NCM 109 B CHECKLIST OF PROCEDURES

CARE OF MOTHER AND CHILD AT RISK

OR WITH PROBLEMS

(ACUTE AND CHRONIC)

Prepared by:

Marichu N. Ocampo, RN

Edelaine M. Aguilar, RN

Ann Jenash A. Gunazon, RN

Table of Contents

PROCEDURE PAGE

I. Catheterization 3

II. Removal of Indwelling Catheter 6

III. Hot Sitz Bath 8

IV. Cleansing Enema 10

V. Perineal Light 12

VI. Intravenous Insertion 14

VII. Removal of Intravenous Infusion 17

VIII. Open Gloving Technique 19

IX. Administering IM Injection (Adult) 21

X. Administering IM Injection (Infant) 23

XI. Wound Dressing 25

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NAME: _________________________________________ DATE:__________

COURSE & SECTION: _____________________________ RLE GROUP:____

CHECKLIST ON CATHETERIZATION

PROCEDURE ABLE TO ABLE TO UNABLE TO

PERFORM PERFORM PERFORM
WITH
ASSISTANCE
ASSESSMENT
1. Assess the client and check the order.
2. Determine if the procedure is to be a
straight or indwelling catheterization.
3. Assess need for collection of specimen.
PLANNING
4. Wash hands.
5. Select specific type and size of catheter.
6. Assemble all the equipment including
catheterization set, light source, bath blanket
or sheet for draping and extra equipment as
individually determined
IMPLEMENTATION
7. Identify the client and explain the procedure.
8. Assist the client to appropriate position
a. Female-Dorsal recumbent
b. Male-Supine with legs slightly abducted.
9. Open the catheterization set and arranges
the sterile field.
10. Set up the receptacle for soiled cleaning swabs.
11. Open the drainage bag and attach to bed.
12. Wear sterile gloves.

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 13. Attach syringe and test balloon by instilling
sterile water and deflating by withdrawing the
water.
14. Connect distal end of catheter to
drainage tubing.
15. Clean urinary meatus with antiseptic
solution using a downward stroke.
16. Lubricate the distal portion of the catheter
and place it on a nearby sterile field.
17. Insert the catheter gently, in rotating motion 2-
3 inches in female or 6-9 inches in male; hold
the penis at 45 degree angle until urine flows.
Instruct to take a deep breath upon insertion.
18. Inflate the retention balloon with sterile water.
19. Tape the catheter to the thigh of a female client
and to the lower abdomen for a male client.
20. Place drainage bag below the level of
the bladder.
21. Assist the client to a comfortable position.
22. Gather and discard disposable equipment.
23. Wash hands.
EVALUATION
24. Evaluate using the ff. criteria:
a. Indwelling catheter must drain properly or
straight catheter must be inserted and
removed without discomfort.
b. Client must be comfortable
DOCUMENTATION
25. Document the following
a. Date and time.
b. Type and size of catheter.
c. Whether a specimen was obtained,
d. Amount of urine.

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 e. Description of urine.
f. Client’s response to procedure.

Remarks:

Grade:

Rating Scale:

Excellent : 96-

100% Very Satisfactory : 90-

95% Very Good : 85-89%

Good : 80-84%

Fair : 75-79%

Poor : 74 & below

Clinical Instructor Student's Signature

5
NAME: _________________________________________ DATE:_____________

COURSE & SECTION: _____________________________ RLE GROUP:______

CHECKLIST ON REMOVAL OF INDWELLING CATHETER

PROCEDURE ABLE TO ABLE TO UNABLE TO

PERFORM PERFORM PERFORM
WITH
ASSISTANCE
ASSESSMENT
1. Check the physician’s written order.
2. Assess the characteristics and amount of
urine output.
PLANNING
3. Wash hands.
4. Assemble the equipment.
IMPLEMENTATION
5. Identify the client and explain the procedure.
6. Wear sterile gloves.
7. Place protective pad under the patient’s thighs.
8. Empty urine tubing into catheter bag.
9. Remove any tape that may be hold the
catheter to the leg.
10. Insert syringe end into balloon port and
pull the plunger to remove all the air and
fluid.
11. Gently pull out the catheter as the client take
a deep breath.
12. Cleanse the client’s perineal area.
13. Dispose equipment used and remove gloves.
14. Wash hands.
EVALUATION
15. Evaluate the amount and characteristics of
output.

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 16. Evaluate if the client resumes usual voiding
pattern
DOCUMENTATION
17. Record the amount and characteristics
of output.
18. Record if the patient resumes voiding pattern

Remarks:

Grade:

Rating Scale:

Excellent : 96-

100% Very Satisfactory : 90-

95% Very Good : 85-89%

Good : 80-84%

Fair : 75-79%

Poor : 74 & below

Clinical Instructor Student's Signature

7
NAME: _________________________________________ DATE:_____________

COURSE & SECTION: _____________________________ RLE GROUP:______

CHECKLIST ON HOT SITZ BATH

PROCEDURE ABLE TO ABLE TO UNABLE TO

PERFORM PERFORM PERFORM
WITH
ASSISTANCE
ASSESSMENT
1. Check the doctor’s order for specific type of
treatment.
2. Assess client’s knowledge of the benefits of the
sitz bath.
3. Assess appearance and condition of
treatment area.
PLANNING
4. Wash hands.
5. Assemble equipment needed.
IMPLEMENTATION
6. Identify the client.
7. Explain the procedure.
8. Provide privacy.
9. Fill a clean sitz bath tub or basin with 1/3
full of warm water.
10. Check the temperature of water
with thermometer or with your
wrist.
11. Assist the client to the chair padding
as necessary.
12. Place a bath blanket on the client’s shoulder
and knees during the procedure.
13. Assess reaction to the engulfing heat by
observing facial expressions and body
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 motions.
14. Observe for signs of dizziness and
faintness. Check blood pressure and pulse
rate.
15. Instruct the client on he use of call light and
place it within the client’s reach.
16. Recheck client every 5-10 minutes.
17. Assist the client to dry thoroughly after the
sitz bath.
18. Dispose soiled materials and clean equipment
for reuse.
19. Wash hands.
EVALUATION
20. Evaluate client response to treatment
DOCUMENTATION
21. Document the treatment and length of time
applied and unusual reactions to treatment.

Remarks:

Grade:

Rating Scale:

Excellent : 96-

100% Very Satisfactory : 90-

95% Very Good : 85-89%

Good : 80-84%

Fair : 75-79%

Poor : 74 & below

Clinical Instructor Student's Signature

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NAME: _________________________________________ DATE:_____________

COURSE & SECTION: _____________________________ RLE GROUP:______

CHECKLIST ON CLEANSING ENEMA

PROCEDURE ABLE TO ABLE TO UNABLE TO

PERFORM PERFORM PERFORM
WITH
ASSISTANCE
ASSESSMENT
1. Verify doctor’s order.
2. Check client’s ability to retain fluid and tolerate
the activity ordered.
PLANNING
3. Wash hands.
4. Gather all equipment.
IMPLEMENTATION

5. Identify client and explain the procedure.

6. Prepare client by positioning and draping.

7. Put on gloves.

8. Administer enema (use specific procedure

for specific enema)

9. Encouraging client to retain fluid as long

as possible.

10. Assist client with bedpan, commode or to

the toilet.

11. Help client to a comfortable position.

12. Give client the opportunity to refresh.

13. Replace top bedding, remove bath
blanket. Ventilate the room and leave the
client in
comfortable environment.

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 EVALUATION

14. Evaluate using the following criteria:

a. Quantity and description of feces.

b. Client’s response; skin color, respirations,
pulse rate, and degree of fatigue.
DOCUMENTATION
15. Record date and time, type of enema, amount
of fluid instilled, results and degree of
comfort.

Remarks:

Grade:

Rating Scale:

Excellent : 96-

100% Very Satisfactory : 90-

95% Very Good : 85-89%

Good : 80-84%

Fair : 75-79%

Poor : 74 & below

Clinical Instructor Student's Signature

11
NAME: _________________________________________ DATE:_____________

COURSE & SECTION: _____________________________ RLE GROUP:______

CHECKLIST ON PERINEAL LIGHT

PROCEDURE ABLE TO ABLE TO UNABLE TO

PERFORM PERFORM PERFORM
WITH
ASSISTANCE
ASSESSMENT
1. Assess the client status
2. Assess the client’s perineal area note for
unusual findings.
PLANNING
3. Wash hands.
4. Gather the equipment.
IMPLEMENTATION
5. Identify the patient.
6. Explain the procedure.
7. Ask the client to void.
8. Cover the patient exposing only the
perineal area.
9. Assist the patient to lie flat on her back,
knees flexed and thighs far apart.
10. Check each time the bulb is used. A bulb
over 60 watts must be used.
11. Place the heat lamp far enough from
the perineum approximately 12 inches.
12. Expose the perineum to lamp for 15-
20 minutes and remain with the
patient throughout the treatment.
13. Observe the sutures.
14. Chart patient’s reaction.

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 15. Leave client in a comfortable position.

EVALUATION
16. Evaluate the client for any untoward reaction.
17. Evaluate the effectiveness of the procedure.
DOCUMENTATION
18. Record pertinent observations.

Remarks:

Grade:

Rating Scale:

Excellent : 96-

100% Very Satisfactory : 90-

95% Very Good : 85-89%

Good : 80-84%

Fair : 75-79%

Poor : 74 & below

Clinical Instructor Student's Signature

13
NAME: _________________________________________ DATE:_____________

COURSE & SECTION: _____________________________ RLE GROUP:______

CHECKLIST ON INTRAVENOUS INSERTION

PROCEDURE ABLE TO ABLE TO UNABLE TO

PERFORM PERFORM PERFORM
WITH
ASSISTANCE
ASSESSMENT
1. Check the physician’s written order for the type,
amount and rate of IV fluid.
2. Assess client’s previous experience with IV therapy
and arm placement preferences.
3. Assess client’s vein, location, size and condition of
the vein.
PLANNING
4. Wash hands.
5. Prepare necessary articles/equipment for initiation
of IV.
IMPLEMENTATION
6. Identify the client and explain the procedure.
7. Assist the client to a comfortable position.
8. Open the sterile package using aseptic technique.
9. Check and open the seal of IV solution using the
Rights of drug administration then open the seal.
10. Open the infusion set, push spike into the bottle
port.
11. Fill drip chamber to at least half and prime the
tubing aseptically.
12. Wear gloves.
13. Select the vein for IV placement, apply tourniquet 2-
6 inches above the selected insertion site.

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 14. Clean the vein area using cotton balls soaked with
alcohol, beginning at the vein and circling outward
in a 2-inch diameter.
15. Encourage the client to take a slow, deep breath.
16. Hold skin taut with one hand while the other hand
holds the appropriate IV cannula/catheter; pierce
skin with needle positioned on 15-30 degrees angle.
17. Lower the needle until it almost flushes with the
vein.
18. Push needle into the vein about ¼ inches after the
blood is noted. Slide the catheter over needle and
into the vein before pulling needle out of the vein
and skin.
19. Slip sterile gauze under the hub. Release the
tourniquet; remove the stylet while applying digital
pressure over the catheter with one finger about ½
inches from the tip of inserted catheter.
20. Connect the infusion tubing to the IV catheter.
21. Open roller clamp slowly to allow fluid to flow
freely for few seconds.
22. Anchor the needle firmly in place with the use of
transparent tape directly on the puncture site;
using a chevron configuration or U-method.
23. Tape a small loop of IV tubing for additional
anchoring. Apply splint or arm board if needed.
24. Regulate IV flow manually or set infusion device at
appropriate rate.
25. Write on the IV label the date, time of IV insertion
and its regulation.
26. Placed patient back into comfortable position.
27. Dispose off used needles in appropriate sharp’s
container.
28. Remove gloves and wash hands
EVALUATION
29. Observe the client every hour to determine if the
fluid is infusing accurately.

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 30. Evaluate the client for any discomfort or pain on the
IV site
DOCUMENTATION
31. Record the type of fluid, flow rate, date and time
the infusion was started.
32. Record client’s response to IV fluid

Remarks:

Grade:

Rating Scale:

Excellent : 96-

100% Very Satisfactory : 90-

95% Very Good : 85-89%

Good : 80-84%

Fair : 75-79%

Poor : 74 & below

Clinical Instructor Student's Signature

16
NAME: _________________________________________ DATE:_____________

COURSE & SECTION: _____________________________ RLE GROUP:______

CHECKLIST ON REMOVAL OF INTRAVENOUS INFUSION

PROCEDURE ABLE TO ABLE TO UNABLE TO

PERFORM PERFORM WITH PERFORM
ASSISTANCE
ASSESSMENT
1. Assess IV site
PLANNING
2. Wash your hands.
3. Obtain necessary equipment
IMPLEMENTATION
4. Identify the client.
5. Explain the procedure.
6. Prepare all the equipment needed.
7. Close IV clamp tubing.
8. Moisten adhesive tapes around the IV catheter
with the cotton balls soaked in 70% alcohol.
Remove plaster gently.
9. Get cotton balls with alcohol and without
applying pressure, withdraw needle or
catheter by pulling it along the line of the
vein.
10. Apply firm pressure to the site, using
sterile gauze for 2 to 3 minutes.
11. Inspect IV catheter.
12. Remove and discard all waste articles
including IV cannula.
13. Wash hands
EVALUATION

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 14. Evaluate effectiveness of procedure for desired
purpose
DOCUMENTATION
15. Document pertinent observations.
a. Time of removal
b. Status of insertion site
c. Integrity of IV catheter

Remarks:

Grade:

Rating Scale:

Excellent : 96-

100% Very Satisfactory : 90-

95% Very Good : 85-89%

Good : 80-84%

Fair : 75-79%

Poor : 74 & below

Clinical Instructor Student's Signature

18
NAME: _________________________________________ DATE:_____________

COURSE & SECTION: _____________________________ RLE GROUP:______

CHECKLIST ON OPEN GLOVING TECHNIQUE

PROCEDURE ABLE TO ABLE TO UNABLE TO

PERFORM PERFORM PERFORM
WITH
ASSISTANCE
1. Remove jewelry, particularly rings.
2. Wash hands.
3. Remove outer wrapper, peeling apart sides
and lay it on a clean, flat surface.
4. Open inner wrapper, touching only the outside.
5. Secure both flaps open, Identify right and left
glove.
6. Grasp the inner fold with thumb and first
two fingers of non dominant hand and slip
the hands touching only the inner surface.
7. With dominant gloved hand, slip four fingers
underneath, second gloved cuff. Lift the glove
away from the body. Slide the second hand
into the second glove.
8. Adjust fingers of both Gloved hand
9. Raise gloved hand above waist level
Gloves Disposal
10. Grasp outside of one cuff with other
gloved hand.
11. Pull glove off, turning it inside out.
12. Take fingers of bare hand and tuck remaining
glove cuff. Pull glove off inside out. Discard
receptacle

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Remarks:

Grade:

Rating Scale:

Excellent : 96-

100% Very Satisfactory : 90-

95% Very Good : 85-89%

Good : 80-84%

Fair : 75-79%

Poor : 74 & below

Clinical Instructor Student's Signature

20
NAME: _________________________________________ DATE:_____________

COURSE & SECTION: _____________________________ RLE GROUP:______

CHECKLIST ON ADMINISTERING INTRAMUSCULAR INJECTION (ADULT)

PROCEDURE ABLE TO ABLE TO UNABLE TO

PERFORM PERFORM PERFORM
WITH
ASSISTANCE
ASSESSMENT
1. Assess client and check the doctor’s order.
2. Assess adequacy of adipose tissue by
selecting appropriate injection site
PLANNING
3. Wash hands before client contact.
4. Prepare equipment needed.
IMPLEMENTATION
5. Identify the client.
6. Check the potency of vaccine and its
expiry date.
7. Rub the vial in between palms.
8. Place client to appropriate position.
9. Clean site with antiseptic swab.
10. Aspirate the medication and making sure no
air in the syringe.
11. Place thumb and index finger on each side
of the injection site. Grasp the muscle
slightly.
12. Inject the needle at 90 degrees angle. Aspirate.
13. Inject medication slowly. Remove the needle
slowly. Apply pressure at the site with a
piece of cotton.
14. Discard needle in the sharp object container.

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 15. Wash hands

EVALUATION
16. Evaluate by observing for any adverse
reactions
DOCUMENTATION
17. Record and chart the injected medicine in
the medication sheet and in the nurses notes,
indicating:
a. Time given;
b. Name of medication; and
c. Dosage given

Remarks:

Grade:

Rating Scale:

Excellent : 96-

100% Very Satisfactory : 90-

95% Very Good : 85-89%

Good : 80-84%

Fair : 75-79%

Poor : 74 & below

Clinical Instructor Student's Signature

22
NAME: _________________________________________ DATE:_____________

COURSE & SECTION: _____________________________ RLE GROUP:______

CHECKLIST ON ADMINISTERING INTRAMUSCULAR INJECTION (INFANT)

PROCEDURE ABLE TO ABLE TO UNABLE TO

PERFORM PERFORM WITH PERFORM
ASSISTANCE
ASSESSMENT
1. Assess client by reviewing the chart or
immunization record.
2. Assess adequacy of adipose tissue by selecting
appropriate injection site
PLANNING
3. Wash hands before client contact.
4. Prepare equipment needed.
IMPLEMENTATION
5. Identify the client.
6. Explain the procedure to mother or
significant other.
7. Request mother to hold the child across her
knees. Ask her to hold the child’s leg firmly.
8. Clean the skin with antiseptic swab. Pat
and dry.
9. Place your thumb and index fingers on
each side of the injection site. Grasp the
muscle slightly.
10. Inject the needle at 90 degrees and aspirate.
11. If there is no blood, inject the vaccine slowly.
Remove the needle and apply pressure on the
site with a piece of cotton.

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 12. Discard needle in the sharp object container
without recapping.
13. Wash hands again.
14. Make an appointment for the next schedule
of immunization
EVALUATION
15. Evaluate by observing for any adverse
reactions.
DOCUMENTATION
16. Record and chart the injected vaccine in the
baby’s chart or record book. Affix signature

Remarks:

Grade:

Rating Scale:

Excellent : 96-

100% Very Satisfactory : 90-

95% Very Good : 85-89%

Good : 80-84%

Fair : 75-79%

Poor : 74 & below

Clinical Instructor Student's Signature

24
NAME: _________________________________________ DATE:_____________

COURSE & SECTION: _____________________________ RLE GROUP:______

CHECKLIST ON WOUND DRESSING

PROCEDURE ABLE TO ABLE TO UNABLE TO

PERFORM PERFORM PERFORM
WITH
ASSISTANCE
ASSESSMENT
1. Check the doctor’s order for the frequency and
need for dressing.
2. Check the present dressing.
PLANNING
3. Perform hand hygiene.
4. Gather all necessary equipment.
5. Prepare the sterile field and add
necessary sterile supplies.
IMPLEMENTATION
6. Prepare patient and expose dressed wound.
7. Apply non-sterile gloves.
8. Remove outer dressing carefully. Pour NSS if
gauze is strongly attached to the wound.
9. Assess wound.
10. Cleanse the wound using a sterile gauze
or cotton balls soaked with 10%
Antiseptic solution.
a. From clean to dirty (incision, then
outer edges)
11. Cleanse around drain (if present)
12. Apply inner dressing (4x4 gauze) with
forceps to incision

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 13. Discard the non-sterile gloves used.
14. Apply the outer dressing, keeping the inside of
the sterile dressing touching the wound.
15. Assist patient to a comfortable position.
16. Discard and remove waste articles used.
17. Perform hand hygiene.
EVALUATION
18. Evaluate the characteristic of wound
(color, texture, or any drainages)
19. Compare the present to the previous wound
and determine healing progress, if any.
DOCUMENTATION
20. Document procedure and findings.

Remarks:

Grade:

Rating Scale:

Excellent : 96-

100% Very Satisfactory : 90-

95% Very Good : 85-89%

Good : 80-84%

Fair : 75-79%

Poor : 74 & below

Clinical Instructor Student's Signature

26