton ball in the appropriate
receptacle.
13. If gloves were applied, removed and discarded gloves. Performed hand
hygiene.
14. Read the temperature and record it on a worksheet.
15. Washed the thermometer if necessary and returned it to storage location
16. Document the temperature in the client record.
SKILLS:
TOTAL SCORE = = %
16
KNOWLEDGE: %
ASSESSING PULSE RATE (RADIAL PULSE)
Materials:
watch with second hand
CHECKLIST 1 2 3 4 5

5. Selected pulse point.
6. Assisted client to a comfortable resting position. When the radial pulse is

assessed, with the palm facing downward, the client’s arm can rest
alongside the body or the forearm can rest at a 90-degree angle across the
chest. For the client who can sit, the forearm can rest across the thigh, with
the palm of the hand facing downward or inward.
7. Palpated and counted the pulse. Place two or three middle fingertips lightly
and squarely over pulse point. Count for 15 seconds and multiply by 4.
Record the pulse in beats per minute on your worksheet. If taking a client’s
pulse for the first time, when obtaining baseline data, or if the pulse is
irregular, count for a full minute. If an irregular pulse is found, also take the
apical pulse.
8. Assessed pulse rhythm and volume.
9. Document the pulse rate, rhythm, and volume and your actions in the client
record.
SKILLS:
TOTAL SCORE = = %
9
KNOWLEDGE: %
ASSESSING RESPIRATORY RATE
Materials:
watch with second hand
CHECKLIST 1 2 3 4 5

6. Observe and count the respiratory rate. Count the respiratory rate for 30
seconds if the respirations are regular. Count for 60 seconds if they are
irregular. An inhalation and an exhalation count as one respiration.
7. Observed depth, rhythm, and character of respirations.
8. Document the respiratory rate, depth, rhythm, and character on the

appropriate record.
SKILLS:
TOTAL SCORE = = %
8
KNOWLEDGE: %
ASSESSING BLOOD PRESSURE
Materials:
Sphygmomanometer stethoscope cotton balls with alcohol (antiseptic wipe)
CHECKLIST 1 2 3 4 5

6. Positioned the client appropriately.
7. Wrapped the deflated cuff evenly around the upper arm. Applied the center
of the bladder directly over the brachial artery.
8. Performed a preliminary palpatory determination of systolic pressure, if

client’s initial examination.
a. Palpated the brachial artery with the fingertips.
b. Pumped up the cuff until the brachial pulse was no longer felt.
c. Released the pressure completely in the cuff, and waited 1 to 2 minutes
before making further measurements.
9. Positioned stethoscope appropriately.

a. Cleanse the earpieces with antiseptic wipe.
b. Inserted the ear attachments of the stethoscope in ears so that they
tilted slightly forward.
c. Ensured that the stethoscope hung freely from the ears to the
diaphragm.
d. Placed the bell side of the amplifier of the stethoscope over the brachial
pulse site.
e. Placed the stethoscope directly on the skin, not on clothing over the
site.
10. Auscultated client’s blood pressure.

a. Pumped up the cuff until the sphygmomanometer read 30 mm Hg
above the point where the brachial pulse disappeared.
b. Release the valve cuff carefully so that the pressure decreased at rate
of 2 to 3 mm Hg per second.
c. Identified the manometer reading at Korotkoff phases 1, 4, and 5 as
pressure fell.
d. Deflated the cuff rapidly and completely.
e. Waited 1 to 2 minutes before making further determinations.
f. Repeated above steps to confirm the accuracy of the reading.
11. Removed the cuff from the client’s arm.
12. Wiped the cuff with an approved disinfectant.

13. Document and report pertinent assessment data according to agency policy.
SKILLS:
TOTAL SCORE = = %
13
KNOWLEDGE: %
PREPARING STERILE FIELD
Materials:
Sterile wrap (2 pcs) kidney basin betadine 10cc syringe Sterile Gauze 4in x 4 in
CHECKLIST 1 2 3 4 5
PLANNING

5. Provided for client privacy if appropriate.
TO OPEN A WRAPPED PACKAGE ON A SURFACE:
6. Placed the package in the work area so that the top flap opened away from
self.
7. Reached around the package and pinched the top of the flap on the outside
of the wrapper between the thumb and index finger. Pull the flap open,
laying it flat on the far surface.
8. Repeated for side flaps using right hand for right flap and left hand for left
flap.
9. Pulled the fourth flap towards self by grasping the corner that was turned
down.
ESTABLISHED A STERILE FIELD BY USING A DRAPE.
10. Opened package containing drape as described above.
11. Plucked corner of the drape that is folded back on the top with one hand.
12. Lifted drape out of its cover and allowed it to open freely without touching
any objects.
13. Picked up another corner of the drape, holding it away from body, and
touching only the same side of the drape as the first hand
14. Laid drape on a clean and dry surface placing the bottom furthest from self.
ADDED COMMERCIALLY PACKAGED SUPPLIES TO A STERILE FIELD.
15. Opened each package as previously described.
16. Held package 15 cm above field, and allow contents to drop on the field,
avoiding the 2.5 cm edge.
ADDED SOLUTION TO A STERILE BOWL.

17. Obtain an exact amount of solution if possible.
18. Read the label three times to ensure it was the correct solution and
concentration. Wiped outside of the bottle with a damp towel to remove any
large particles that could have fallen into the bowl or field.
19. Removed lid or cap from bottle and inverted lid before placing it on surface
that was not sterile.
20. Held the label was against the palm of the hand.
21. Held bottle of fluid at a height of 10 to 15 cm over bowl and to side of sterile
field.
22. Poured solution gently to avoid splashing liquid.
23. Tilted neck of bottle back to vertical quickly when done pouring.
24. Replaced the lid securely and wrote the date and time of opening on the
label if the bottle was going to be used again.
SKILLS:
TOTAL SCORE = = %
24
KNOWLEDGE: %
DONNING AND REMOVING STERILE GLOVES (OPEN GLOVING)
Materials:
sterile gloves
CHECKLIST 1 2 3 4 5

5. Provided for client privacy if appropriate.
6. Opened the package of sterile gloves.
7. Put the first glove on the dominant hand.
8. Grasped the glove for the dominant hand by the folded cuff edge with the
thumb and first finger of the nondominant hand.
9. Inserted the dominant hand keeping the thumb of the inserted hand against
the palm.
10. Put the second glove on the nondominant hand.
11. Picked up the second glove with the sterile gloved hand, inserting the glove
to the fingers under the cuff and holding the gloved thumb close to the gloved
palm.
12. Pulled on the second glove holding the thumb of the first gloved hand as
far as possible from the palm.
13. Adjusted the gloves, pulling up by sliding fingers under the cuffs.
14. Removed soiled gloves inside out.
15. Performed hand hygiene
SKILLS:
TOTAL SCORE = = %
15
KNOWLEDGE: %
FEMALE CATHETERIZATION (Indwelling)
Materials:
Cherry balls soaked in Betadine Sharps bin Sterile water

Picking forceps Clean Gloves 10 cc syringe
Lubricating jelly Sterile Gloves Plaster
Waterproof drape Foley Catheter Bandage scissors
Urobag
CHECKLIST 1 2 3 4 5
1. Introduce yourself and verified the client’s identity.
4. Performed hand hygiene and observed other appropriate infection control

procedures.
Prepared equipment:
6. Opened 10cc syringe and filled with 10cc sterile water
7. Opened the drainage bag package and placed the end of tubing within reach.
8. Opened Sterile Catheter:

a. Opened the outer package of sterile catheter half way.
b. Opened the top part of inner package and exposed the balloon and urine
drainage tube, making sure not to touch with unsterile hand the part of inner
package with the catheter tube.
9. Pretested the balloon applying agency policy and/or manufacturer

recommendations.
a. Attached syringe.
If using needle-access catheter:
i. Held an inflation valve between two fingers of a nondominant hand.
ii. Using a dominant hand, insert a needle parallel to the balloon tube,
making sure not to injure yourself.
b. Injected 10cc of sterile water.
c. Observed for leaks or any damages in the balloon.
d. If none, aspirated sterile water.
e. Removed syringe and recap.
If using syringe with needle,
i. Recap safely using a one-hand scoop method. Do not use the other
hand to hold the cap in the process.
f. Placed syringe within reach.
10. Attach end of tubing of the drainage bag at the urine drainage port of the
catheter
11. Prepare Sterile field using the inner package of sterile gloves:
a. Opened sterile gloves.
b. Poured lubricating jelly
Prepared client:
12. Placed client in appropriate position: supine with knees flexed, feet about 2 feet
apart, and hips slightly, externally rotated.
13. Draped all areas except perineum.
14. Established adequate lighting
15. Stood on client’s right if nurse was right-handed and on left if nurse was
left-handed
16. Placed a waterproof drape under the buttocks without contaminating the center
of the drape.
17. Open container of cherry balls soaked in betadine
18. Don Clean Gloves
19. Cleansed the meatus.

a. With the thumb and one finger of a nondominant hand, spread labia and
identified meatus. Did not allow the labia to close over cleaned meatus.
b. Use the dominant hand to handle picking forceps.
c. Pick up a cherry ball using picking forceps.
d. Cleansed in anteroposterior direction using one cherry ball for each wipe.
a. Wipe the farther labia and discard the cherry ball.
b. Wipe the nearer labia and discard the cherry ball.
c. Lastly, wipe over the meatus and discard cherry ball
2. Remove clean gloves
Inserted catheter:
20. Don Sterile gloves
21. Inserted the catheter.

a. Removed catheter from package holding the sterile catheter tube.
b. Grasped catheter firmly 2 to 3 in. from tip.
c. Lubricated the tip (1-2 inches)
d. Asked the client to take a slow deep breath and inserted a catheter
approximately 2 to 3 in. as the client exhaled.
e. After urine begins to flow through it, advance the catheter another 2-3 in.
farther.
f. If the catheter becomes contaminated by touching labia or other tissue
before entering meatus, perform catheterization with a new sterile catheter.
g. Held catheter with a nondominant hand.
22. Inflated retention balloon with designated volume.

a. Without releasing the catheter, held the inflation valve between two fingers
of the nondominant hand while the nurse inflated with the dominant hand.
b. If patient complains pain, it could indicate the catheter is not in the bladder.
Deflate the balloon and insert the catheter further into the bladder. ALWAYS
ensure urine is flowing before inflating the balloon.
c. Pulled gently on the catheter until resistance was felt.
23. Secured an indwelling catheter to client’s inner thigh.
24. Secured collecting tubing and hung bag below bladder level.
25. Wiped the perineal area of any remaining antiseptic or lubricant

26. Returned the client to a comfortable position. Instructed client on positioning and
moving with catheter in place.
27. Discarded all used supplies in appropriate receptacles.
28. Removed and discarded gloves.
29. Performed hand hygiene.
30. Documented procedure and all relevant information
SKILLS:
TOTAL SCORE = = %
30
KNOWLEDGE: %
MALE CATHETERIZATION (Indwelling)
Materials:
Cherry balls soaked in Betadine Sharps bin Sterile water

Picking forceps Clean Gloves 10 cc syringe
Lubricating jelly Sterile Gloves Plaster
Waterproof drape Foley Catheter Bandage scissors
Urobag
CHECKLIST 1 2 3 4 5
1. Introduced yourself and verified the client’s identity.
4. Performed hand hygiene and observed other appropriate infection control

procedures.
Prepared equipment:
6. Opened 10cc syringe and filled with 10cc sterile water
7. Opened the drainage bag package and placed the end of tubing within reach.
8. Opened Sterile Catheter:

a. Opened the outer package of sterile catheter half way.
b. Opened the top part of the inner package and exposed the balloon and urine
drainage tube, making sure not to touch with unsterile hand the part of inner
package with the catheter tube.
9. Pretested the balloon applying agency policy and/or manufacturer

recommendations.
a. Attached syringe.
If using needle-access catheter:
i. Held an inflation valve between two fingers of a nondominant hand.
ii. Using a dominant hand, insert a needle parallel to the balloon tube,
making sure not to injure yourself.
c. Injected 10cc of sterile water.
d. Observed for leaks or any damages in the balloon.
e. If none, aspirated sterile water.
f. Removed syringe and recap.
If using syringe with needle,
i. Recap safely using a one-hand scoop method. Do not use the other
hand to hold the cap in the process.
g. Placed syringe within reach.
10. Attach end of tubing of the drainage bag at the urine drainage port of the catheter
11. Prepare Sterile field using the inner package of sterile gloves:
h. Opened sterile gloves.
i. Poured lubricating jelly
Prepared client:
12. Placed client in appropriate position: supine, thighs slightly abducted or apart
13. Draped all areas except perineum.
14. Established adequate lighting
15. Stood on client’s right if nurse was right-handed and on left if nurse was
left-handed
16. Placed a waterproof drape under the penis without contaminating the center
of the drape.
Applied sterile gloves.
17. Cleansed the meatus.

a. Grasped penis just below glans with nondominant hand. Retracted foreskin if
necessary.
b. Using your dominant hand, pick up a cherry ball. Cleansed in circular motion
from the meatus down the glans of the penis. Used a new cherry ball each time
for three more wipes.
c. Discarded each cherry ball after one use.
Inserted catheter:
18. . Inserted the catheter.

a. Removed catheter from package holding the sterile catheter tube.
b. Lubricated the tip (6-7 inches)
c. Hold the catheter an inch or two from the tip.
d. Ask the patient to take deep breaths.
e. Advance the catheter to the bifurcation or “Y” level of the ports. Do not use
force to introduce the catheter.
f. If the catheter resists, ask the patient to breathe deeply and slowly advance
while rotating the catheter.
g. Hold the catheter securely at the meatus with your nondominant hand
19. Inflated retention balloon with designated volume.

a. Without releasing the catheter, held the inflation valve between two fingers of
the nondominant hand while the nurse inflated with the dominant hand.
(ALWAYS ensure urine is flowing before inflating the balloon.)
c. Lower the penis.
d. Pull gently on the catheter until resistance is felt.
20. Secured an indwelling catheter to client’s abdomen or anterior thigh.
21. Secured collecting tubing and hung bag below bladder level.
22. Wiped the perineal area of any remaining antiseptic or lubricant.
23. Returned the client to a comfortable position. Instructed client on positioning

and moving with catheter in place.
25. Discarded all used supplies in appropriate receptacles.
28. Documented procedure and all relevant information

SKILLS:
TOTAL SCORE = = %
28
KNOWLEDGE: %
ONE-HAND SCOOP TECHNIQUE
Materials:
Syringe with Needle Sharps bin Kelly Forceps Clean gloves (worn prior to procedure)
CHECKLIST 1 2 3 4 5
One-Hand Scoop to recap needle:
1. Leave the needle cap on the surface
2. Keep a non-dominant hand at the side.
3. Using Dominant hand, hold the barrel of the syringe
4. Guide the sharp used needle tip into the cap using only one hand
(dominant hand)
5. Recap the bulk of the length of the needle by moving the syringe forward -
this allows the needle to enter the cap in a scooping movement
6. Lift the needle and syringe vertically
7. Once the tip is covered:

1. use the other hand to affix the cap into place, or
2. use a hard surface to snap the cap into place without using the other
hand
8. Discard the needle into a sharps bin following the facility policy.
SKILLS:
TOTAL SCORE = = %
10
KNOWLEDGE: %
ADMINISTERING INTRADERMAL INJECTION
Materials:
Cotton balls in Sterile Water Clean gloves Bandage scissors

container Tuberculin syringe Plaster Withdrawal Needle
Alcohol Medication Tray
Ampule (Vit. C or PCM)
CHECKLIST 1 2 3 4 5
1. Check the physician's order.
2. Assemble equipment
3. Perform hand hygiene.
4. Prepare medication. If necessary, withdraw medication from ampule or vial.
5. Introduce yourself.
6. Identify the patient carefully. There are three ways to do this:

a. Check the name of the patient’s identification badge.
b. Ask the patient his or her name.
c. Verify the patient’s identification with the staff member who knows the patient.
7. Explain procedure to patient.
8. Locate site of choice. Ensure that the area is not tender and is free of lumps or nodules.
a. Select an area on the inner aspect of the forearm that is not heavily pigmented or
covered with hair.
b. Upper chest or upper back beneath the scapulae are also sites for intradermal
injections.
9. Don disposable gloves.
10. Clean area around the injection site. Use a firm circular motion while moving outward
from the injection site. Allow the area to dry.
11. Remove the needle cap with a non-dominant hand by pulling it straight off.
12. Use a non-dominant hand to spread skin taut over the injection site.
13. Place the needle almost flat against the patient's skin, bevel side up. Insert needle into
skin so that point of the needle can be seen through skin. Insert needle only about 1/8
inch with the entire bevel under the skin.
14. Slowly inject agent while watching for a small wheal or blister to appear. If none
appears, withdraw the needle to ensure the bevel is intradermal tissue.
15. Once the agent has been injected, withdraw the needle quickly at the same angle it was
inserted.
16. Do not massage the area after removing the needle. Tell the patient not to rub or
scratch the side.
17. Do not recap the used needle. Discard needle and syringe in appropriate receptacle.
18. Assist patients to a position of comfort.
19. Remove gloves, and dispose of them properly.
20. Do after care.
22. Evaluate patient response to medication within an appropriate time frame.
23. Chart administration of medication, including the site of administration and if there are
any reactions (usually at 24 to 72 hours periods).
24. Observe the area for signs of a reaction at ordered intervals,
SKILLS:
TOTAL SCORE = = %
24
KNOWLEDGE: %
ADMINISTERING SUBCUTANEOUS INJECTION
Materials:
Cotton balls in Medication Tray Syringe 3cc Plaster Withdrawal

container Sterile Water Clean gloves Needle Bandage
Alcohol scissors
CHECKLIST 1 2 3 4 5
1. Check physician's order.

9. Have patients assume a position appropriate for the most commonly used sites.
a. Outer aspects of the upper arm- Patient's arm should be relaxed and at the side of the
body.
b. Anterior thighs- Patients may sit or lie with their legs relaxed.
c. Abdomen- Patient may lie in a semi recumbent position.
11. Clean area around injection site with an antimicrobial swab. Use a firm circular motion
while moving outward from the injection site. Allow the area to dry.
12. Remove the needle cap with a non-dominant hand, pulling it straight off.
13. Grasp and bunch area surrounding injection site or spread skin at site.
14. Hold the syringe using the dominant hand between thumb and forefinger. Inject needle
quickly at an angle of 45 to 90 degrees, depending on amount and turgor of tissue and
length of needle.
15. After the needle is in place, release tissue. If you have a large skin fold pinched up, ensure
that the needle stays in place as the skin is released. Immediately move your
non-dominant hand to steady the lower end of the syringe. Slide your dominant hand to
the tip of the barrel.
16. Aspirate, if recommended, by pulling back gently of the syringe plunger to determine
whether the needle is in the blood vessel. (According to the CDC (2009) this procedure is
not required).
17. If blood appears, the needle should be withdrawn, the medication syringe and needle
discarded, and a new syringe with medication prepared. Do not aspirate when giving
insulin or heparin.
18. If no blood appears, inject the solution slowly.
19. Withdraw the needle quickly at the same angle at which it was inserted.
20. Apply gentle pressure. Do not massage the site. Apply a small bandage if needed.
23. Remove gloves, and dispose of them properly.
24. Do after care.
any reactions.
SKILLS:
TOTAL SCORE = = %
27
KNOWLEDGE: %
ADMINISTERING INTRAMUSCULAR INJECTION
Materials:
Cotton balls in Medication Tray Syringe 3cc Plaster Withdrawal

container Sterile Water Clean gloves Needle Bandage
Alcohol scissors
CHECKLIST 1 2 3 4 5
1. Check physician's order.

9. Have patients assume a position appropriate for the most commonly used sites.
a. Ventrogluteal- Patient may lie on back or side with hip and knee flexed.
b. Vastuslateralis- Patient may lie on the back or may assume a sitting position.
c. Deltoid- patients may sit or lie with their arms relaxed.
d. Dorsogluteal- Patient may lie prone with toes pointing inward or on side with upper
leg flexed and placed in front of lower leg.
11. Clean area around injection site with an antimicrobial swab. Use a firm circular motion
while moving outward from the injection site. Allow the area to dry.
12. Remove the needle cap with a non-dominant hand, pulling it straight off.
13. Displace skin in a Z-track manner by pulling to one side or spread skin at the site using
your non-dominant hand.
14. Hold a syringe using your dominant hand between thumb and forefinger. Quickly dart
needle into the tissue at the 90-degree angle.
15. As soon as the needle is in place, move your non-dominant hand to hold the lower end
of the syringe. Slide your dominant hand to tip of the barrel.
16. Aspirate, if recommended, by pulling back gently of the syringe plunger to determine
whether the needle is in the blood vessel. (According to the CDC (2009) this procedure is
not required).
17. If blood appears, the needle should be withdrawn, the medication syringe and needle
discarded, and a new syringe with medication prepared. Do not aspirate when giving
insulin or heparin.
18. If no blood appears, inject the solution slowly.
19. Withdraw needle quickly at the same angle at which it was inserted
20. Replace displaced tissue if Z-track technique was used.
21. Apply gentle pressure. Do not massage the site. Apply a small bandage if needed.
24. Remove gloves and dispose of them properly.
25. Do after care.
any reactions.
SKILLS:
TOTAL SCORE = = %
28
KNOWLEDGE: %
WOUND CARE
Materials:
waste PNSS cherry balls sterile pack Forceps plaster

receptacle cherry balls soaked in betadine old wound dressing kidney basin sterile gloves 5 pcs gauze
clean gloves
CHECKLIST 1 2 3 4 5
1. Review the medical orders for wound care or the nursing plan of care related to
wound care.
2. Gather the necessary supplies and bring to the bedside stand or overbed table.
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around the bed and close door to room if possible.
6. Explain what you are going to do and why you are going to do it to the patient.
7. Assess the patient for possible need for nonpharmacologic pain-reducing

interventions or analgesic medication before wound care dressing change.
Administer appropriate prescribed analgesic. Allow enough time for analgesic to
achieve its effectiveness.
8. Place a waste receptacle or bag at a convenient location for use during the
procedure.
9. Adjust bed to comfortable working height, usually elbow height of the caregiver
10. Assist the patient to a comfortable position that provides easy access to the wound
area. Use the bath blanket to cover any exposed area other than the wound. Place
a waterproof pad under the wound site.
11. Check the position of drains, tubes, or other adjuncts before removing the dressing
12. Put on clean, disposable gloves
13. Loosen tape on the old dressings. If necessary, use an adhesive remover or normal
saline to help get the tape off.
14. Carefully remove the soiled dressings. If any part of the dressing sticks to the
underlying skin, use small amounts of sterile saline to help loosen and remove
15. After removing the dressing, note the presence, amount, type, color, and odor of
any drainage on the dressings.
16. Place soiled dressings in the appropriate waste receptacle.

17. Remove your gloves and dispose of them in an appropriate waste receptacle
18. Inspect the wound site for size, appearance, and drainage. Assess if any pain is
present. Check the status of sutures, adhesive closure strips, staples, and drains or
tubes, if present. Note any problems to include in your documentation.
19. Using sterile technique, prepare a sterile work area and open the needed supplies
20. Open the sterile cleaning solution. Depending on the amount of cleaning needed,
the solution might be poured directly over gauze sponges over a container for small
cleaning jobs, or into a basin for more complex or larger cleaning.
21. Put on sterile gloves
22. Clean the wound with gauze dampened with normal saline.
a. Clean the wound from top to bottom and from the center to the outside. Following
this pattern, use new gauze for each wipe, placing the used gauze in the waste
receptacle.
b. If a drain is in use at the wound location, clean around the drain from center to
outside
23. Once the wound is cleaned, dry the area using a gauze sponge in the same manner.
24. Apply betadine, ointment or antiseptic medications, as ordered, in the same

manner.
25. Apply a layer of dry, sterile dressing over the wound. Forceps may be used to apply
the dressing.
a. 1st layer serves as a wick for drainage
b. 2nd layer is for increased absorption of drainage
c. 3rd layer act as additional protection for the wound against microorganism
26. Remove and discard gloves.
27. Apply tape
28. After securing the dressing, label dressing with date and time.
29. Remove all remaining equipment; place the patient in a comfortable position, with
side rails up and bed in the lowest position.
31. Check all wound dressings every shift. More frequent checks may be needed if the
wound is more complex or dressings become saturated quickly.
SKILLS:
TOTAL SCORE = = %
31
KNOWLEDGE: %
DONNING AND REMOVING STERILE GLOVES (OPEN GLOVING)
Materials:
Sterile gloves
CHECKLIST 1 2 3 4 5
DONNING STERILE GLOVES
2. Identify the patient. Explain the procedure to the patient.
3. Check that the sterile glove package is dry and unopened. Also note expiration date,
making sure that the date is still valid.
4. Place a sterile glove package on clean, dry surface at or above your waist.
5. Open the outside wrapper by carefully peeling the top layer back. Remove the inner
package, handling only the outside of it.
6. Place the inner package on the work surface with the side labeled ‘cuff end’ closest to
the body.
7. Carefully open the inner package. Fold open the top flap, then the bottom and sides.
Take care not to touch the inner surface of the package or the gloves.
8. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the
glove for the dominant hand, touching only the exposed inside of the glove.
9. Keeping the hands above the waistline, lift and hold the glove up and off the inner
package with fingers down. Be careful it does not touch any unsterile object.
10. Carefully insert the dominant hand palm up into the glove and pull the glove on. Leave
the cuff folded until the opposite hand is gloved.
11. Hold the thumb of the gloved hand outward. Place the fingers of the gloved hand
inside the cuff of the remaining glove. Lift it from the wrapper, taking care not to touch
anything with the gloves or hands.
12. Carefully insert a nondominant hand into the glove. Pull the glove on, taking care that
the skin does not touch any of the outer surfaces of the gloves.
13. Slide the fingers of one hand under the cuff of the other and fully extend the cuff down
the arm, touching only the sterile outside of the glove. Repeat for the remaining hand.
14. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile
areas
15. Continue with procedure as indicated

REMOVING SOILED GLOVES
16. Use your dominant hand to grasp the opposite glove near the cuff end on the outside
exposed area. Remove it by pulling it off, inverting it as it is pulled, keeping the
contaminated area on the inside. Hold the removed glove in the remaining gloved hand
17. Slide fingers of ungloved hand inside the remaining glove cuff. Take care to avoid
touching the outside surface of the glove. Remove it by pulling it off, inverting it as it is
pulled, keeping the contaminated area on the inside, and securing the first glove inside
the second.
18. Discard gloves in the appropriate container. Remove additional PPE, if used. Perform
hand hygienest
SKILLS: TOTAL SCORE = = %

18
KNOWLEDGE: %
BLOOD TRANSFUSION
Materials:
Blood bag blood set waste receptacle IV Main line PNSS clean gloves
CHECKLIST 1 2 3 4 5
1. Performed pre administration protocol:
1.1. Obtained blood component following agency protocol.
1.2. Checked blood bag for signs of contamination and presence of leaks.
1.3. Compared verbally; correctly verified patient, blood product, and type
with another qualified person before initiating transfusion.
1.3.1. identifies patients using at least two identifiers.
1.3.2. Matched transfusion record number and patient’s ID number.
1.3.3. Ensured patient name is correct on all documents
1.3.4. Checked unit number on blood bag with blood bank, checked
expiration date and time.
1.3.5. Ensure blood type matches transfusion record and blood bag
1.3.6. Checked that patient’s blood type and Rh type are compatible with
donor’s
1.3.7. Checked expiration date and time on the unit of blood.
1.3.8. Check patient’s ID information with blood unit label, do not

administer if patient has no ID bracelet.
1.3.9. Verified patient and unit identification record process properly.
1.4. Reviewed purpose of transfusion, asked patient to report any changes he

or she may feel during the transfusion.
1.5. Had patient empty urine drainage collection container or applied gloves
and emptied for him or her
2. Administered transfusion:
2.1. Performed hand hygiene, applied gloves, re-inspected blood product for
leakage or unusual appearance.
2.2. Opened Y-tubing blood administration set, used multiset if needed.
2.3. Set all clamps to off position.
2.4. Spiked normal saline IV bag with spike, hung bag on pole, primed tubing,
opened upper clamp on saline side of tubing, squeezed drip chamber
until fluid covered filter and appropriate amount of drip chamber.
2.5. Maintained clamp on blood product side of tubing in off position, opened
common tubing clamp, closed clamp when tubing was filled with saline,
maintained protective sterile cap on tubing connector.
2.6. Prepared blood component for administration, agitated blood unit bag,
removed covering from access port, spiked unit with another Y
connection, closed saline clamp, opened blood unit clamp, primed tubing
with blood, ensured residual air was removed.
2.7. Maintained asepsis, attached primed tubing to patient’s VAD, connected

primed blood administration tubing to patient’s VAD.
2.8. Opened tubing clamp, regulated blood flow properly.
2.9. Monitored patient’s vital signs at the appropriate times.
2.10. Regulated rate appropriately if there was no transfusion reaction,

checked drop factor for the blood tubing.
2.11. Cleared IV line with saline, discarded blood bag appropriately, maintained
patency when consecutive units were ordered.
2.12. Disposed of all supplies appropriately, removed gloves, performed hand

hygiene.
3. Evaluate for transfusion reaction. If no blood transfusion reaction,

increase the rate to 25-30 drops or according to hospital policy
SKILLS:
TOTAL SCORE = = %
28
KNOWLEDGE: %
ASSESSING THE RESPIRATORY SYSTEM
Materials:
Gloves Stethoscope Light source Mask Skin marker Metric ruler
CHECKLIST 1 2 3 4 5
1. Gather all equipment.
2. Perform Hand hygiene and explain procedure to patient
3. Provide privacy and expose only the part to be examined.
INSPECTION
4. Anterior/Posterior/Lateral. Compare side to side. Work apex to base
5. Assess respiratory rate and rhythm, depth, symmetry for chest movement
6. Assess AP ratio, costal angle, spinal deformities muscles for breathing and condition of
skin
PALPATION
7. Anterior/Posterior/Lateral. Compare side to side. Work apex to base
8. Palpate the trachea.
9. Palpate chest for tenderness and sensation.
10. Palpate the chest for crepitus and other abnormalities.

Crepitus- Use your fingers and follow the appropriate sequence when palpating. Note
if there is a crackling sensation (like bones or hairs rubbing against each other) as you
palpate.
11. Assess for tactile fremitus. Use the ball or ulnar edge of one hand to assess for
fremitus. As you move your hand to each area, ask the client to say “ninety-nine.”
Assess all areas for symmetry and intensity of vibration.
12. Assess for chest expansion. Place your hands on the posterior chest wall with your
thumbs at the level of T9 or T10 and pressing together a small skin fold. As the client
takes a deep breath, observe the movement of your thumbs
PERCUSSION
13. Percuss Anterior/Posterior/Lateral portion of chest.
14. Note the general percussion sound of the chest.
15. Percuss for diaphragmatic chest excursion.

● Ask the client to exhale forcefully and hold the breath. Beginning at the scapular line
(T7), percuss the intercostal spaces of the right posterior chest wall.
● Percuss downward until the tone changes from resonance to dullness. Mark this level
and allow the client to breathe.
● Next ask the client to inhale deeply and hold it. Percuss the intercostal spaces from
the mark downward until resonance changes to dullness.
● Mark the level and allow the client to breathe. Measure the distance between the two
marks.
AUSCULTATION
16. Use the diaphragm of a stethoscope. Have patients take slow, deep breaths through
their mouths.
17. Assess Anterior/Posterior/Lateral. Compare side to side, apex to base.
18. Assess breath sounds (bronchial, bronchovesicular, vesicular)

● Bronchial- heard over the trachea and thorax.
● Bronchovesicular- heard over the major bronchi—posterior: between the
scapulae; anterior: around the upper sternum in the first and second intercostal
spaces.
● Vesicular- heard over the peripheral lung fields.
19. Assess for voice sounds.

● Bronchophony: Ask the client to repeat the phrase “ninety-nine” while you
auscultate the chest wall.
● Egophony: Ask the client to repeat the letter “E” while you listen over the chest
wall.
● Whispered pectoriloquy: Ask the client to whisper the phrase “one–two–three”
while you auscultate the chest wall.
20. After the assessment, make the patient comfortable and perform hand hygiene. Do
after care.
21. Document the data.
SKILLS:
TOTAL SCORE = = %
21
KNOWLEDGE: %
ASSESSING THE ABDOMEN
Materials:
Gloves Stethoscope Light source Mask Skin marker Metric ruler
CHECKLIST 1 2 3 4 5
1. Gather all equipment
INSPECTION
3. Have patient void before exam. Inspect from side and foot of bed.
4. Assess the abdomen. Note size, shape and symmetry and condition of skin
5. Note abdominal movements: respiratory, pulsations and peristalsis
6. Note position, contour, color and herniation of umbilicus
AUSCULTATION
7. Auscultate for bowel sounds in each quadrant
8. Auscultate for bruits over aorta, renal, iliac, and femoral arteries
9. Use a scratch test to locate the inferior edge of the liver.

● Place the diaphragm of your stethoscope at the second to last intercostal
space, MCL.
● Use one finger to very lightly stroke the skin horizontally, starting at the
umbilicus. Continue to stroke the skin, moving toward the lower costal
margin.
● The sound will suddenly be transmitted through the stethoscope and
increase in intensity. This indicates the lower border of the liver.
PERCUSSION
10. Percuss the tone of the abdomen in each quadrant.
11. Note areas of tympany, dullness or tenderness.
12. Percuss the span or height of the liver by determining its lower and upper borders.
● To assess the lower border, begin in the RLQ at the mid-clavicular line
(MCL) and percuss upward.
● Note the change from tympany to dullness. Mark this point: It is the lower
border of liver dullness.
● To assess the upper border, percuss over the upper right chest at the MCL
and percuss downward, noting the change from lung resonance to liver
dullness.
● Mark this point: It is the upper border of liver dullness.
● Measure the distance between the two marks: this is the span of the liver.
13. Percuss the spleen.

● Begin posterior to the left mid-axillary line (MAL), and percuss downward,
noting the change from lung resonance to splenic dullness.
14. Blunt percussion for costovertebral angle

- Place non-dominant hand over organ
- Make fist with dominant hand
- Note any tenderness
15. If indicated, use blunt percussion to assess for organ (liver or gallbladder)
tenderness.
16. Percuss the urinary bladder.
PALPATION
17. Palpate all four quadrants beginning with a light palpation, then do deep,
bimanual palpation
18. Note for masses, bulges, or swelling around the umbilicus.
19. Test abdominal reflexes by lightly stroking each quadrant toward the umbilicus.
20. Assess the pulsation of the abdominal aorta.
21. Palpate the liver. (Bimanual and Hooking techniques)

● Bimanual Technique
o Stand at the client’s right side and place your left hand under the
client’s back at the level of the eleventh to twelfth ribs.
o Lay your right hand parallel to the right costal margin (your fingertips
should point toward the client’s head).
o Ask the client to inhale, then compress upward and inward with your
fingers.
o Have the client exhale and hold your hand in place as the client
inhales a second time.
o With deep inhalation the edge of the liver is more easily palpated.
● Hooking Technique
o To palpate by hooking, stand to the right of the client’s chest.
o Curl (hook) the fingers of both hands over the edge of the right costal
margin.
o Ask the client to take a deep breath and gently but firmly pull inward
and upward with your fingers.
22. Palpate the spleen, kidneys, urinary bladder.
23. Palpate for inguinal lymph nodes. Use light palpation; palpate horizontal and
vertical inguinal nodes. Note size, shape, consistency, tenderness, and mobility.
24. TEST FOR ASCITES: Test for shifting dullness and perform the fluid wave test.
25. TEST FOR APPENDICITIS: If indicated, assess for rebound tenderness at

McBurney’s point, referred rebound tenderness, the iliopsoas test, and the
Obturator test.
26. TEST FOR CHOLECYSTITIS: Press your fingertips under the liver border at the right
costal margin and ask the client to inhale deeply.
27. After the assessment, make the patient comfortable and perform hand hygiene.
Do after care.
SKILLS:
TOTAL SCORE = = %
28
KNOWLEDGE: %
ASSESSING HEAD & NECK
Materials:
Penlight Clean Gloves Stethoscope
CHECKLIST 1 2 3 4 5
3. Performed hand hygiene and observed other appropriate infection prevention procedures.
HEAD
INSPECTION
5. Inspect head size and shape and symmetry of facial features.
6. Inspect frontal sinuses above the eyes and maxillary sinuses below the eyes.
7. Transillumination
● Frontal sinuses: shine light upward under eyebrow.
● Maxillary sinuses: shine light below eyes while looking for a red glow on the roof
(palate) of the mouth.
8. Inspect external nose for size, shape, and symmetry.
PALPATION
9. Use light palpation to note head size, shape, symmetry, masses or areas of tenderness.
10. Use light palpation to palpate the scalp for mobility and tenderness.
11. Palpate the TMJ by placing fingers over the TMJ and palpating the joint as the patient
opens and closes his or her mouth.
12. Sinuses: (note for any tenderness)

● Frontal sinuses: press upward just below eyebrows
● Maxillary sinuses: press below eyes
13. Glands (Parotid, Submandibular, and Sublingual)
● Parotid: Palpate in front of ears.
● Submandibular and sublingual: Palpate under the mandible.
PERCUSSION
14. Sinuses:
● Frontal sinuses: use direct or immediate percussion above eyebrows.
● Maxillary sinuses: use direct or immediate percussion below eyes.
NECK
INSPECTION
15. Inspect neck in neutral and hyperextended positions and as patient swallows.
PALPATION
16. Use light palpation and check for masses or areas of tenderness.
17. Cervical Nodes

● Occipital node: Lightly palpate at the back of the head at the base of the skull.
● Postauricular node: Lightly palpate behind the ears.
● Preauricular node: Lightly palpate in front of the ears.
● Tonsillar node: Lightly palpate at the angle of the jaw.
● Submandibular: Lightly palpate under the mandible.
● Submental: Lightly palpate under the tip of the chin.
● Supraclavicular node: Lightly palpate above the clavicle.
● Infraclavicular node: Lightly palpate below the clavicle.
18. Thyroid
● Locate the thyroid isthmus below the cricoid cartilage.
● Right lobe: Have patient tilt head to right, and then gently displace trachea to right,
slide fingers to right, and palpate right thyroid lobe as patient swallows (the gland
moves up with the cartilage as the patient swallows).
● Left lobe: repeat the same technique but have patient tilt head to left, displace
trachea to left, and palpate the left lobe.
AUSCULTATION
19. If thyroid gland is palpable, have patient hold breath and then listen over the thyroid
gland with the bell portion of the stethoscope for bruits.
20. After the assessment, make the patient comfortable and perform hand hygiene. Do
after care.
SKILLS:
TOTAL SCORE = = %
21
ASSESSING THE CRANIAL NERVES
Materials:
Clean Gloves Cotton-tipped applicators Tongue depressor (3 pcs)
Snellen Chart Substance to smell and taste (salt, sugar, and vinegar to Tuning Fork Toothpick Penlight
taste and coffee grounds for smelling)
CHECKLIST 1 2 3 4 5
2. Remove jewelry, if possible, and secure in a safe place. A plain wedding band may
remain in place.
3. Introduce yourself and verify the client’s identity. Explain the procedure to the client
and how the client can cooperate.
4. Perform hand hygiene and observe other appropriate infection control procedures.
Provide for client privacy.
5. Inquire if the client has any history of the following:

● Present health concern and current symptoms (headaches, numbness, tingling,
dizziness, lightheadedness)
● Past history of head injury, stroke, encephalitis, meningitis
● Family history of high blood pressure, stroke, epilepsy, brain cancer
● Lifestyle and health practices that are risk factors for neurological impairment
CRANIAL NERVES
6. Test Cranial Nerve I (Olfactory)
● ensure patency of each nostril
● ask client to close his/her eyes
● occlude one nostril and hold an aromatic substance beneath the nose.
● ask the patient to identify the substance. repeat with another nostril.
7. Test Cranial Nerve II (Optic)

● use a Snellen chart to assess visual acuity
● assess visual fields of each eye by confrontation test
8. Test Cranial Nerve III, IV, VI (Oculomotor, Trochlear & Abducens)

● assess extraocular muscle movements using six cardinal fields of gaze
● assess pupillary response to light and accommodation
9. Test Cranial Nerve V (Trigeminal)
● testing motor function: Ask the patient to move jaw from side to side against
resistance and then clench jaw as you palpate contraction of temporal and
masseter muscles.
● testing sensory function: Ask a patient to close eyes and tell you when he or she
feels sensation on the face. Touch jaw, cheeks, and forehead with a cotton
applicator. Touch the same areas with a toothpick. Compare both bilaterally.
10. Test Cranial Nerve VII (Facial)

● testing motor function: ask patient to perform these movements: smile, frown,
raise eyebrows, puff out cheeks, purse lips, close eyes tightly against resistance
● testing sensory function: Test taste on anterior two-thirds of tongue for
sweet,sour,salty
11. Test Cranial Nerve VIII (Acoustic/Vestibulocochlear)

- Perform Weber & Rinne tests for hearing
● WEBER: Strike a tuning fork softly with the back of your hand and place it at the
center of the client’s head or forehead. Ask whether the client hears the sound
better in one ear or the same in both ears.
● RINNE: Strike a tuning fork and place the base of the fork on the client’s
mastoid process. Ask the client to tell you when the sound is no longer heard.
Move the prongs of the tuning fork to the front of the external auditory canal.
Ask the client to tell you if the sound is audible after the fork is moved.
12. Test Cranial Nerve IX & X (Glossopharyngeal & Vagus)

● observe the ability to cough, swallow, and talk.
● test motor function: Ask patient to open mouth and say “ah” while you depress
● the tongue with a tongue blade. Observe soft palate and uvula. Soft palate and
uvula should rise medially.
● testing sensory function (CN IX) and motor function (CN X): stimulate gag reflex.
lightly touch the tip of the tongue blade to the posterior pharyngeal wall.
13. Test Cranial Nerve XI (Spinal Accessory)

● ask the patient to shrug shoulders upward against your resistance. Then ask her
or him to turn your head from side to side against your resistance. Observe the
symmetry of contraction and muscle strength.
14. Test Cranial Nerve XII (Hypoglossal)

● ask the client to protrude the tongue. observe any deviations, lesions, or
atrophy
● ask the client to move the tongue from side to side against resistance using a
tongue blade.
15. After the assessment, make the patient comfortable and perform hand hygiene. Do after
care.
SKILLS:
TOTAL SCORE = = %
16
KNOWLEDGE: %
OBTAINING A SAMPLE FOR CAPILLARY BLOOD
GLUCOSE
Materials:
Blood Glucose meter Sterile lancet Cotton balls Testing strips Clean gloves Sharps Bin
CHECKLIST 1 2 3 4 5
1. Check the patient’s medical record or nursing plan of care for monitoring schedule.
2. Gather equipment.
5. Explain the procedure to the patient and instruct the patient about the need for
monitoring blood glucose.
6. Close curtains around bed and close the door to the room, if possible
7. Turn on the glucose monitor device.
8. Put on nonsterile gloves.
9. Prepare the lancet using aseptic technique.
10. Remove the test strip from the vial. Recap container immediately.
11. Check that the code number for the strip matches the code number on the
monitor screen.
12. Insert the strip into the meter according to directions for that specific device.
13. For adults, massage the side of the finger toward the puncture site.
In infants and young children, use the heel to obtain the blood specimen. In an
infant, use the outer aspect of the heel. If the heel is cool, place a warm compress
on the foot.
14. Cleanse the skin with an alcohol swab. Allow the skin to dry completely.
15. Hold lancet perpendicular to skin and pierce site with lancet
16. Wipe away the first drop of blood with a cotton ball.
17. Encourage bleeding by lowering the hand, making use of gravity. Lightly stroke the
finger, if necessary, until a sufficient amount of blood has formed to cover the
sample area on the strip, based on monitor requirements. Take care not to
squeeze the finger, not to squeeze at the puncture site, or not to touch the
puncture site or blood.
18. Gently touch a drop of blood to pad to the test strip without smearing it
19. Press the time button if directed by the manufacturer.
20. Apply pressure to the puncture site with a cotton ball or dry gauze. Do not use
alcohol.
21. Read blood glucose results and document appropriately at bedside. Inform the
patient of the test result.
22. Turn off the meter, remove the test strip, and dispose of supplies appropriately.
Place the lancet in a sharps container.
23. Remove gloves and any other PPE, if used. Perform hand hygiene.
24. Document results in the chart.
SKILLS:
TOTAL SCORE = = %
24
KNOWLEDGE: %
INTRAVENOUS THERAPY: PRIMING
Materials:
IV Bottle IV Tag IV Tubing/ line IV Pole Clean gloves Alcoho Cotton balls Plaste Bandage Scissors
l r
CHECKLIST 1 2 3 4 5
1. Verify the IV solution order on the chart. Clarify any inconsistencies. Check the
patient’s chart for allergies.
2. Gather all equipment and bring it to the bedside.
5. Close curtains around bed and close the door to the room, if possible.
6. Explain what you are going to do and why you are going to do it to the
patient.
7. Ask the patient about allergies to medications, as appropriate.
8. Remove IV bag from outer wrapper, if indicated.
9. Check expiration dates.
10. Compare the patient identification band with the chart.
11. Label the solution container with the patient’s name, solution type,
additives, date, and time.
12. Maintain aseptic technique when opening sterile packages and IV solution.
13. Remove administration set from package
14. Close the roller clamp or slide clamp on the IV administration set
15. Invert the IV solution container and remove the cap on the entry site, taking
care not to touch the exposed entry site.
16. Remove the cap from the spike on the administration set.
17. Using a twisting and pushing motion, insert the administration set spike into
the entry site of the IV container
18. Hang the IV container on the IV pole.

19. Squeeze the drip chamber and fill at least halfway
20. Open the IV tubing clamp, and allow fluid to move through tubing. Some
brands of tubing may require removal of the cap at the end of the IV tubing
to allow fluid to flow.
21. Allow fluid to flow until all air bubbles have disappeared and the entire
length of the tubing is primed (filled) with IV solution
22. Close the clamp.
23. Maintain its sterility. After fluid has filled the tubing, recap the end of the
tubing.
24. Attach the end of the tubing to Roller clamp.

SKILLS:
TOTAL SCORE = = % KNOWLEDGE: %
24
INTRAVENOUS THERAPY: CHANGING IV SOLUTION
Materials:
IV Bottle IV Tag IV Tubing/ line IV Pole Clean gloves Alcoho Cotton balls Plaste Bandage Scissors
l r
CHECKLIST 1 2 3 4 5
1. Verify the IV solution order on the chart. Clarify any inconsistencies. Check the
patient’s chart for allergies.
2. Gather all equipment and bring it to the bedside.
patient.
7. Ask the patient about allergies to medications, as appropriate.
8. Remove IV bag from outer wrapper, if indicated.
9. Check expiration dates.
10. Compare the patient identification band with the chart.
11. Label the solution container with the patient’s name, solution type,
additives, date, and time.
12. Maintain aseptic technique when opening sterile packages and IV solution.
13. Remove administration set from package
14. Close the roller clamp or slide clamp on the IV administration set
15. Invert the new IV solution container and remove the cap on the entry site,
taking care not to touch the exposed entry site.
16. Remove the cap from the spike on the administration set.
17. Lift an empty old container off the IV pole and invert it.
18. Quickly remove the spike from the old IV container, being careful not to
contaminate it.
19. Discard old IV containers.
20. Using a twisting and pushing motion, insert the administration set spike into
the entry site of the new IV container
21. Hang the new IV container on the IV pole.
22. Slowly open the roller clamp on the administration set and adjust the drops
according to the doctor's order.
23. Evaluate patient reaction.
24. Document procedure and patient reaction.
SKILLS: TOTAL SCORE = = % KNOWLEDGE: %

24
INTRAVENOUS THERAPY: IV TERMINATION
Materials:
Clean gloves Cotton balls Plaster Bandage Scissors
CHECKLIST 1 2 3 4 5
1. Verify medical order for removal and facility policy and procedure.
2. Gather equipment and bring it to the bedside.
patient.
7. Adjust bed to comfortable working height, usually elbow height of the

caregiver
8. Put on gloves.
9. Stabilize hub with your nondominant hand.
10. Carefully remove all the tape that is securing the cannula in place.
11. With your non-dominant hand, apply a cotton ball on the insertion site.
12. Using the dominant hand, remove the cannula slowly keeping it parallel to
the skin.
13. After removal, apply pressure to the site until hemostasis is achieved
(minimum 1 minute).
14. Then apply a small sterile dressing or plaster to the site.
15. Dispose of cannula and IV tubing according to facility policy.
16. Remove gloves.
17. Ensure patient’s comfort.
18. Lower bed, if not in lowest position.
19. Remove additional PPE, if used. Perform hand hygiene.
20. Document procedure and patient reaction.

SKILLS: TOTAL SCORE = = % KNOWLEDGE: %
20
ADMINISTERING NGT FEEDING
Materials:
Clean gloves Stethoscope Osterized Feeding Water
CHECKLIST 1 2 3 4 5
1. Introduce yourself and verify the client's identity.
2. Explain procedure to client and discuss how he or she can participate.
3. Gather appropriate equipment.
4. Perform hand hygiene and observe other appropriate infection

5. Provide for client privacy if the client desires it.
6. Assist the client to Fowler’s position in bed or a sitting position in a

chair. If a sitting position was contraindicated, place the client slightly
elevated right side-lying.
7. Assess tube placement.
8. Assess residual feeding contents.
9. Administer the feeding.
a. Remove plunger from syringe and connected syringe to a pinched

or clamped nasogastric tube.
b. Add feeding to the syringe barrel.
c. Permit feeding to flow in slowly at prescribed rate. Raised or

lowered syringe to adjust flow as needed. Pinched or clamped tubing
to stop flow for a minute if the client experienced discomfort.
10. Clamp feeding tube before all water was instilled.
11. Ensure client comfort and safety.
a. Secure tubing to client’s gown.

b. Ask the client to remain in sitting upright in Fowler’s position or in
a slightly elevated right lateral position for at least 30 minutes.
d. Remove and discard gloves. Perform hand hygiene.
12. Dispose of equipment appropriately.
TOTAL SCORE = = %
13
BED SHAMPOO
CHECKLIST 1 2 3 4 5
1. Introduce self and verify the client’s identity using agency protocol. Explain to the
client what you are going to do, why it is necessary, and how he or she can participate.
2. Perform hand hygiene and observe other appropriate infection control procedures.
Gloves may be worn.
3. Provide client privacy.
4. Gather equipment and place at bedside.
5. Lower head of bed. Position and prepare the client appropriately. Assist the client to
the side of the bed from which you will work.
6. Remove pins and ribbons from the hair (if present) and brush or comb it to remove any
tangles.
7. Arrange the equipment and place protective pad/plastic sheet under patient’s head
and shoulders
8. Remove pillow from under the patient’s head and place it under the shoulders unless
there is an underlying condition.
9. Tuck the bath towel around the patient’s shoulders.

10. Place the shampoo basin/Kelly pad under the patient’s head, putting a folded
washcloth for the client’s neck resting on the edge of the basin.
11. Cover the upper part of the client with a bath blanket. Fanfold the top bedding down to
the waist.
12. Place receiving receptacle or pail on floor underneath the drain of the Kelly pad.
13. Protect the client’s eyes. Place a damp washcloth over the patient’s eyes and put
cottonballs on both ears.
14. Feel the pitcher with warm water (40.5°C to 46°C or 105°F to 115°F)
15. Pour pitcher of warm water slowly over patient’s head making sure that all hair is
saturated. Refill pitcher, if needed.
16. Apply a small amount of shampoo. Make a good lather and massage hair deep into
scalp avoiding any cuts or sore spots.
17. Rinse with warm water briefly.
18. Apply shampoo again and make a good lather. Massage scalp.
19. Rinse with warm water thoroughly this time until all conditioner is out of hair.
20. Remove the Kelly pad and wrap a towel around the patient’s head to dry the hair and
ensure they do not feel cold.
21. Dry the surrounding skin, paying particular attention to skin folds in the neck.
22. Gently brush hair removing tangles as needed. Blow dry hair on a cool setting if
allowed and if patient wishes.
23. Remove protective pad and change patient’s gown if necessary.
24. Assist the patient into a comfortable position. Place back the pillow.
25. Remove gloves. Perform hand hygiene.
26. Document that hair was washed and any cuts or lesions found.
TOTAL SCORE = = %
26
UNOCCUPIED BED MAKING
CHECKLIST 1 2 3 4 5
1. If the client is in bed, prior to performing the procedure, introduce

self and verify the client’s identity using agency protocol. Explain to
the client what you are going to do, why it is necessary, and how he or
she can participate.

control procedures.
3. Provide for client privacy.
4. Assemble equipment and place the fresh linen on the client’s chair or
overbed table in the order in which items will be used; do not use
another client’s bed.
5. Adjust the bed to a comfortable working height, usually elbow height

of the caregiver. Drop the side rails and make sure wheels are locked.
6. Apply clean gloves if linens and equipment have been soiled with
secretions and/or excretions.
7. Strip the bed.

• Check bed linens for any items belonging to the client, and
detach the call bell or any drainage tubes from the bed linen.
• Loosen all bedding systematically, starting at the head of the bed
on the far side and moving around the bed up to the head of the
bed on the near side.
• Remove the pillowcases, if soiled, and place the pillows on the
bedside chair near the foot of the bed.
• Roll all soiled linen inside the bottom sheet, hold it away from
your uniform, and place it directly in the linen hamper, not on the
floor.
• Remove and discard gloves if used. Perform hand hygiene.
8. Place the bottom sheet starting from the foot of the bed, with its
center fold placed in the center. Make sure the sheet is hem side
down. Open the sheet and spread it out over the mattress, and allow
a sufficient amount of sheet at the top to tuck under the mattress.
Fan-fold sheet to the center.
9. Miter the sheet at the top corner on the near side and tuck the sheet
under the mattress, working from the head of the bed to the foot.
10. Place drawsheet over the bottom sheet so that the center fold is at
the centerline of the bed and the top and bottom edges extend from
the middle of where the client’s back would be on the bed to the area
where the midthigh or knee would be. Fanfold the uppermost half of
the folded drawsheet at the center or far edge of the bed.
11. Place protective pad over the drawsheet with centerfold in the center
of the bed and fanfold to the center of the mattress. Tuck the rest of
the sheet and protective pad.
12. Place the top sheet, hem side up, on the bed so that its center fold is
at the center of the bed and the top edge is even with the top edge of
the mattress. Unfold the sheet over the bed.
13. Follow the same procedure for the blanket, but place the top edges
about 15 cm (6 in.) from the head of the bed to allow a cuff of sheet
to be folded over them.
14. Tuck in the top sheet and blanket at the foot of the bed, and miter the
bottom corner.
15. Move to the other side of the bed to secure bottom linens. Pull the
bottom sheet tightly and secure over the corners at the head and foot
of the mattress. Pull the drawsheet tightly and tuck it securely under
the mattress and miter the corner.
16. Tuck the top sheet and blanket under the foot of the bed on the near
side. Miter the corners.
17. Fold the upper 6 inches of the top sheet down over the blanket and
make a cuff.
18. Put clean pillowcases on the pillows as required.
• Grasp the closed end of the pillowcase at the center with one
hand.
• Gather up the sides of the pillowcase and place them over the
hand grasping the case. Then grasp the center of one short side
of the pillow through the pillowcase.
• With the free hand, pull the pillowcase over the pillow.
• Adjust the pillowcase so that the pillow fits into the corners of
the case and the seams are straight.
• Place the pillows appropriately at the head of the bed with the
opening facing away from the door covered by the top sheet.
19. OPEN BED: If the bed is currently being used by a client, either fold
back the top covers at one side or fanfold them down to the center of
the bed.
20. Provide for client comfort and safety. Raise side rail and lower bed.
21. Document and report pertinent data.

● Record any nursing assessments, such as the client’s physical
status and pulse and respiratory rates before and after being out
of bed, as indicated.
VARIATION: SURGICAL BED
1. Strip the bed
2. Place and leave the pillows on the bedside chair
3. Apply the bottom linens as for an unoccupied bed. Place a bath

blanket on the foundation of the bed if this is agency practice
4. Place the top covers (sheet, blanket, and bedspread) on the bed as
you would for an unoccupied bed. Do not tuck them in, miter the
corners, or make a toe pleat.
5. Make a cuff at the top of the bed as you would for an unoccupied
bed. Fold the top linens up from the bottom.
6. On the side of the bed where the client will be transferred, fold up
the two outer corners of the top linens so they meet in the middle of
the bed forming a triangle
7. Pick up the apex of the triangle and fanfold the top linens lengthwise
to the other side of the bed
8. Leave the bed in high position with the side rails down
9. Lock the wheels of the bed if the bed is not to be moved
TOTAL SCORE = = %
30
OCCUPIED BED MAKING
CHECKLIST 1 2 3 4 5
1. If the client is in bed, prior to performing the procedure, introduce

self and verify the client’s identity using agency protocol. Explain to
the client what you are going to do, why it is necessary, and how he or
she can participate.

control procedures.
3. Provide for client privacy.
4. Remove any equipment attached to the bed linen, such as a signal

light.
5. Replace top sheet with a bath blanket. Spread the bath blanket
over the top sheet.
6. Ask the client to hold the top edge of the blanket.
7. Reaching under the blanket from the side, grasp the top edge
of the sheet and draw it down to the foot of the bed, leaving
the blanket in place.
8. Remove the sheet from the bed and place it in the soiled linen
hamper.
9. Raise the side rail that the client will turn toward.
10. Assist the client to turn on the side away from the nurse and
toward the raised side rail.
11. Loosen the bottom linens on the side of the bed near the nurse
12. Fanfold the dirty linen (i.e., drawsheet and the bottom sheet)
toward the center of the bed as close to and under the client as
possible.
13. Place the new bottom sheet on the bed and vertically fanfold
the half to be used on the far side of the bed as close to the
client as possible.
14. Tuck the bottom sheet under the near half of the bed and miter
the corner.
15. Place the clean drawsheet on the bed with the center fold at
the center of the bed. Fanfold the uppermost half vertically at
the center of the bed and tuck the near side edge under the
side of the mattress.
16. Assist the client to roll over toward you, over the fanfolded bed
linens at the center of the bed, onto the clean side of the bed.
17. Move the pillows to the clean side for the client’s use.
18. Raise the side rail before leaving the side of the bed.
19. Move to the other side of the bed and lower the side rail.
20. Remove the used linen and place it in the portable hamper.
21. Unfold the fanfolded bottom sheet from the center of the bed.
22. Facing the side of the bed, use both hands to pull the bottom
sheet so that it is smooth and tuck the excess under the side of
the mattress.
23. Unfold the drawsheet fanfolded at the center of the bed and
pull it tightly with both hands. Tuck the excess drawsheet under
the side of the mattress.
24. Reposition the pillows at the center of the bed.
25. Assist the client to the center of the bed. Determine what
position the client requires or prefers and assist the client to
that position.
26. Spread the top sheet over the client and either ask the client to
hold the top edge of the sheet or tuck it under the shoulders.
The sheet should remain over the client when the bath blanket
or used sheet is removed.
27. Place the bath blanket in the linen hamper.
28. Raise the side rails.
29. Place the signal cord/light within the client’s reach. Put items
used by the client within easy reach.
30. Place the bed in the low position before leaving the bedside.
TOTAL SCORE = = %
30
BED BATH
CHECKLIST 1 2 3 4 5
1. Introduce yourself and verify the client’s identity.
2. After explaining the procedure, put on clean gloves and follow

infection control procedures to clean all surfaces you will be
using.
3. Provide for client privacy by drawing the curtains around the

bed or closing the door to the room, if needed.
4. Remove your gloves, perform hand hygiene, and gather the

appropriate equipment.
5. Use two basins of comfortably warm water (43°C to 46°C or
110°F to 115°F) so that there is always one for the clean rinse
water.
6. Place a waterproof pad behind the client’s head. Prepare the

client and his/her environment.
7. You may offer the client a bedpan or urinal if the client asks.
8. Raise the bed to the appropriate working height.
9. Lower the side rail closest to yourself and assist patient to side
of bed where you will work. Have patient lie on his or her back.
10. Place a bath blanket over the top sheet and bedspread.
Remove the linen from under the bath blanket by starting at
the client’s shoulders and moving the linen down toward the
client’s feet.
11. If linen is to be reused, fold it over at chair. Place soiled linen at

the laundry bag.
12. Remove the client’s gown while keeping the client covered with
the bath blanket. If patient has an IV line and is not wearing a
gown with snap sleeve remove gown from the other arm first.
lower the IV container and pass down over the tubing and the
container. Rehang the container and check the drip rate.
13. Take a washcloth and make it into a bath mitt folded around
the hand.
14. With no soap on the washcloth, wipe one eye from the inner
part of the eye, near the nose, to the outer part.
15. Rinse or turn the cloth before washing the other eye.
16. Wash the other parts of client’s face. Ask whether the client
wants soap used on his/her face, ears or neck.
17. Use a clean/separate towel to dry off the face, ears, and neck.
18. Remove the pad from behind the client’s head.
19. Place a towel lengthwise under one arm.
20. Open and wet a bar of soap and use it to wash the arm.
21. Use long, firm strokes from wrist to shoulder, including the
axillary area.
22. Rinse and dry the hand and arm. Rinse the washcloth in a
separate basin. You may apply deodorant or powder if desired.
23. To wash the chest and abdomen, first place a bath towel
lengthwise over the client’s chest. Fold the bath blanket down,
as needed.
24. Lift the bath towel off the chest and bathe the chest and
abdomen with a mitted hand.
25. To wash the legs and feet, expose one leg by folding the bath
blanket toward the other leg.
26. Lift the exposed leg and place a bath towel lengthwise under
the leg.
27. Wash, rinse, and dry the leg using long, firm strokes from ankle
to knee to thigh.
28. You may wash the feet by placing them in a basin or using your
mitted hand.
29. Dry each foot, paying particular attention to the spaces

between the toes.
30. Remove the bath towel beneath the leg and cover the client.
31. Return the side railing and the bed to the original position.
32. Obtain fresh, warm bathwater before continuing to the other

side of the body. Remove your gloves and wash your hands
before rinsing out each basin.
33. Put on clean gloves and return with the refilled basins to the
client.
34. Cleanse the other side of the body in the same manner as the
first side.
35. When you are done with the arms and legs, remove the bath
blanket and cover the client. If the client requests, help him/her
with grooming aids such as powder, lotion, or deodorant.
36. Remove all items that you used for the procedure. Rinse and
refill the basins using proper hand hygiene.
37. Return with towels to wash the client’s back and clean
blankets.
38. Move the bed’s position as needed and help the client turn to a
side-lying or prone position.
39. Place a towel under the area to be bathed.

40. Wash, rinse, and dry the client’s back, moving from the
shoulders to the buttocks.
41. Remove the towel from under the client and help the client
onto his/her back.
42. Complete perineal care at this time. Assist the client to the
supine position and determine whether the client can wash the
perineal area independently. If the client cannot do so, drape
the client and wash the area.
43. Remove your gloves and dispose of them. Perform hand

hygiene.
44. Assist the client to dress in a clean hospital gown. Tie the clean
gown at the neck for the client.
45. Remove the old gown and blanket that was placed on the
client.
46. Return blankets, sheets, bed, and side rails to the original
position.
47. When you are done, clean and store the bath equipment.
Dispose of the dirty linen according to facility guidelines.
TOTAL SCORE = = %
47
ASSESSING THE CARDIOVASCULAR SYSTEM
Materials:
Gloves Stethoscope Light source Mask Skin marker (2) Metric ruler
CHECKLIST 1 2 3 4 5
2. Remove jewelry, if possible, and secure in a safe place. A plain wedding band may
remain in place.
3. Introduce yourself, and verify the client’s identity. Explain the procedure to the client
and how the client can cooperate.
4. Perform hand hygiene, and observe other appropriate infection control procedures.
Provide for client privacy.
5. Inquire if the client has any history of the following:
- Family history of incidence and age of heart disease, high cholesterol levels,
high blood pressure, stroke, obesity, congenital heart disease,
hypertension, and rheumatic fever
- Client’s past history of rheumatic fever, heart murmur, heart attack,
varicosities, or heart failure
- Present symptoms indicative of heart disease
- Presence of diseases that affect the heart
- Lifestyle habits that are risk factors for cardiac disease
NECK VESSELS
INSPECTION
6. Inspect the jugular veins for distention. The client is placed in a semi-Fowler’s
position, with the head supported on a small pillow.
7. If jugular vein distention is present, assess the jugular venous pressure (JVP)
- Locate the highest visible point of distention of the internal jugular vein.
- Measure the vertical height of this point in centimeters from the sternal
angle, the point at which the clavicles meet.
- Repeat the steps above on the other side.
AUSCULTATION
8. Auscultate the carotid arteries.
- Always auscultate the carotid artery first before palpating because palpation
may increase or slow the heart rate, changing the strength of the carotid
impulse heard
- Place the bell of the stethoscope over the carotid artery and ask the client
to hold his or her breath for a moment so that breath sounds do not
conceal any vascular sounds.
- Auscultate for bruit.
PALPATION
9. If occlusion is detected during auscultation, palpate very lightly to avoid blocking

circulation or triggering vagal stimulation and bradycardia, hypotension, or even
cardiac arrest.
10. Palpate the carotid arteries.
- Palpate each carotid artery alternately.
- Bilateral palpation could result in reduced cerebral blood low.
- Place the pads of the index and middle fingers medial to the
sternocleidomastoid muscle on the neck.
- Note amplitude and contour of the pulse, elasticity of the artery, and any
thrills.
HEART (PRECORDIUM)
INSPECTION
11. Inspect the aortic and pulmonic areas, observing them at an angle and to the side,
to note the presence or absence of pulsations
12. Inspect for Apical Impulse.
- This represents the brief early pulsation of the left ventricle as it moves
anteriorly during contraction and through the chest wall located at 4th or 5th
intercostal Space (ICS).
- If displaced laterally, record distance between the apex and the MCL in
centimeters
13. Inspect epigastric area at the base of the sternum for abdominal aortic pulsations
PALPATION
14. Palpate the aortic and pulmonic areas, observing them at an angle and to the side,
to note the presence or absence of pulsations
15. Palpate Apical Impulse. You may ask the client to roll to the left side to better feel
the impulse using palmar surfaces of the hand.
16. Palpate epigastric area at the base of the sternum for abdominal aortic pulsations.
PERCUSSION
17. Percussion estimates cardiac border.

- Determine size and location of heart, note displacement or enlargement.
- There should be dullness at 3rd, 4th and 5th ICS to the left sternum at left
mid-clavicular line.
- Begin at the anterior axillary line and percuss to the sternum at the 5th ICS.
- There should be a change of sound from resonance to dullness as you reach
the left sternal border of the heart.
AUSCULTATION
18. Auscultate for S1, S2, S3, S4 and murmurs.
19. Auscultate from apex to base; mitral, tricuspid, Erb’s point, pulmonic and aortic
areas, noting for murmurs, rate, rhythm, pitch and intensity, duration, timing,
quality and location.
LOCATION:
· Aortic area: Second ICS at the right sternal border—the base of the heart
· Pulmonic area: Second or third ICS at the left sternal border—the base of the
heart
· Erb point: Third ICS at the left sternal border
· Mitral (apical): Fifth ICS near the left MCL—the apex of the heart
· Tricuspid area: Fourth or fifth ICS at the left lower sternal border
20. After the assessment, make the patient comfortable. Perform hand hygiene and do
after care.
21. Document findings in the client record.
SKILLS:
TOTAL SCORE = = %
21
KNOWLEDGE:

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l

Liquid hand soap paper towel

2. Remove jewelry, if possible, & secure in a safe place. A plain wedding

6. Rub hands Palm to palm

8. Rub palm with fingers interlaced.

9. Rub back of fingers to opposite palms with finger interlocked

Thermometer dry tissue clean gloves cotton ball with alcohol

1. Introduced self and verified client’s identity.

2. Explained procedure to client and discussed how results will be used.

3. Gathered appropriate equipment.

4. Performed hand hygiene and observed other appropriate infection

5. Provided for client privacy.

6. Placed the client in the appropriate position.

8. Expose the axilla and pat dry if very moist.

11. Waited the appropriate amount of time.

14. Read the temperature and record it on a worksheet.

15. Washed the thermometer if necessary and returned it to storage location

16. Document the temperature in the client record.

watch with second hand

1. Introduced self and verified client’s identity.

2. Explained procedure to client and discussed how results will be used.

3. Performed hand hygiene and observed other appropriate infection

4. Provided for client privacy.

5. Selected pulse point.

6. Assisted client to a comfortable resting position. When the radial pulse is

8. Assessed pulse rhythm and volume.

watch with second hand

1. Introduced self and verified client’s identity.

2. Explained procedure to client and discussed how results will be used.

3. Gathered appropriate equipment.

4. Performed hand hygiene and observed other appropriate infection

5. Provided for client privacy.

7. Observed depth, rhythm, and character of respirations.

8. Document the respiratory rate, depth, rhythm, and character on the

Sphygmomanometer stethoscope cotton balls with alcohol (antiseptic wipe)

1. Introduced self and verified client’s identity.

2. Explained procedure to client and discussed how results will be used.

3. Gathered appropriate equipment.

4. Performed hand hygiene and observed other appropriate infection

5. Provided for client privacy.

6. Positioned the client appropriately.

8. Performed a preliminary palpatory determination of systolic pressure, if

9. Positioned stethoscope appropriately.

10. Auscultated client’s blood pressure.

11. Removed the cuff from the client’s arm.

12. Wiped the cuff with an approved disinfectant.

1. Introduced self and verified client’s identity.

2. Explained procedure to client and discussed how results will be used.

3. Gathered appropriate equipment.

4. Performed hand hygiene and observed other appropriate infection

5. Provided for client privacy if appropriate.

TO OPEN A WRAPPED PACKAGE ON A SURFACE:

ESTABLISHED A STERILE FIELD BY USING A DRAPE.

10. Opened package containing drape as described above.

ADDED COMMERCIALLY PACKAGED SUPPLIES TO A STERILE FIELD.

15. Opened each package as previously described.

ADDED SOLUTION TO A STERILE BOWL.

22. Poured solution gently to avoid splashing liquid.

1. Introduced self and verified client’s identity.

2. Explained procedure to client and discussed how results will be used.

3. Gathered appropriate equipment.

4. Performed hand hygiene and observed other appropriate infection

5. Provided for client privacy if appropriate.