CHECKLIST 2022 2023

PREFACE
Nursing is an essential component of the health-care delivery system, which includes health
promotion, illness prevention, curative, and rehabilitative health measures. Clinical nursing skills
are critical for students’ nurses to not only provide complete care but also to improve clinical
competence. The purpose of preparing this laboratory manual is to equip student nurses with
basic clinical nursing skills.
Developing clinical competency is an important challenge for each fundamentals nursing student.
To facilitate the mastery of nursing skills, this manual will provide skill checklists for each skill
included in Kozier and Erb’s Fundamentals of Nursing, Concepts, Process, and Practice, 10th
Edition. Students can use the checklists to facilitate self-evaluation, and faculty will find them
useful in measuring and recording student performance.
The checklists follow each step of the skill to provide a complete evaluative tool. They are
designed to record an evaluation of each step of the procedure.
● EXCELLENT. Carries out procedure efficiently, systematically and independently
● VERY SATISFACTORY. Carries out procedure efficiently, but requires minimal

guidance and supervision
● SATISFACTORY. With moderate guidance and supervision
● FAIR, but requires close guidance and supervisions
● POOR. Carries out the procedure inefficiently, unsystematically even after close
.
The Comments section allows you to highlight suggestions that will improve skills.
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TABLE OF CONTENT
Preface 1
Table Of Content 2
Medical Handwashing 4
Surgical Handwashing 5
Donning And Removing Sterile Gloves (Open Method) 6
Donning A Sterile Gown And Gloves (Closed Method) 8
Establishing And Maintaining A Sterile Field 10
Assessing Body Temperature (Axilla) 13
Assessing Body Temperature (Rectal)
Assessing Body Temperature (Oral)
Assessing Apical Pulse
Assessing Radial Pulse
Assessing Respiratory Rate
Assessing Blood Pressure
Range Of Motion Exercises
Positioning
Bed Bath
Perineal Care
Shampooing The Hair Of A Client Confined In Bed
Providing Special Oral Care
Back Massage
Application Of Hot Compress
Application Of Cold Compress
Making An Unoccupied Bed
Making An Occupied Bed
Application Of Eye Medication Or Irrigation
Administration Of Ottic Medications
Administration Of Nasal Installation
Administration Of Nasal Inhalation
Administration Of Rectal Suppository
Preparing Medications From Ampules
Preparing Medications From Vials
Administering Intradermal Injection (Skin Test)
Administering Subcutaneous Injection
Administering Intramuscular Injection
Intravenous Therapy
Adding Medications To Intravenous Fluid Containers
Administering Intravenous Medications Using Iv Push
Steam Inhalation
Suctioning (Oropharyngeal And Nasopharyngeal)
Oxygen Administration
Inserting Nasogastric Tube (Gastric Intubation)
Administering Tube Feeding (NGT Feeding/Gastric Gavage)
2
Administering Enema
Inserting Urinary Catheter
Admitting Patients
Transferring Patients
Discharging Patients
Monitoring Intake And Output
Caring For Patients Under Isolation Precautions
Using A Bed Or Chair Exit Safety Monitoring Device
Implementing Seizure Precautions
Applying Restraints
Post Mortem Care
Intravenous Therapy
Internal Examination
Fundic Height Measurement
Prenatal
Post Partum
Essential Newborn Care
Post Natal Care
Complications Of Pregnancy And Postpartum
Post Partum Complications
Total Patient Care
Complications Of Pregnancy
Immediate Care Of Newborn ( Hospital Setting)
Leopold’s Maneuver
Fetal Heart Tone Auscultation
Intramuscular Injection Of Tetanus Toxoid
Intramuscular Injection Of Oxytocin
Intramuscular Injection Of Dexamethasone
Intramuscular Injection Of Ampicillin
Intramuscular Injection Of Magnesium Sulfate
Intramuscular Injection In Newborn
Intradermal Injection In Newborn
Repair Of First Degree Laceration
Repair Of Second Degree Laceration
References
3
NURSING PROCEDURES
PROCEDURE CHECKLIST
RUBRIC FOR RETURN DEMONSTRATION

5 EXCELLENT. Carries out procedure efficiently, systematically and independently
4 VERY SATISFACTORY. Carries out procedure efficiently, but requires minimal
3 SATISFACTORY. With moderate guidance and supervision
2 FAIR, but requires close guidance and supervisions
1 POOR. Carries out the procedure inefficiently, unsystematically even after close
4
PROCEDURE CHECKLIST 1
MEDICAL HANDWASHING (WHO 1,2,3,4,5 STEPS)
PREPARATION 5 4 3 2 1 REMARKS
1. Gather equipment needed.
2. Assess the hands. Nails should be kept short.
3. Check the hands for breaks in the skin.
4. Remove all jewelry.
PROCEDURE
5. If you are washing your hands where the
client can observe you, explain to the client
what you are going to do and why it is
necessary.
6. Turn on the water and adjust the flow. Be
sure to adjust flow so that the water is warm.
7. Wet the hands thoroughly by holding them
under the running water, and apply soap to
the hands.
8. Hold the hands lower than the elbows so that
the water flows from the arms to the
fingertips.
9. If the soap is liquid, apply 2-4Ml (1tsp). if it
is bar soap, granules, or sheets, rub them
firmly between the hands.
10. Thoroughly wash the hands. Use firm,
rubbing, and circular movements to wash the:
Palm
Finger interlace
Back of the hands
Fingers
Thumb
Rub the fingertips against the palm of the
opposite hand
Wrist
For 5 seconds (each part)
11. Rinse the hands.
12. Dry the hands and arms thoroughly with
paper towel.
13. Discard the paper towel in the appropriate
container.
14. Turn-off the faucet using paper towel.
TOTAL SCORE/RATING
5
SURGICAL HANDWASHING
2. Remove all jewelries.
3. Be sure fingernails are short and clean.
4. Wear shoe cover, cap, mask, and protective
eyewear.
PERFORMANCE
5. Position yourself on the sink with hands
higher than the elbow. Turn on the faucet.
6. Do initial handwashing. (up to elbow)
7. Apply cleansing agent to brush or sponge.
8. Wet hands and arms. Keep hands above
elbows.
9. Scrub the non-dominant hand using the
appropriate pattern:
● Fingertips and fingernails – 20
circular strokes
● Thumb – 5 downward stroke
● Interdigitals – 5 strokes each
● Palm – 10 circular strokes
● Dorsum – 10 circular strokes
● Wrist to forearm (4 angles) – 5

circular strokes
● Elbow – 5 circular strokes
10. Rinse the brush. Put liquid soap. Repeat step 9
to the dominant hand.
11. With hands higher than the elbows. Drop

brush into the sink.
12. Rinse the first hand and arm from the finger
tips to the elbow thoroughly with hands higher
than the elbows. Follow the same procedure to
the next hand.
13. Turn of the faucet.
14. Move to the sterile area to dry hands.
TOTAL SCORE
6
DONNING AND REMOVING STERILE GLOVES (OPEN METHOD)
1. Check client record, and ask the client about
latex allergies.
3. Insure the sterility o f the packaged gloves.
4. Remove jewelries.
PROCEDURE (APPLYING GLOVES)
6. Introduce yourself, and verify the client’s
identity. Explain to the client what you are
going to do, why it is necessary, and how the
client can cooperate.
7. Observe other appropriate infection control
procedures.
8. Provide for client privacy.
9. Perform handwashing before opening the
sterile package on a clean, dry surface above
your waist.
10. Open the outside wrapper by carefully
peeling back the top of the package or as
directed by the manufacturer without
contaminating the gloves or the inner
package. Remove the inner package, making
sure you are handling only the outside part of
it.
11. Lay the inner package on clean, flat, dry
surface about waist level. Carefully open the
inner package and expose the gloves with the
cuff close to you.
12. Grasp the glove for the dominant hand by its
folded cuff edge, with the thumb and first
finger of the non dominant hand. Touch only
the inside of the cuff. Position your dominant
hand.
13. Insert your dominant hand into glove. Keep
hands in front of you and away from your
uniform so that nothing touches the gloves.
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14. Pick up the other glove with the sterile
gloved hand, inserting the gloved fingers
under the cuff and holding the gloved thumb
close to the thumb.
15. Insert your second hand carefully.
16. Keeping hands above waist, adjust each
glove so that it fits smoothly, touching only
sterile areas.
PROCEDURE
(REMOVING AND DISPOSE OF USED
GLOVES)
17. Grasp the glove of the non-dominant hand
near the cuff end and remove it by inverting
with the dominant hand without touching
exposed wrist.
18. Slide the fingers of the ungloved hand inside
the remaining glove. Grasp the glove from
the inside and remove by turning inside out
over the hand and other glove.
19. Discard gloves into appropriate receptacle
and perform handwashing.
20. Document the procedure and sterile

technique used.
TOTAL SCORE
8
DONNING A STERILE GOWN AND GLOVES (CLOSED METHOD)
1. Gather equipment.
2. Insure the sterility of the package.
3. Observe appropriate infection control
procedure.
PROCEDURE (DONNING A STERILE GOWN)
4. Unwrap the sterile gown pack.
5. Open the package of sterile gloves. Remove
the outer wrap from the sterile gloves, and
leave the gloves in their inner sterile wrap on
the sterile field.
6. Wear shoe covers, cap that covers the hair,
face mask and protective eye wear.
7. Perform hand hygiene. (Surgical scrub)
8. Put on sterile gown. Grasp the sterile gown at
the crease near the neck; hold it away from
you, and permit it unfold freely without
touching anything, including the uniform.
9. Put the hands inside the shoulders of the
gown, and work the arms partway into the
sleeves without touching the outside of the
gown. Work the hands down the sleeves only
to the proximal edge of the cuffs.
10. Have a coworker grasp the neck tie without
touching the outside of the gown, and pull
the gown upward to cover the neckline of
your uniform in front and back. (Gowning
continues at step 21 )
PROCEDURE
(DONNING STERILE GLOVES - CLOSED
METHOD)
11. Open the sterile glove wrapper while the
hands are still covered by the sleeves.
12. With the dominant hand, pick up the opposite
glove with the thumb and index fingers,
handling it through the sleeve.
13. Lay the glove on the opposite gown cuff,
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thumb side down, with the glove opening
pointed toward the fingers. Position the
dominant hand palm upward inside the
sleeve.
14. Use the non dominant hand to grasp the cuff
of the glove through the gown cuff, and
firmly anchor it.
15. With dominant hand working through its
sleeve, grasp the upper side of the gloves
cuff, and stretch it over the cuff of the gown.
16. Pull the sleeve up to draw the cuff over the
wrist as you extend the fingers of the non-
dominant hand into the glove’s finger.
17. Put the glove on the non-dominant hand.
Place the fingers of gloved hand under the
cuff of the remaining glove.
18. Place the glove under the cuff of the second
sleeve.
19. Extend the fingers into the glove as you pull
the glove up over the cuff.
PROCEDURE (COMPLETION OF GOWNING)

20. Have a coworker take the two ties at each
side of the gown, and tie them at the back of
the gown, making sure that your uniform is
completely covered.
21. When worn, sterile gowns should be
considered sterile in front from the waist to
the shoulder. The sleeves should be
considered sterile from 2 inches above the
elbow to the cuff since the arms of a
scrubbed person must move across a sterile
field.
22. Remove protective devices: remove gloves
first, then the mask, gown, the eye wear or
goggles, cap and shoe cover.
TOTAL SCORE
10
ESTABLISHING AND MAINTAINING A STERILE FIELD
1. Ensure that the package is clean and dry; if
moisture is noted on the inside of a plastic-
wrapped package or the outside of a cloth-
wrapped package, it is considered
contaminated and must be discarded
2. Check the sterilization expiration dates on the
package, and look for any indications that it
has been previously opened. Spots or stains
on cloth or paper-wrapped objects may
indicate contamination, and the objects
should not be used.
3. Follow agency practice for disposal of
possibly contaminated packages
PROCEDURE
going to do, why it is necessary, and how he
or she can cooperate.
5. Perform hand hygiene and observe other
appropriate infection prevention procedures.
7. Open the package. If the package is inside a
plastic cover, remove the cover.
To Open a Wrapped Package on a Surface
● Place the package in the work area so that the
top flap of the wrapper opens away from you
● Reaching around the package (not over it),
pinch the first flap on the outside of the
wrapper between the thumb and index finger.
● Repeat for the side flaps, opening the
topmost one first. Use the right hand for the
right flap, and the left hand for the left flap
● Pull the fourth flap toward you by grasping
the corner that is turned down
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Opening a Wrapped Package While Holding It
● Hold the package in one hand with the top
flap opening away from you..
● Using the other hand, open the package as
described above, pulling the corners of the
flaps well back. Tuck each of the corners into
the hand holding the package so that they do
not flutter and contaminate sterile objects.
Opening Commercially Prepared Packages
● If the flap of the package has an unsealed
corner, hold the package in one hand, and
pull back on the flap with the other hand.
● If the package has a partially sealed edge,
grasp both sides of the edge, one with each
hand, and pull apart gently..
Establish a sterile field by using a drape
● Open the package containing the drape as
described above.
● With one hand, pluck the corner of the drape
that is folded back on the top touching only
one side of the drape
● Lift the drape out of the cover, and allow it to
open freely without touching any objects
● With the other hand, carefully pick up
another corner of the drape, holding it well
away from you and, again, touching only the
same side of the drape as the first hand
● Lay the drape on a clean and dry surface,
placing the bottom (i.e., the freely hanging
side) farthest from you
● Add necessary sterile supplies, being careful
not to touch the drape with the hands
To Add Wrapped Supplies to a Sterile Field
● Open each wrapped package as described in
the preceding steps.
● With the free hand, grasp the corners of the
wrapper, and hold them against the wrist of
the other hand
● Place the sterile bowl, drape, or other supply
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on the sterile field by approaching from an
angle rather than holding the arm over the
field
● Discard the wrapper.
Adding Commercially Packaged Supplies to a Sterile
Field
● Open each package as previously described
● Hold the package 15 cm (6 in.) above the

field, and allow the contents to drop on the
field.
Adding Solution to a Sterile Bowl
● Obtain the exact amount of solution, if
possible
● Before pouring any liquid, read the label
three times to make sure you have the correct
solution and concentration (strength). Wipe
the outside of the bottle with a damp towel to
remove any large particles that could fall into
the bowl or field.
● Remove the lid or cap from the bottle and
invert the lid before placing it on a surface
that is not sterile
● Hold the bottle so that the label is against the
palm of the hand
● Hold the bottle of fluid at a height of 10 to 15
cm (4 to 6 in.) over the bowl and to the side
of the sterile field so that as little of the bottle
as possible is over the field
● Pour the solution gently to avoid splashing
the liquid
● Tilt the neck of the bottle back to vertical
quickly when done pouring so that none of
the liquid flows down the outside of the
bottle
● If the bottle will be used again, replace the lid
securely and write on the label the date and
time of opening.
8. Use sterile forceps to handle sterile supplies
● If forceps tips are wet, keep the tips lower
13
than the wrist at all times, unless you are
wearing sterile glove
● Hold sterile forceps above waist or table
level, whichever is higher
● Hold sterile forceps within sight
● When using forceps to lift sterile supplies,

be sure that the forceps do not touch the
edges or outside of the wrapper
● When placing forceps whose handles were
in contact with the bare hand, position the
handles outside the sterile area
● • Deposit a sterile item on a sterile field
without permitting moist forceps to touch
the sterile field when the surface under the
absorbent sterile field is unsterile and a
barrier drape is not used.
9. Document that sterile technique was used in
the performance of the procedure.
TOTAL SCORE
ASSESSING BODY TEMPERATURE (AXILLA)
10. Gather the equipment needed
11. Check that all equipment is functioning
normally.
PROCEDURE
13. Wash hands and observe appropriate
infection control procedures.
15. Place the client in the appropriate position.
14
Move the gown to expose the axilla.
16. Clean the thermometer using cotton ball with
alcohol starting from bulb to stem, using firm
twisting motion.
17. Dry the thermometer using dry cotton ball
starting from bulb to stem, using firm
twisting motion.
18. Wipe the axilla of the patient using paper
towel in order to dry it without using friction.
19. Press the button.
20. Place the bulb of the thermometer into the
center of the axilla. Bring the patient’s arm
down close to his body and place his forearm
over his chest.
21. Remove the thermometer when you heard a
beeping sound. It means that the final reading
is done.
22. Remove the thermometer. Clean the
thermometer with dry cotton ball from stem
to bulb with one stroke only.
23. Read the thermometer. Press the button.
24. Clean the thermometer using cotton ball will
alcohol starting from the stem to bulb, using
firm twisting motion. Discard the cotton
balls.
25. Wash hands.
26. Document the temperature in the client
record.
TOTAL SCORE
ASSESSING BODY TEMPERATURE (RECTAL)
normally.
PROCEDURE
infection control procedures. Don gloves.
6. Place the client in Lateral or Sim’s position,
15
and then expose the buttocks of the patient.
7. Clean the thermometer using cotton ball with
alcohol starting from bulb to stem, and then
rinse it with water.
twisting motion.
9. Lubricate the rectal thermometer 1 to 2inches
from the bulb.
11. Insert the thermometer (1 to 1½ inches for
adult; ½ to 1 inch for children). Instruct the
patient to take a deep breath while inserting
the thermometer.
12. Remain with the client and leave the
thermometer in place until it beeps.
14. Read the thermometer and then press the
button.
15. Clean the thermometer using cotton ball will
alcohol starting from the stem to bulb, using
firm twisting motion. Discard the cotton
balls.
16. Remove gloves and wash hands.
17. Document the temperature in the client
record.
TOTAL SCORE
ASSESSING BODY TEMPERATURE (ORAL)
normally.
PROCEDURE
6. Place the client in the appropriate position.
16
7. Rinse the thermometer. Clean it using cotton
ball with alcohol, and then rinse with water to
remove the alcohol.
twisting motion.
10. Place the bulb of the thermometer under the
tongue.
11. Remove the thermometer when you heard a
beeping sound. It means that the final reading
is done.
13. Read the thermometer. Press the button.
14. Rinse the thermometer. Clean it with cotton
ball with alcohol, and rinse again. Dry using
a cotton ball from stem to bulb using firm
twisting motion.
15. Wash hands.
16. Document the temperature.
TOTAL SCORE
ASSESSING APICAL PULSE
normally.
PROCEDURE
4. Wash hands
5. Provide client privacy.
6. Position the client appropriately in a
comfortable supine position. Expose the area
17
of the chest over the apex of the heart.
7. Locate the apical impulse. This is the point
over the apex of the heart where the apical
pulse can be most clearly heard.
8. Palpate the fifth intercostal scape (for adults)
and the fourth intercostal space (for children)
and move to the left mid-clavicular line.
9. Clean the earpiece and diaphragm of the
stethoscope using cotton balls with alcohol.
10. Warm the diaphragm of the stethoscope by
holding it against your palm.
11. Insert the earpiece of the stethoscope into
your ears in the direction of the ear canals, or
slightly forward.
12. Tap your finger lightly on the diaphragm. If
necessary, rotate the head to select the
diaphragm.
13. Place the diaphragm of the stethoscope over
the apical impulse and listen to the normal
S1, and S2 heart sounds, which are heard as
“lub-dub”. Each lub-dub is counted as one
heartbeat.
14. Assess the rhythm and strength of the
heartbeat.
15. Document the pulse rate, rhythm, and
volume.
TOTAL SCORE
ASSESSING RADIAL PULSE
normally.
PROCEDURE
5. Position the client appropriately. Have the
client lie down and rest his arm along the
side of the body with the wrist extended and
18
the palm of the hand downward. Or the client
can sit with his or her forearm at a 90˚ angle
to the body resting on a support and with the
wrist extended and the palm of the hand
downward.
6. Place the first, second, and third finger pads
along the client’s radial artery, and press
gently against the radius; rest your thumb in
position to fingers on the back of the client’s
wrist.
7. Apply one enough pressure so that the
client’s pulsating artery can be felt distinctly.
8. Using a watch with second hand, count the
number of pulsations for one full minute.
9. Assess the rhythm while counting.
10. Record the pulse rate. Report any findings.
TOTAL SCORE
ASSESSING RESPIRATORY RATE
1. Gather equipment and check if functioning
well.
PROCEDURE
3. Wash hands.
5. If you anticipate the client’s awareness of
respiratory assessment, place the client’s arm
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across his/her chest. Observe the patient’s
respiration.
6. Note the rise and the fall of the patient’s chest
with each inspiration and expiration.
7. Count for the required one full minute.
8. Observe the depth, rhythm, and character of
respirations.
9. Document the breathing characteristics, rate
and rhythm.
TOTAL SCORE
ASSESSING BLOOD PRESSURE
1. Gather equipment needed
2. Select a blood pressure cuff of an appropriate
size for the client.
PROCEDURE
4. Perform hand hygiene
5. Provide for client privacy
6. Have the client assume a comfortable lying
or sitting position with the forearm supported
20
at a level of the heart and the palm of the
hand upward.
7. Select appropriate arm for the application of
cuff ( no intravenous infusion, breast or axilla
surgery on that side, cast, arteriovenous,
shunt, or injured or diseased limb).
8. Expose the area of brachial artery by
removing garments, or move the sleeve up.
9. Place the lower edge of the bladder cuff 1
inch (2.5cm) above the antecubital space.
10. Wrap the cuff around the client’s arm
properly. Check the gauge. It must be within
the zero area.
11. Palpate the brachial or the radial pulse by
pressing gently with the fingertips.
12. Tighten the screw valve on the bulb.
13. Inflate the bladder cuff while palpating the
artery. Note the point on the gauge where the
pulse disappears.
14. Deflate the cuff and wait for 1 to 2 minutes.
15. Clean the earpiece and the bell using cotton
ball with alcohol. Place the stethoscope
earpiece at the ear properly.
16. Place the bell of the stethoscope over the
brachial artery. Hold the diaphragm with the
thumb and index finger.
17. Inflate the cuff 30mmHg above the point at
which the pulse disappeared. Release the
valve and allow the gauge to drop 2 to 3
mmHg per second.
18. Listen for the Korotkoff sounds while
releasing the valve. Note the first faint but
clear sound (systolic), and the point at which
the sound disappears (diastolic). Read the
pressure closest to the number.
19. Allow the remaining air to escape quickly
and completely. Wait for 2 minutes if you
want to recheck the BP reading.
20. Remove the cuff. Clean and store the
equipment. Wash your hands.
21. Record blood pressure.
TOTAL SCORE
21
RANGE OF MOTION EXERCISES
PROCEDURE 5 4 3 2 1 REMARKS
NECK
a. Flexion
b. Extension
c. Hyperextension
d. Lateral Flexion
e. Rotation
SHOULDER
a. Flexion
b. Extension
c. Hyperextension
d. Abduction
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e. Adduction
f. Circumduction
g. External rotation
h. Internal rotation
ELBOW
a. Flexion
b. Extension
c. Rotation for supination
d. Rotation for pronation
WRIST
a. Flexion
b. Extension
c. Hyperextension
d. Radial Flexion (abduction)
e. Ulnar flexion (adduction)
HAND AND FINGERS
a. Flexion
b. Extension
c. Hyperextension
d. Abduction
e. Adduction
THUMB
a. Flexion
b. Extension
c. Abduction
d. Adduction
e. Opposition
HIP
a. Flexion
b. Extension
c. Hyperextension
d. Abduction
e. Adduction
f. Circumduction
g. Internal rotation
h. External rotation
KNEE
a. Flexion
b. Extension
ANKLE
a. Extension (plantar flexion)
b. Flexion (dorsiflexion)
FOOT
a. Eversion
b. Inversion
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TOES
a. Flexion
b. Extension
TRUNK
a. Flexion
b. Extension
c. Hyperextension
d. Lateral flexion
e. Rotation
TOTAL SCORE
POSITIONING
1. PRONE
Client lies face down
2. SUPINE
Client lies flat on the back
3. SIDE-LYING
Clients lies on the side with weight on the hip
and shoulder, with pillows support legs, arms,
head and back
4. SIM’S POSITION
In this semiprone position, the clients lies on
the side with weight distributed toward the
anterior ileum, humerus, and clavicle with
24
pillows support on flexed arms and legs
5. HIGH FOWLER’S
Sitting position raises clients head 80-90
degrees (high) pillows support for head, arms
and legs.
6. SEMI-FOWLER’S
Semi-sitting position with head elevation of
30-45 degrees
7. DORSAL RECUMBENT
Client lies supine with legs flexed and rotated
outward.
8. KNEE CHEST
Lies prone with buttocks elevated and knees
drawn to the chest
9. LITHOTOMY
Lies supine with hips flexed and calves and
heels parallel to the floor using stirrups.
10. TRENDELENBURG’S –
Lies supine with head 30-40 degrees lower
than the feet. (SHOCK POSITION is flat
with upper and lower extremities elevated by
pillow)
11. ORTHOPNEIC
Client sits either in bed or on the side of the
bed with an overbed table across the lap
TOTAL SCORE
BED BATH
PERPARATION 5 4 3 2 1 REMARKS
1. Gather and assemble equipment needed.
PERFORMANCE
identity. Explain what you are going to do,
why it is necessary, and how he or she can
cooperate.
3. Wash hands and observe other appropriate
infection control procedure.
4. Provide for client privacy by drawing the
curtains around the bed or closing the door to
the room.
25
5. Prepare the client and environment.
a. Invite a family member or significant
other to participate if desired.
b. Close windows and doors to ensure the
room is a comfortable temperature.
c. Offer the client a bedpan or urinal or ask
whether the client wishes to use the toilet
or commode.
d. During the bath, assess each area of the
skin carefully.
6. Prepare the bed and position the client
appropriately.
a. Position the bed at a comfortable working
height. Lower the side rail on the side
close to you. Keep the other side rail up.
Assist the client to move near you.
b. Place bath blanket over top sheet.
Remove the top sheet from under the
bath blanket by starting at client’s
shoulders and moving linen down toward
client’s feet. Ask the client to grasp and
hold the top of the bath blanket while
pulling linen to the foot of the bed.
c. Remove the client’s gown while keeping
the client’s gown while keeping the client
covered with bath blanket. Place gown in
linen hamper.
7. Make a bath mitt with the washcloth.
8. Wash the face. Begin the bath at the cleanest
area and work downward toward the feet.
a. Place towel under client’s head.
b. Wash the client’s eyes with water only
and dry them well. Use a separate corner
of washcloth for each eye.
c. Wipe from inner canthus to outer
canthus.
d. Ask the client wants soap used on the
face. Wash, rinse, and dry the client’s
face, ears, and neck.
e. Remove the towel from under the client’s
head.
9. Wash the arms and hands.
a. Place the towel lengthwise under the arm
away from you.
b. Wash, rinse and dry the arms and support
the client’s wrist and elbow. Use long,
firm strokes from wrist to shoulder,
including the axillary area.
c. Place a towel on the bed and put a
26
washbasin on it.
d. Place the client’s hands in the basin.
Assists the client as needed to wash,
rinse, and dry the hands, paying attention
to the spaces between the fingers.
e. Repeat for the hands and arms near you.
10. Wash the chest and abdomen.
a. Place bath towel lengthwise over chest.
Fold bath blanket down to the client’s
pubic area.
b. Lift the bath towel off the chest, and
bathe the chest and abdomen with your
mitted hand using long firm strokes. Give
special attention to the skin under the
breasts and any other skin folds
particularly if the client is overweight.
Rinse and dry well.
c. Replace the bath blanket when the areas
have been dried.
11. Wash the legs and feet. (Obtain fresh, warm
bathwater now or when necessary)
a. Expose the leg farthest from you by
folding the bath blanket toward the other
leg being careful to keep the perineum
covered.
b. Lift leg and place the bath towel
lengthwise under leg. Wash, rinse, and
dry the leg using long, smooth, firm
strokes from the ankle to the knee to the
thigh.
c. Reverse the coverings and repeat for the
other leg.
d. Wash the feet by placing them in the
basin of water.
e. Dry each foot. Pay particular attention to
the spaces between the toes. If you
prefer, wash one foot after that leg before
washing the other leg.
12. Wash the back and then the perineum.
a. Assist the client into a prone or side-lying
position facing away from you. Place the
bath towel lengthwise alongside the back
and buttocks while keeping the client
covered with the bath blanket as much as
possible.
b. Wash and dry the client’s back, moving
from the shoulders to the buttocks, and
upper thighs, paying attention to the
gluteal folds.
27
c. Perform back massage now or after
completion of bath.
d. Assists the clients to a supine position
and determine whether the client can
wash the perineal area independently. If
the client cannot do so, drape the client.
13. Assist the client with grooming aids such as
powder, lotion, or deodorant.
a. Use powder sparingly. Release as little as
possible into the atmosphere.
b. Help the client put on gown or pajamas.
c. Assist the client to care for hair, mouth,
and nails. Some people prefer or need
mouth care prior to their bath.
TOTAL SCORE
PERINEAL CARE
PERPARATION 5 4 3 2 1 REMARKS
1. Gather and assemble equipment needed.
PERFROMANCE
cooperate.
28
the room.
5. Prepare the client:
a. Fold the top bed linen to the foot of the
bed and fold the gown up to expose the
genital area.
b. Place a bath towel under the client’s hips.
6. Position and drape the client and clean the
upper inner thighs.
FOR FEMALES
a. Position the female in back-lying position
with the knees flexed and spread well
apart.
b. Cover her body and leg with the bath
blanket. Drape the legs by tucking the
bottom corners of the bath blanket under
the inner sides of the legs. Bring the
middle portion of the base of the blanket
up over the pubic area.
c. Put on gloves, wash and dry the upper
inner thighs.
FOR MALES
a. Position the male client in a supine
position with knees slightly flexed and
hips slightly externally rotated.
b. Put on gloves, wash and dry the upper
inner thighs.
7. Inspect the perineal area.
a. Note particular areas of inflammation,
excoriation, or swelling, especially
between the labia in females and scrotal
folds in males.
b. Also note excessive discharge or
secretions from the orifices and the
presence of odors.
8. Wash and dry the perineal-genital area.
FOR FEMALES
a. Clean the labia majora. Then spread the
labia to wash the folds between the labia
majora and the labia minora.
b. Use separate quarters of the washcloth
for each stroke, and wipe from the pubis
to the rectum. For menstruating women
and clients with indwelling catheters, use
clean wipes, cotton balls, or gauze. Take
a clean ball for each stroke.
c. Rinse the area well. You may place the
client on a bedpan and use a periwash or
solution bottle to pour warm water over
the area. Dry the perineum thoroughly,
29
paying particular attention to the folds
between the labia.
FOR MALES
a. Wash and dry the penis, using firm
strokes.
b. If the client is uncircumcised, retract the
prepuce (foreskin) to expose the glans
penis (the tip of the penis) for cleaning.
Replace the foreskin after cleaning the
glans penis.
c. Wash and dry the scrotum. The posterior
folds of the scrotum may need to be
cleaned when the buttocks are cleaned.
9. Inspect perineal orifices for intactness.
a. Inspect particularly around the urethra in
clients with indwelling catheters
10. Clean between buttocks.
a. Assist the client to turn onto the side
facing away from you.
b. Pay particular attention to the anal area
and posterior folds of the scrotum in
males. Clean the anus with the toilet
tissue before washing it, if necessary.
c. Dry the area well.
d. For post delivery or menstruating
females, apply a perineal pad as needed
from front to back.
11. Document any unusual findings such as
redness, excoriation, skin breakdown,
discharge or drainage and any localized areas
or tenderness.
TOTAL SCORE
SHAMPOOING THE HAIR OF A CLIENT CONFINED IN BED
PERFORMANCE
cooperate.
the room.
30
5. Position and prepare the client appropriately.
a. Assist the client to the side of the bed
from which you will work.
b. Remove pins and ribbons from the hair,
and b rush and comb it to remove tangles.
6. Arrange the equipment.
a. Put the plastic sheet or pad on the bed
under the head.
b. Remove the pillow from under the
client’s head, and place it under the
shoulders unless there is some underlying
conditions.
c. Tuck a bath towel around the client’s
shoulders.
d. Place the shampoo basin under the head,
putting a folded washcloth or pad where
the client’s neck rests on the edge of the
basin. If the client is on a stretcher, the
neck can rest on the edge of the sink with
the washcloth as padding.
e. Fanfold the top bedding down to the
waist, and cover the upper part of the
client with the bath blanket.
f. Place the receiving receptacle on the
table or chair at the bedside. Put the spout
of the shampoo basin over the receptacle.
7. Protect the client’s eyes and ears.
a. Place a damp washcloth over the client’s
eyes.
8. Shampoo the hair
a. Wet the hair thoroughly with the water.
b. Apply shampoo to the scalp. Make a
good lather with the shampoo while
massaging the scalp with the pads of your
fingertips. Massage all the areas of the
scalp systematically.
c. Rinse the hair briefly, and apply shampoo
again.
d. Make a good lather and massage the
scalp as before.
e. Rinse the hair thoroughly this time to
remove all shampoo.
f. Squeeze as much water as possible out of
the hair with your hands.
9. Dry the hair thoroughly.
10. Ensure client comfort.
a. Assist the client to a comfortable
position.
31
b. Arrange the hair using a clean brush and
comb.
11. Document the shampoo and any assessments.
TOTAL SCORE
32
PROVIDING SPECIAL ORAL CARE
1. Gather all equipment needed.
PROCEDURE
cooperate.
the room.
5. Prepare the client.
a. Position the client in side lying position,
with the head of the bed lowered. This
position is one of the choices for the
unconscious clients receiving oral care.
b. Place a towel under the client’s shin
c. Place the curved basin against the client’s
chin and lower check to receive the fluid
from the mouth
d. Put on gloves
6. Clean the teeth and rinse the mouth
a. Hold the brush against the teeth with the
bristles at a 45 degree angle. The tips of
the bristles should rests against and
penetrate under the gingival sulcus. The
brush will clean under the sulcus of two
or three teeth at one time. Brush gently
and carefully to avoid injuring the gums.
b. Rinse the client’s mouth by drawing
about 10mL of water or alcohol free
mouthwash into the syringe and injecting
it gently into each side of the mouth.
c. Watch carefully to make sure that all the
rinsing solution has run out of the mouth.
d. Repeat from rinsing until the mouth is
free of dentifrice, if used.
7. Ensure client comfort.
a. Remove basin and dry around the client’s
mouth with the towel.
b. Lubricate the client’s lips with petroleum
jelly.
8. Document assessment.
TOTAL SCORE
33
BACK MASSAGE
PERFORMANCE
cooperate.
the room.
5. Adjust bed to an appropriate working
position. Lower side rail nearer to you and
position your client into prone position.
6. Expose the back of your patient. Cover the
lower part of the body with a bath blanket.
7. Apply lotion to the client’s back, shoulder
and sacral area using a light, gliding motion
(effleurage).
8. Place your hands on the base of the client’s
spine and start stroking in a slow continuous
motion, working upward until the shoulders
and downward to the sacral area. Repeat
several times.
9. Apply circular motion strokes to the
shoulder, entire back, sacrum and iliac crest
several times.
10. Using petrissage, knead the client’s skin
gently.
11. Apply additional long stroking movements
slowly becoming lighter to the back to finish
the massage.
12. Assess the client’s skin for redness or lesions
while performing the massage.
13. Wipe the client’s back with bath towel to
keep the back dry. Remove excess lotion.
14. Wash hands.
15. Document any findings.
TOTAL SCORE
34
APPLICATION OF HOT COMPRESS
1. Gather and prepare equipment needed.
2. Determine the need of the client.
PERFORMANCE
cooperate.
the room.
6. Fill the hot water bag with hot water. Be sure
that the screw cover is tight.
7. Wrap the hot water bag with a hand towel and
then place it on the affected body part for 10-
15 minutes or maximum of 20 minutes
8. Observe the skin of the client after hot
compress application.
9. Document.
TOTAL SCORE
35
APPLICATION OF COLD COMPRESS
1. Gather and prepare equipment needed.
2. Determine the need of the client.
PERFORMANCE
cooperate.
the room.
6. Fill the ice pack with ice. Be sure that the
screw cover is tight.
7. Apply the ice pack on the affected body part
for 10-15 minutes or maximum of 20 minutes
8. Observe the skin of the client after cold
compress application.
9. Document.
TOTAL SCORE
36
MAKING AN UNOCCUPIED BED
1. Gather equipment needed. Assemble
equipment and arrange on a bed side chair in
the order in which the items will be used.
PROCEDURE
cooperate.
4. Adjust bed to appropriate working level.
5. Grasp the pillow and remove the pillow case.
Place the pillow on the bedside chair.
6. Loosen the bed linen as you move around the
bed from the head of the bed on the far side
to the head of the bed on the near side.
7. Snugly roll all of the soiled linen inside the
bottom sheet and place directly into the
laundry hamper.
8. Grasp mattress securely and move the
mattress up to the head of the bed.
9. Place the bottom sheet with its center fold on
the center of the bed (hem side down).
Spread the sheet out over the mattress and
allow a sufficient amount of the sheet at the
top to tuck under the head of the mattress.
Unfold the bottom sheet in place and then
fanfold.
10. Tuck the linen at the head part of the
mattress. Then miter the corner. Tuck the
linen at the foot part of the mattress, and then
miter the corner. And then tuck the remaining
bottom sheet securely under the mattress.
11. Place the rubber sheet with its center fold on
the center of the bed. Unfold the rubber sheet
in place and then fanfold it.
12. Place the draw sheet with its center fold on
the center of the bed. Unfold the draw sheet
in place and then fanfold it. Tuck the rubber
and draw sheet under the mattress.
13. Place top linen before moving to the other
side of the bed (hem side up). Same manner
with the bottom sheet. Allow a sufficient
amount of sheet at the foot part to tuck under
the mattress.
14. Fanfold the top sheet. Tuck the foot part and
37
then miter the corner.
15. Move to the other side of the bed. Pull the
bottom sheet gently. Tuck bottom sheet
under the head of the mattress and miter the
corner. Secure the foot part and miter the
corner. Secure the remaining bottom sheet
under the mattress.
16. Pull the rubber and draw sheet tightly and
tuck under the mattress.
17. Pull the top sheet. Make a vertical toe pleat,
5 to 10cm (2-4 inches) or a horizontal toe
pleat, 5-10cm (2-4 inches) in the sheet to
provide additional room for the client’s feet.
18. Tuck the top sheet the foot of the bed and
miter the corner.
19. Fold the upper 6 inches of the top sheet down
over the spread and make a cuff.
20. Put clean pillowcase on the pillow.
21. Place the pillow appropriately at the head of
the bed.
22. Dispose soiled linen according to agency
policy. Wash your hands.
TOTAL SCORE
38
MAKING AN OCCUPIED BED
1. Gather equipment needed. Assemble
equipment and arrange on a bed side chair in
the order in which the items will be used.
PROCEDURE
2. Explain what you are going to do, why it is
necessary, and how he or she can cooperate.
5. Lower the side rail nearest to you, leaving the
opposite side rail up. Place the bed in flat
position if the client can tolerate it.
6. Grasp the pillow and remove the pillow case.
Put it back under the head of the client.
7. Place a bath blanket over the client. Have the
client hold onto the bath blanket while you
reach under it and remove top linens. Discard
soiled linen in laundry bag or hamper.
8. Assist the client in turning to opposite side of
the bed.
9. Loosen all bottom linens from the head to
foot on the side nearest you.
10. Fan fold or roll soiled linens as close to the
client as possible.
11. Place the bottom sheet with its center fold in
the center of the bed and high enough to have
a sufficient amount of the sheet to tuck under
the head of the mattress. Unfold the bottom
sheet in place and then fanfold.
12. Tuck the linen at the head part of the
mattress. Then miter the corner. Tuck the
linen at the foot part of the mattress, and then
miter the corner. Tuck the remaining bottom
sheet securely under the mattress.
13. Place the rubber sheet with its center fold in
the center of the bed. Unfold the rubber sheet
14. Place the draw sheet with its center fold in
the center of the bed. Unfold the draw sheet
15. Tuck the rubber sheet and draw sheet
securely under the mattress on one side of the
bed.
16. Assist the patient to roll over toward you
onto the clean side of the bed. Move the
39
pillow to the clean side.
17. Raise side rail.
18. Move to the other side of the bed. Lower the
side rail.
19. Loosen all bottom linens from the head to
foot on the side nearest you.
20. Pull soiled linens and put it in the hamper.
21. Pull the bottom sheet gently. Secure bottom
sheet under the head of the mattress and
miter the corner. Secure the foot part and
miter the corner. Secure the remaining
bottom sheet under the mattress.
22. Pull the rubber and draw sheet tightly and
tuck under the mattress.
23. Reposition the pillow at the center of the bed.
Assist the client to the center of the bed.
24. Spread a top sheet over the client (same with
the bottom sheet). Ask the client to hold the
top edge of the sheet. Tuck the foot part and
then miter. Tuck the remaining sheet. Raise
the side rails.
25. Move to the other side. Lower side rails. Pull
the top sheet. Make a vertical toe or
horizontal pleat (5 to 10cm) in the sheet to
provide additional room for the client’s feet.
Pull the bath blanket and put in the hamper.
26. Tuck the top sheet at the foot of the bed and
miter the corner.
27. Fold the upper 6 inches of the top sheet down
over the spread and make a cuff.
28. Put clean pillowcase on the pillow.
29. Place the pillow under the head of the client.
30. Dispose soiled linen according to agency
policy. Wash your hands.
40
APPLICATION OF EYE MEDICATION OR IRRIGATION
1. Check doctor’s order.
PROCEDURE
3. Identify the client.
4. Explain the procedure to the client.
6. Check medication label.
7. Position the client
8. Cleanse the eyelids and eyelashes of the client
from inner to outer canthus.
9. Slightly tilt the head of the client.
10. Ask the client to look up and focus on an object
11. Separate the lids gently using the thumb and
two fingers. Squeeze the container and allow to
drop the prescribed amount of medicine. Allow
it to fall on the lower conjuctival sac. Wait for
5minutes if additional drop need to be
administered.
12. Ask the client to close his/her eye gently.
13. Apply gentle pressure on the nasolacrimal duct
using cotton balls for at least 30 secs.
14. Discard contaminated materials used in
appropriate receptacle.
15. Perform handwashing.
16. Document.
TOTAL SCORE
41
ADMINISTRATION OF OTTIC MEDICATIONS
PROCEDURE
7. Position the client (Side lying position with the
ear being treated uppermost)
8. Warm solution at room or body temperature.
9. Clean the pinna and the meatus of the ear canal
with cotton-tipped applicator
10. Straighten the ear canal (0-3 yrs old: pull pinna
downward then backward; 3 and above: pull
pinna upward then backward)
11. Instill eardrops on the side of the auditory canal
to allow the drops to flow in and to continue to
adjust to body temperature.
12. Press gently but firmly a few times on the tragus
of the ear to assist the flow of medication into
the ear canal.
13. Ask the client to remain in side lying position
for about 5 minutes.
14. Insert a small piece of cotton fluff loosely at the
meatus of the auditory canal for 15 to 20
minutes.
15. Discard materials used in appropriate
receptacle.
16. Document
TOTAL SCORE
42
ADMINISTRATION OF NASAL INSTALLATION
PROCEDURE
7. Have the client blow the nose prior to nasal
installation
8. Assume back lying position, or sit up and lean
head back
For sinus installation:
-Parkinson’s position for frontal and
maxillary sinuses
-Proetz position for ethmoid and
sphenoid sinuses.
9. Elevate the nares slightly by pressing the thumb
against the client’s tip of the nose. While the
client inhales, squeeze the bottle.
10. Keep head tilted backward for 5 minutes after
installation of nasal drops
11. When the medication is used on a daily basis,
alternate nares to prevent irritation.
receptacle.
13. Document
TOTAL SCORE
43
ADMINISTRATION OF NASAL INHALATION
PROCEDURE
7. Position the client in semi or high fowler’s
position or standing position.
8. Shake the canister several times
9. Position the mouth piece 1-2 inches from the
client’s open mouth
10. Instruct client to hold breath for 10 seconds
every after administration of the medication.
11. If bronchodilator, administer a maximum of 2
puffs, for at least 30 secs interval.
12. Wait at least 1 minute before administration of
the second dose or inhalation of a different
medication by MDI
13. Instruct the client to rinse mouth, if steroid had
been administered.
receptacle.
15. Document
TOTAL SCORE
44
ADMINISTRATION OF RECTAL SUPPOSITORY
3. Make sure that suppository was refrigerated.
PROCEDURE
6. Perform hand hygiene and gloving.
8. Have client lie on left side and breathe through
the mouth
9. Insert suppository until a sensation of “as if
something has grabbed it away,” occurs,
10. Ensure the suppository comes in contact with

the rectal wall.
11. Client must remain on side for 20 minutes
after insertion
receptacle.
13. Document
TOTAL SCORE
45
PREPARING MEDICATIONS FROM AMPULES
1. Check the MAR
a. Check the label on the ampule carefully
against the MAR to make sure that the
correct medication is being prepared.
b. Follow the three checks for administering
medications
PROCEDURE
appropriate infection prevention procedures
3. Prepare the medication ampule for drug
withdrawal..
a. Flick the upper stem of the ampule several
times with a fingernail.
b. Use an ampule opener or place a piece of
sterile gauze or alcohol wipe between your
thumb and the ampule neck or around the
ampule neck, and break off the top by
bending it toward you to ensure the
ampule is broken away from yourself and
away from others.or
c. Place the antiseptic wipe packet over the
top of the ampule before breaking off the
top
d. Dispose of the top of the ampule in the
sharps container
4. . Withdraw the medication.
a. Place the ampule on a flat surface.
b. Attach the filter needle/straw to the
syringe.
c. Remove the cap from the filter needle and
insert the needle into the center of the
ampule. Do not touch the rim of the
ampule with the needle tip or shaft.
d. With a single-dose ampule, hold the
ampule slightly on its side, if necessary, to
obtain more than the ordered amount
of medication
e. Dispose of the filter needle by placing in a
sharps container
f. If giving an injection replace the filter
needle with a regular needle, tighten the
cap at the hub of the needle, and push
solution into the needle, to the prescribed
amount.
TOTAL SCORE
46
PREPARING MEDICATIONS FROM VIALS
1. Check the MAR
a. Check the label on the ampule carefully
against the MAR to make sure that the
correct medication is being prepared.
b. Follow the three checks for administering
medications
PROCEDURE
3. Prepare the medication for drug withdrawal..
a. Mix the solution, if necessary, by rotating
the vial between the palms of the hands,
not by shaking
b. Remove the protective cap, or clean the
rubber cap of a previously opened vial
with an antiseptic wipe by rubbing in a
circular motion
4. Withdraw the medication.
a. Attach a filter needle, as agency practice
dictates, to draw up premixed liquid
medications from multidose vials
b. Ensure that the needle is firmly attached to
the syringe
c. Remove the cap from the needle, then draw
up into the syringe the amount of air equal
to the volume of the medication to be
withdrawn
d. Carefully insert the needle into the upright
vial through the center of the rubber cap,
maintaining the sterility of the needle.
e. Inject the air into the vial, keeping the
bevel of the needle above the surface of the
medication.
f. Withdraw the prescribed amount of
medication using either of the following
methods:
● . Hold the vial down (i.e., with the base
lower than the top), move the needle tip
so that it is below the fluid level, and
withdraw the medication. Avoid
drawing up the last drops of the vial...or
● Invert the vial, ensure the needle tip is
below the fluid level, and gradually
withdraw the medication.
47
g. Hold the syringe and vial at eye level to
determine that the correct dosage of drug is
drawn into the syringe. Eject air remaining
at the top of the syringe into the vial
h. When the correct volume of medication
plus a little more (e.g., 0.25 mL) is
obtained, withdraw the needle from the
vial, and replace the cap over the needle
using the scoop method, thus maintaining
its sterility
i. If necessary, tap the syringe barrel to
dislodge any air bubbles present in the
syringe.
j. If giving an injection, replace the filter
needle, if used, with a regular or safety
needle of the correct gauge and length.
Eject air from the new needle and verify
correct medication volume before injecting
the client
TOTAL SCORE
48
ADMINISTERING INTRADERMAL INJECTION (SKIN TEST)
PROCEDURE
5. Withdraw medication from the ampule or vial.
6. Identify the client and explain the procedure.
7. Select appropriate ID site.
8. Expose the area and clean it thoroughly with
cotton balls with alcohol in circular motion.
9. Stretch the skin.
10. Place the needle almost flat to the skin. Bevel
up.
11. Inject the solution slowly until a wheal was
formed.
12. Withdraw the needle and discard it.
13. Do not press or massage the ID site.
14. Get a pen and encircle the wheal. Do not use
red pen. Write ANST and the time the
medicine will be due.
15. Wash hands.
16. Document.
TOTAL SCORE
49
ADMINISTERING SUBCUTANEOUS INJECTION
PROCEDURE
5. Withdraw medication from the ampule or vial.
7. Select appropriate site for injection.
9. Grasp the area surrounding the injection site
10. Hold the syringe and position it. Inject the at
45˚ angle.
11. Pull the plunger to check for blood. If there’s
no blood, inject the solution slowly.
12. Withdraw the needle and massage the area
gently using cotton balls.
13. Discard the syringe and other equipment used
in appropriate receptacle.
14. Perform hand hygiene.
15. Document.
TOTAL SCORE
50
ADMINISTERING INTRAMUSCULAR INJECTION
PROCEDURE
5. Withdraw medication from the ampule or
vial.
7. Select appropriate site for injection.
9. Pinch the skin together forming a cushion of a
muscle.
10. Hold the syringe and position it. Inject the at
90˚ angle.
11. Pull the plunger to check for blood. If there’s
no blood, inject the solution slowly.
12. Withdraw the needle and massage the area
gently using cotton balls.
13. Discard the syringe and other materials used
in appropriate receptacle.
15. Document.
TOTAL SCORE
51
INTRAVENOUS THERAPY
PROCEDURE 5 4 3 2 1
1.Explain to the client what you are going to do, why it is necessary
and she can cooperate.
2.Wash hand and observe other appropriate infection control
procedures.
3.Provide for client privacy.
4.Open and prepare the infusion set.
● Remove tubing from the container and straighten it out.
● Slide the tubing clamp along the tubing until it is just below
the drip chamber to facilitate its access.
● Close the clamp.
● Leave the ends of the tubing covered with the plastic caps
until the infusion is started.
5.Spike the solution container.
● Remove the protective cover from the entry site of the
container.
● Remove the cap from the spike and insert the spike into the
insertion site of the bag or bottle. Follow the manufacturer
instructions.
6. Apply the medication label to the solution container if a
medication was added.
7. Apply a timing label on the solution container.
● The timing label may be applied at the time of the infusion
Is started. Follow agency practice.
8.Hang the solution container on the pole.
● Adjust the pole so that the container is suspended about 1m
3 ( 3 feet ) above the clients head.
9.Partially fill the drip chamber with solution.
● Squeeze the chamber gently until is half full of solution.
10.Prime the tubing.
● Remove the protective cap and hold the tubing over a
container. Maintain the sterility of the end of the tubing
● Release the clamp, and let the fluid run through the tubing
until all bubbles are removed. Tap the tubing with your
fingers if necessary to help the bubbles move.
52
● Reclamp the tubing and replace the tubing cap, maintaining
sterile technique.
● For caps with air vents, do not remove the cap when priming
this tubing.
● If an infusion control pump electronic device, or controller is

being used , follow the manufacturer’s directions for
inserting the tubing and setting the infusion rate.
11.Wash your hands.
12.Select the venipuncture site.
● Unless contraindicated, use the client’s non dominant arm.
● Check agency protocol about shaving if the site is very

hairy.
● Place a towel or bed protector under the extremity to protect
linens.
13.Dilate the vein.
● Place the extremity in a dependent position.
● Apply a tourniquet firmly 15-20 cm (6-8 in)above the

venipuncture site.
● If the vien is not sufficiently dilated:
● Massage or stroke the vein distal to the site and in the

direction of venous flow toward the heart.
● Encourage the client to clench and unclench the fist.
● Lightly tap the vein with your fingertips.
● If the preceding steps fail to distend the vein so that it is

palpable, remove the tourniquet and apply heat to the entire
extremity for 10-15 minutes.
14.Don clean gloves and clean the venipuncture site.
● Clean the skin at the site of entry with a topical antiseptic
swab, 25% chlorhexidine, or alcohol. Check for allergies
to iodine or shellfish before cleansing skin with Betadine
or iodine products.
● Use a circular motion, moving from the center outward
for several inches.
● Permit the solution to dry on the skin.
15.Insert the catheter and initiate the infusion
53
● If desired and permitted by policy, inject 0.05 ml 1%
lidocaine intradermal over the site where you plan to insert
the IV needle. Allow 5-10 seconds for the anesthetic to
take effect.
● Use the non dominant hand to pull the skin taut below the
entry site.
● Holding the over-the-needle catheter at a 15- to 30 degree
angle with the bevel up, insert the catheter through the skin
and into the vein in one thrust.
● Once blood appears in the lumen of the needle or you feel
the lack of resistance reduce the angle of the catheter until
it is almost parallel with the skin , and advance the needle
and catheter approximately 0.5-1 cm (about 1/4inch)
further. Holding the needle portion steady, advance the
catheter until the hub is at the venipuncture site.
● Release the tourniquet
● Remove the protective cap from the distal end of the

tubing , and hold it ready to attach to the catheter,
maintaining the sterility of the end.
● Carefully remove the needle, engage the needle safety
device and attach the end of the infusion tubing to the
catheter tub.
● Initiate the infusion.
16.Tape the catheter
● Tape the catheter by the “U’’ method. Using three strips of
adhesive tape, each about 7.5 cm (3 in) long.
● Place one strip, sticky-side up, under the catheter’s hub.
● Fold each end over so that the sticky sides are against the
skin.
● Place second trip, sticky side down, over catheter hub
● Place third strip, sticky side down over catheter hub.

17.Dress and label the venipuncture site and tubing according to
agency policy.
● Cover venipuncture site according to policy.
● Remove soiled gloves and discard appropriately.
● Loop the tubing and secure it with tape.
54
● Label the dressing with the date and time of insertion, type
and gauge of needle or catheter used and your initials.
18.Ensure appropriate infusion flow
● Apply a padded arm board to splint the joint ,as needed.
● Adjust the infusion rate of flow according to the order.

19. Label the IV tubing
● Label the tubing with the date and time of attachment and
your initials.
20. Document relevant data. Record:
● The time of the start of the infusion.
● The flow rate of the infusion
● The date and time of venipuncture
● The amount and type of solution used , including any

additives
● The type and guage of the needle or catheter
● The venipuncture site
● The clients general response.
ADDING MEDICATIONS TO INTRAVENOUS FLUID CONTAINERS
PROCEDURE
4. Prepare the medication ampule or vial for
drug withdrawal.
55
5. Add the medication.
New IV Container
a. Locate the injection port. Clean the port with
the antiseptic or alcohol swab
b. Remove the needle cap from the syringe,
insert the needle through the center of the
injection port, and inject the medication into
the bag. Activate the needle safety device.
c. Mix the medication and solution by gently
rotating the bag or bottle
d. Complete the IV additive label with name and
dose of medication, date, time, and nurse’s
initials. Attach it on the bag or bottle
e. Clamp the IV tubing. Spike the bag or bottle
with IV tubing and hang the IV. R
f. Regulate infusion rate as ordered. Often a
controller device such as an IV pump is used
to ensure accurate rate of infusion.
To an Existing Infusion
a. Determine that the IV solution in the
container is sufficient for adding the
medication.
b. Confirm the desired dilution of the
medication, that is, the amount of medication
per milliliter of solution
c. Close the infusion clamp
d. Wipe the medication port with the alcohol or
disinfectant swab
e. While supporting and stabilizing the bag with
your thumb and forefinger, carefully insert
the syringe needle through the port and inject
the medication.
f. Remove the bag from the pole and gently
rotate the bag.
g. Rehang the container and regulate the flow
rate.
h. Complete the medication label and apply to
the IV container.
6. Dispose of the equipment and supplies
according to agency practice
7. Document the medication(s) on the
appropriate form in the client’s record.
TOTAL SCORE
56
ADMINISTERING INTRAVENOUS MEDICATIONS USING IV PUSH
1. Check the MAR.
2. Assemble and gather equipment needed.
3. Check equipment if functioning well.
PROCEDURE
4. Introduce yourself to your client. And explain
the procedure to the client.
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7. Place the client in semi-fowler’s position.
8. Cover the client’s eyes with washcloth to
prevent irritation.
9. Place the steam inhalator in a flat, stable area.
10. Place the spout 12-18 inches away from the
client’s nose or adjust the distance as
necessary.
11. Cover the chest with towel
12. Assess for redness on the side of the face
which indicates first degree burns.
13. Render steam inhalation therapy for 15-20
minutes.
14. Instruct the client to perform deep breathing
and coughing exercises after the procedure
15. Provide oral hygiene.
16. Make relevant documentation.
TOTAL SCORE
STEAM INHALATION
19. Check equipment if functioning well.
PROCEDURE
58
23. Place the client in semi-fowler’s position.
24. Cover the client’s eyes with washcloth to
prevent irritation.
25. Place the steam inhalator in a flat, stable area.
26. Place the spout 12-18 inches away from the
client’s nose or adjust the distance as
necessary.
27. Cover the chest with towel
28. Assess for redness on the side of the face
which indicates first degree burns.
29. Render steam inhalation therapy for 15-20
minutes.
30. Instruct the client to perform deep breathing
and coughing exercises after the procedure
31. Provide oral hygiene.
TOTAL SCORE
SUCTIONING (OROPHARYNGEAL AND NASOPHARYNGEAL)
1. Assess indicators for suctioning.
PROCEDURE
4. Wash hands and apply gloves
5. Position the client: Conscious – Semi
fowler’s; Non-conscious: Lateral/side lying
6. Measure the suction catheter (Tip of the nose
59
to tip of the earlobe)
7. Lubricate the catheter : Nasopharyngeal
(water soluble lubricant); Oropharyngeal
(Sterile water or NSS)
8. Insert the catheter.
9. Apply intermittent suctioning while
withdrawing the catheter.
10. Apply suction for 5-10 seconds (max 15
secs); 20-30 secs interval
11. Hyperventilate client with 100% O2 before
and after suctioning to prevent hypoxia
13. Document.
TOTAL SCORE
OXYGEN ADMINISTRATION
1. Determine the need for oxygen.
Assess signs and symptoms of hypoxemia.
Ensure proper functioning of the equipment.
PROCEDURE
60
7. Position the client in semi-fowler’s position.
8. Set up the oxygen equipment and humidifier.
9. Turn on the oxygen at the prescribed rate,
and ensure proper functioning.
10. Put the cannula or appropriate oxygen device
over the client’s face.
Cannula – put over the client’s face, with the

outlet prongs fitting into the nares and the
elastic band around the head. Tape if
necessary.
Facemask – Apply from nose downward.

Secure elastic band around the client’s head.
Face tent – place the tent over the client’s

face, and secure the ties around the head.
11. Place “No Smoking” sign at the bedside.
Avoid use of oil, greases, alcohol and ether
near the client receiving O2.
Check electrical appliances before use.
Avoid materials that generate static
electricity.
12. Assess the client regularly
13. Inspect the equipment on a regular basis.
TOTAL SCORE
INSERTING NASOGASTRIC TUBE (GASTRIC INTUBATION)
1. Verify doctor’s order.
PROCEDURE
3. Inform the patient and explain the procedure.
4. Wash hands and apply gloves.
5. Place patient in high-fowler’s position.
6. Measure length of NGT to be inserted (tip of
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the nose to the tip of the earlobe to the
xiphoid process = 50cm) also called the NEX
technique
7. Lubricate tip of the tube with water-soluble
lubricant
8. Hyperextend the neck, gently advance the
tube toward the nasopharynx.
9. Tilt the patient’s head forward once the tube
reaches the oropharynx (throat) and ask to
swallow, as the tube is advanced.
10. Check NGT placement.
11. Secure the NGT by taping it to the bridge of
the client’s nose.
13. Document.
TOTAL SCORE
ADMINISTERING TUBE FEEDING (NGT FEEDING/GASTRIC GAVAGE)
PROCEDURE
3. Inform the patient and explain the procedure.
4. Assist client to a semi-fowler’s position in
bed or sitting position in a chair, or slightly
elevated right side-lying position.
62
5. Wash hands and apply gloves.
6. Assess tube placement and patency.
a. Introduce 5-20 ml of air into the NGT and
auscultate at the epigastric area, gurgling
sound is heard.
b. Aspirate gastric content, which is yellow
or greenish in color.
c. Immerse tip of the tube in water, no
bubbles should be produced.
d. measure the pH of the aspirated fluid
which should be acidic.
7. Assess residual feeding contents.
8. Introduce feeding slowly.
9. Height of feeding is 12inches above the
tube’s point of insertion into the client.
10. Instill 60mL of water into the NGT after
feeding..
11. Clamp the NGT before all of the water is
instilled.
12. Ask client to remain in Fowler’s position or
in slightly elevated right lateral position for
30 minutes.
13. Do after care of equipment.
TOTAL SCORE
ADMINISTERING ENEMA
PROCEDURE
4. Provide privacy.
6. Promote relaxation.
7. Position client: Adult – Left lateral position;
63
Infant/small children- Dorsal recumbent
8. Lubricate 5cm (2 in) of the rectal tube.
9. Allow solution to flow through the
connecting tubing and rectal tube to expel air
before insertion of rectal tube.
10. Insert 7-10cm (3-4 in) of rectal tube gently in
rotating motion.
11. Introduce solution slowly.
12. Change the position to distribute solution
well in the colon (high enema); if low enema,
remain in lateral position.
13. If abdominal cramps occur during
introduction of solution, temporarily stop the
flow of solution by clamping the tube until
peristalsis relaxes.
14. After introduction of the solution, press
buttocks together.
15. Ask the client who is using the toilet not to
flush it.
16. Do perineal care.
18. Make relevant documentation
TOTAL SCORE
INSERTING URINARY CATHETER
2. Gather and assemble equipment needed
PROCEDURE
3. Provide privacy.
5. Promote relaxation
6. Do perineal care before the procedure.
64
7. Use appropriate size of catheter.
Male: Fr 16-18
Female: Fr 12-14
8. Position the patient
Male: Supine, legs abducted and extended
Female: Dorsal recumbent
9. Don sterile gloves.
10. Inflate and deflate the balloon of the catheter
with air.
11. Locate the urinary meatus properly.
Male: At the tip of the glans penis
Female: Between the clitoris and the vaginal
orifice
12. Cleanse the urinary meatus with antiseptic
solution using downward stroke.
13. Lubricate the catheter using water soluble
lubricant.
14. Insert catheter gently, in rotating motion.
Instruct the patient to take slow deep breaths
and strain as if attempting to void
15. Length of catheter insertion:
Male: 6-9 inches
Female: 3-4 inches
16. During insertion of the catheter in male, hold
the penis at 90 degree angle or perpendicular
to the body.
17. Inflate the balloon with 5ml sterile NSS/
sterile water.
18. Gently pull on the catheter. If resistance is
felt, the catheter balloon is properly inflated
in the bladder.
19. Secure the catheter.
21. Document.
TOTAL SCORE
ADMITTING PATIENTS
Room Preparation
1. Perform hand hygiene and prepare room
equipment and furniture.
2. Prepare bed by adjusting it to the lowest
horizontal position if patient is ambulatory.
Place bed in high position if patient is
arriving by stretcher.
65
3. Turn down top sheet and bedspread..
4. Arrange room furniture for easy access to
bed. Adjust lights, temperature, and
ventilation.
5. Be sure that equipment is in working order.
Assemble any special equipment (e.g.,
suction, oxygen supplies, or IV pole) in
patient’s room.
6. Greet patient and family cordially by name.
Introduce yourself by name and job title;
explain your responsibilities in patient’s care
7. Identify patient using two identifiers (i.e.,
name and birthday or name and account
number) according to agency policy.
Compare identifiers with information on
patient’s identification bracelet
8. If patient does not speak English or has a
severe hearing impairment, arrange for a
translation service so you are able to conduct
a nursing assessment
9. Assess patient’s general appearance, noting
signs or symptoms of physical distress
10. Determine patient’s ability to understand and
implement health information by asking a
health literacy question
11. Assess patient’s and family’s psychological
status by noting verbal and nonverbal
behaviors and responses to greetings and
explanations.
12. Assess vital signs and height and weight.
13. Assess for fall risk using scale with grading
criteria per agency policy. Consider patient’s
risk factors
14. Have family or friends leave room unless
patient wishes to have them assist with
changing into a hospital gown or pajamas.
Close door and curtains. Help patient undress
and assist patient into comfortable position.
15. Obtain nursing history as soon as possible
after patient’s arrival to nursing division.
Apply standards of nursing care adopted by
hospital (e.g., functional health patterns).
Data include:.
a. Patient’s perception of illness and
health care needs.
b. Past medical history.
c. Presenting signs and symptoms and
reason for hospitalization.
d. Completion of a review of health
66
status based on standards such as
elimination, nutrition and
metabolism, activity and exercise,
self-concept, values and beliefs,
cultural factors, social support, and
cognitive function
e. Risk factors for illness.
f. History of allergies, including type of
substance and a description of the
reaction that patient has previously
experienced.
g. Detailed medication history,
including prescribed, overthe-counter
(OTC), and alternative therapies such
as herbs and hormones.
h. Patient’s knowledge of health
problems and expectations of care.
16. Conduct physical assessment of appropriate
body systems. If not obtained in admitting,
instruct patient to provide a urine specimen.
Info
17. Check health care providers’ orders for
treatment measures to initiate immediately.
18. Orient patient to nursing division
a. Introduce staff members who enter
room. Always introduce patient by
last name unless patient indicates
otherwise.
b. Tell patient and family the name of
the nurse manager in charge of the
division and explain that person’s
role in solving problems.
c. Explain visiting hours and their
purpose.
d. Discuss smoking policy and identify
smoking areas for patient and family
if available.
e. Demonstrate use of equipment (e.g.,
bed, over-bed table, lighting).
f. Show patient how to use nurse call
light and position it in a convenient
place. Have patient demonstrate use
of light. Discuss with patient any
specific fall risks and encourage him
or her to ask for assistance when
getting out of bed.
g. Escort patient to bathroom (if able to
ambulate)
h. Explain hours for mealtime and
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nourishments to patient and family.
i. Describe services available (e.g.,
chaplain, beauty shop, activity
therapy).
TOTAL SCORE
TRANSFERRING PATIENTS
1. Obtain transfer order from sending health care
provider. Order includes name of receiving
agency (when applicable), receiving health
care provider’s name, and statement of
patient’s stability for transfer
2. In collaboration with health care provider and
members of the interdisciplinary team, assess
68
reason for patient’s transfer (e.g., change in
condition, services available at agency, patient
or family preferences regarding patient’s
location)
3. Identify patient using two identifiers (i.e.,
name and birthday or name and account
number) according to agency policy. Compare
identifiers with information on patient’s
identification bracelet.
4. Assess individuals at high risk for transitional
care problems (e.g., older adults with multiple
health issues, depression, non-English
speakers, and low-income patients)..
5. Explain purpose of transfer thoroughly and
provide time to discuss patient’s and family’s
feelings about the change in care setting. As
necessary, obtain patient’s written consent to
transfer. If patient is unable to consent,
patient’s family provides this consent.
6. Assess patient’s current physical condition
and determine method for transport. When
transferring to new agency, assess method of
transport to transferring vehicle (e.g.,
wheelchair or stretcher)
7. Assess if patient requires pain relief or other
medications for symptom management
8. Ensure that staff have notified patient’s family
or significant others of transfer as desired by
patient.
TOTAL SCORE
DISCHARGING PATIENTS
1. From time of admission, assess patient’s
discharge needs using nursing history and
discussions with patient and health care
provider. Use care plan to focus on ongoing
assessments of patient’s physical health,
functional status, psychosocial support system,
financial resources, health values, cultural and
ethnic background, level of education, and
69
barriers to care that are needed.
2. Identify patient using two identifiers (e.g., name
and birthday or name and account number)
according to agency policy). Compare identifiers
with information on patient’s identification
bracelet.
3. Assess patient’s and family’s need for health
teaching related to how to perform home
therapies, use of home medical equipment,
restrictions resulting from health alterations, and
possible complications
4. Assess for barriers to learning (e.g., fatigue,
pain, lack of motivation).
5. Assess for environmental factors within the
home that interfere with self-care
6. Collaborate with health care provider and
interdisciplinary team (e.g., physical therapy) in
assessing need for referral for skilled home care
services or extended care facility
7. Assess patient’s and family’s perceptions of
continued health care needs outside the hospital.
Include an assessment of family caregivers’
perceived ability to provide care to patient,
including ability to adjust to demands of patient
care, impact of care demands on their lives (e.g.,
providing hands-on care, preparing special
diets), and potential ongoing nature of patient’s
needs.
8. Assess patient’s acceptance of health problems
and related restrictions.
9. Consult other health care team members (e.g.,
dietitian, social worker) about anticipated needs
after discharge. Make appropriate referrals in a
timely manner.
10. Let patient and family ask questions or discuss
issues related to home care. A final opportunity
to demonstrate learned skills is helpful.
11. Check health care provider’s discharge orders
for prescriptions, change in treatments, or need
for special medical equipment. (Make sure that
orders are written as early as possible.) Arrange
for delivery and setup of equipment (e.g.,
hospital bed, oxygen) before patient arrives
home
12. Determine whether patient or family has
arranged for transportation.
13. Provide privacy and assistance as patient dresses
and packs all personal belongings. Check all
closets and drawers for belongings. Obtain copy
70
of valuables list signed by patient and have
security or appropriate administrator deliver
valuables to patient
14. Complete medication reconciliation per agency
policy. Check discharge medication orders
against the medication administration record and
home medication list. Provide patient with
prescriptions or pharmacy-dispensed
medications ordered by health care provider.
Offer a final review of information needed to
facilitate safe medication self-administration.
15. Provide information on follow-up appointments
to health care provider’s office. Provide phone
number of unit
16. Contact agency business office to determine
whether patient needs to finalize arrangements
for payment of bill. Arrange for patient or
family to visit business office.
17. Acquire utility cart to move patient’s
belongings. Obtain wheelchair for patient.
Transport patients leaving by ambulance on
ambulance stretchers
18. Assist patient to wheelchair or stretcher using
safe patient handling and transfer techniques.
Escort patient to entrance of agency where
source of transportation is waiting. Lock
wheelchair wheels. Assist patient in transferring
into transport vehicle. Help place personal
belongings in vehicle.
19. Return to division. Notify admitting or
appropriate department of time of discharge.
Notify housekeeping of need to clean patient’s
room.
TOTAL SCORE
MONITORING INTAKE AND OUTPUT
1. Identify patients with conditions that increase
fluid loss (e.g., fever, diarrhea, vomiting,
surgical wound drainage, chest tube drainage,
gastric suction, major burns, or severe
trauma).
2. Identify patients with impaired swallowing,
unconscious patients, and patients with
impaired mobility.
3. Identify patients on medications that
71
influence fluid balance (e.g., diuretics and
steroids).
4. Assess signs and symptoms of dehydration
and fluid overload (e.g., bradycardia versus
tachycardia, hypotension versus
hypertension, and reduced skin turgor versus
edema).
5. Weigh patients daily using the same scale,
the same time of day, and with comparable
clothing.
6. Monitor laboratory reports:
a. Urine specific gravity (normal is 1.010 to
1.030)
b. Hematocrit (Hct) (normal range is 38% to
47% for females and 40% to 54% for
males).
7. Assess patient’s and family’s knowledge of
purpose and process of I&O measurement
8. Explain to patient and family the reasons that
I&O are important.
10. Measure and record all fluid intake:
a. Liquids with meals, gelatin, custards, ice
cream, popsicles, sherbets, ice chips
(recorded as 50% of measured volume
[e.g., 100 mL of ice chips equals 50 mL of
water]). Convert household measures to
the metric system: 1 ounce equals 30 mL;
therefore 12 ounces (soda can) equals 360
mL.
b. Count liquid medicines such as antacids
and fluids with medications as fluid
intake.
c. Calculate fluid intake from tube feedings
d. Calculate fluid intake from parenteral
fluids, blood components, and total
parenteral nutrition solutions
11. Instruct patient and family to call you or the
NAP to empty contents of urinal, urine hat, or
commode each time patient uses it. Have
patient and family monitor incontinence,
vomiting, and excessive perspiration and
report it to the nurse
12. Inform patient and family that Foley catheter
drainage bag and wound, gastric, or chest
tube drainage are closely monitored,
measured, and recorded and who is
responsible for this. Each patient must have a
72
graduated container clearly marked with
name and bed location and used only for the
patient indicated.
13. Apply clean gloves. Measure drainage at the
end of the shift or as indicated, using
appropriate containers and noting color and
characteristics. If splashing is anticipated,
wear mask, eye protection, and/or gown.
a. Measure urine drainage using a “hat” into
which patient voids or a graduated
container
b. Observe color and characteristics of urine
in Foley tubing and drainage bag.
Sometimes a measuring device is part of
the drainage bag. Otherwise measure
using a graduated container.
c. Measure chest tube drainage by marking
and recording the time on the collection
chamber at specified intervals. Chest tube
collection devices are changed when they
become full.
d. Measure Jackson-Pratt/Hemovac drainage
using a medicine cup
e. Measure gastric drainage or larger
drainage pouches by opening clamp and
pouring into graduated cup with a 240-mL
capacity
14. Remove gloves and dispose of them in
appropriate receptacle. Perform hand hygiene
15. Note I&O balance or imbalance and report to
health care provider any urine output less
than 30 mL/hr or significant changes in daily
weight.
16. Document on I&O forms or electronic
record.
TOTAL SCORE
CARING FOR PATIENTS UNDER ISOLATION PRECAUTIONS
1. Assess patient’s medical history for possible
indications for isolation (e.g., risk factors for
TB, major draining wound, or purulent
productive cough). Review precautions for the
specific isolation system, including appropriate
barriers to apply
2. Review laboratory test results (e.g., wound
73
culture, acid-fast bacillus [AFB] smears,
changes in WBC count).
3. Consider types of care measures that you will
perform while in patient’s room (e.g.,
medication administration or dressing change).
4. Review nursing care plan notes or confer with
colleagues regarding patient’s emotional state
and reaction/adjustment to isolation. Also assess
patient’s understanding of purpose of isolation.
6. Prepare all equipment needed in patient’s room.
In many cases, dedicated equipment such as
stethoscopes should remain in the room until
patient is discharged
7. Prepare for entrance into isolation room. Prior to
applying PPE, step into patient’s room and stay
by door. Introduce yourself and explain the care
that you are providing
a. Apply gown, being sure that it covers all
outer garments. Pull sleeves down to wrist.
Tie securely at neck and waist
b. Apply either surgical mask or fitted respirator
around mouth and nose (type and fit-testing
depend on type of isolation and agency
policy). You must have a medical evaluation
and be fit-tested before using a respirator
c. If needed apply eyewear or goggles snugly
around face and eyes. If you wear
prescription glasses, side shields may be used
d. Apply clean gloves. (Note: Wear unpowdered
gloves latexfree gloves if you, the patient, or
another health care worker has a latex
allergy.) Bring glove cuffs over edge of gown
sleeves
8. Enter patient’s room. Arrange supplies and
equipment. (Note: if equipment will be reused,
place on a clean paper towel).
9. Explain purpose of isolation and precautions for
patient and family to take. Offer opportunity to
ask questions.
10. Assess vital signs
a. Reusable equipment brought into room must
be thoroughly disinfected when removed
from room
b. If stethoscope is to be reused, clean earpieces
and diaphragm or bell with 70% alcohol or
agency-approved germicide. Set aside on
clean surface
c. Use individual or disposable thermometers
74
and blood pressure cuffs when available.
11. Administer medications
a. Give oral medication in wrapper or cup.
b. Dispose of wrapper or cup in plastic-lined
receptacle.
c. Wear gloves when administering an injection.
d. Discard disposable syringe and uncapped or
sheathed needle into designated sharps
container.
e. Place reusable plastic syringe (e.g.,
Carpuject) on clean towel for eventual
removal and disinfection.
f. If you are not wearing gloves and hands
contact a contaminated article or body fluids,
perform hand hygiene as soon as possible.
12. Administer hygiene, encouraging patient to ask
any questions or express concerns about
isolation. Provide informal teaching at this time
a. Avoid allowing isolation gown to become
wet; carry washbasin outward away from
gown; avoid leaning against wet tabletop.
b. Help patient remove own gown; discard in
leak-proof linen bag.
c. Remove linen from bed; avoid contact with
isolation gown. Place in leak-proof linen bag.
d. Provide clean bed linen and set of towels.
e. Change gloves and perform hand hygiene if
gloves become excessively soiled and further
care is necessary. Reglove.
13. Collect specimens
a. Place specimen containers on clean paper
towel in patient’s bathroom
b. Follow agency procedure for collecting
specimen of body fluids
c. Transfer specimen to container without soiling
outside of container. Place container in plastic
bag and place label on outside of bag or per
agency policy. Label specimen in front of
patient. Perform hand hygiene and reglove if
additional procedures are needed
d. Check label on specimen for accuracy. Send to
laboratory (warning labels are often used,
depending on agency policy). Label containers
of blood or body fluids with a biohazard
sticker
14. Dispose of linen, trash, and disposable items
a. Use single bags that are impervious to
75
moisture and sturdy to contain soiled articles.
Use double bag if necessary for heavily
soiled linen or heavy wet trash.
b. Tie bags securely at top in knot
15. Remove all reusable pieces of equipment. Clean
any contaminated surfaces with hospital-
approved disinfectant
16. Resupply room as needed. Have staff colleague
hand new supplies to you
17. Leave isolation room. Order of removal of PPE
depends on what you wear in room. This
sequence describes steps to take if all barriers
are worn
a. Remove gloves. Remove one glove by
grasping cuff and pulling glove inside
out over hand. Hold removed glove in
gloved hand. Slide fingers of ungloved
hand under remaining glove at wrist.
Peel glove off over first glove. Discard
gloves in proper container
b. Remove eyewear, face shield, or
goggles. Handle by headband or
earpieces. Discard in proper container.
c. Untie neck strings and then untie back
strings of gown. Allow gown to fall
from shoulders (see illustration); touch
inside of gown only. Remove hands
from sleeves without touching outside
of gown. Hold gown inside at shoulder
seams and fold inside out into a bundle;
discard in laundry bag
d. Remove mask. If mask secures over
ears, remove elastic from ears and pull
mask away from face. For a tie-on
mask, untie bottom mask string and then
top strings, pull mask away from face
(see illustration), and drop into trash
receptacle. (Do not touch outer surface
of mask.)
e. Perform hand hygiene.
f. Retrieve wristwatch and stethoscope
(unless items must remain in room) and
record vital sign values on note pape
g. Explain to patient when you plan to
return to room. Ask whether patient
requires any personal care items. Offer
books, magazines, audiotapes
h. Dispose of all contaminated supplies
and equipment in manner that prevents
76
spread of microorganisms to other
persons (see agency policy). Perform
hand hygiene.
i. Leave room and close door if necessary.
Close door if patient is on airborne
precautions or in negative airflow room
18. While in room, ask if patient has had sufficient
chance to discuss health problems, course of
treatment, or other topics important to him or
her
19. Ask patient to describe purpose of isolation and
offer chance to ask questions.
20. Document procedures performed and patient’s
response to social isolation. Also document any
patient education performed and reinforced
TOTAL SCORE
USING A BED OR CHAIR EXIT SAFETY MONITORING DEVICE
1. . Prior to performing the procedure, introduce
self and verify the client’s identity using
agency protocol.
2. . Explain to client and family the purpose and
procedure of using a safety monitoring
device. Explain that the device does not limit
mobility in any manner; rather, it alerts the
77
staff when the client is about to get out of bed
or a chair
3. Explain that the nurse must be called when
the client needs to get out of bed or a chair
6. Test the battery device and alarm sound
7. Apply the leg band or sensor pad.
● Place the leg band according to the
manufacturer’s recommendation. Place the
client’s leg in a straighthorizontal position.
● For the bed or chair device, the sensor is
usually placed under the buttocks area
● For a bed or chair device, set the time delay
from 1 to 12 seconds for determining the
client’s movement patterns
● Connect the sensor pad to the control unit and
the nurse call system
8. Instruct the client to call the nurse when the
client wants or needs to get up, and assist as
required.
● When assisting the client up, deactivate the
alarm.
● Assist the client back to the bed or chair, and
reattach the alarm device.
9. Ensure client safety with additional safety
precautions.
● Place call light within client reach, lift side
rails per agency policy, and lower the bed to
its lowest position.
● Place ambulation monitoring signs on the
client’s door, chart, and other relevant
locations
● Document the type of alarm used, where it
was placed, and its effectiveness in the client
record using forms or checklists
supplemented by narrative notes when
appropriate. Record all additional safety
precautions and interventions discussed and
employed
TOTAL SCORE
78
IMPLEMENTING SEIZURE PRECAUTIONS
1. Prior to performing the procedure, introduce
79
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
appropriate infection prevention procedures. If the
client is actively seizing, apply clean gloves in
preparation for performing respiratory care
measures
4. Pad the bed of any client who might have a
seizure. Secure blankets or other linens around the
head, foot, and side rails of the bed
5. Put oral suction equipment in place and test to
ensure that it is functional.
6. If a seizure occurs:
● • Remain with the client and call for
assistance. Do not restrain the client.
● If the client is not in bed, assist the client
to the floor and protect the client’s head
by holding it in your lap or on a pillow.
Loosen any clothing around the neck and
chest.
● Turn the client to a lateral position if
possible.
● Move items in the environment to ensure
the client does not experience an injury
● Do not insert anything into the client’s
mouth.
● Time the seizure duration.
● Observe the progression of the seizure,

noting the sequence and type of limb
involvement. Observe skin color. When
the seizure allows, check pulse and
respirations
● Apply oxygen via mask or cannula.
● Use equipment to suction the oral airway

if the client vomits or has excessive oral
secretions
● Administer anticonvulsant or antiepileptic
medications, as ordered.
80
● When the seizure has subsided, assist
client to a comfortable position. Reorient.
Explain what happened. Reassure the
client. Provide hygiene as necessary.
Allow the client to verbalize feelings
about the seizure
● Status epilepticus clients may stop
breathing after the seizure. Begin CPR
immediately. Apply oxygen per nasal
cannula or mask when breathing resumes
● If applied, remove and discard gloves.
● Perform hand hygiene.

7. Document the event in the client record using
forms or checklists supplemented by narrative
notes when appropriate.
TOTAL SCORE
81
APPLYING RESTRAINTS
1. Prior to performing the procedure, introduce
self and verify the client’s identity using agency
protocol. Explain to the client and family what
you are going to do, why it is necessary, and how
they can participate. Allow time for the client to
express feelings about being restrained. Provide
needed emotional reassurance that the restraints
will be used only when absolutely necessary and
that there will be close contact with the client in
case assistance is required.
3. Provide for client privacy if indicated.
4. Apply the selected restraint.
Belt Restraint (Safety Belt)
● Determine that the safety belt is in good
order. If a Velcro safety belt is to be used,
make sure that both pieces of Velcro are
intact.
● If the belt has a long portion and a shorter
portion, place the long portion of the belt
behind (under) the bedridden client and
secure it to the movable part of the bed
frame.
● or • Attach the belt around the client’s
waist, and fasten it at the back of the chair
● or • If the belt is attached to a stretcher,
secure the belt firmly over the client’s
hips or abdomen.
Jacket Restraint
● Place vest on client, with opening at the
front or the back, depending on the type.
● Pull the tie on the end of the vest flap
across the chest, and place it through the
slit in the opposite side of the chest.
82
● Repeat for the other tie
● Use a half-bow knot (a type of quick-

release knot) to secure each tie around the
movable bed frame or behind the chair to
a chair leg
● Fasten the ties together behind the chair
using a slip or
● quick-release knot
● Ensure that the client is positioned

appropriately to enable maximum chest
expansion for breathing.
Mitt Restraint
● Apply the commercial thumbless mitt (see
Figure 32–7) to the hand to be restrained.
Make sure the fingers can be slightly
flexed and are not caught under the hand.
● Follow the manufacturer’s directions for
securing the mitt
● If a mitt is to be worn for several days,
remove it at regular intervals per agency
protocol. Wash and exercise the client’s
hand, then reapply the mitt. Check agency
policies about recommended intervals for
removal
● Assess the client’s circulation to the hands
shortly after the mitt is applied and at
regular intervals.
Wrist or Ankle Restraint
● Pad bony prominences on the wrist or
ankle if needed to prevent skin breakdown
● Apply the padded portion of the restraint
around the ankle or wrist
● Pull the tie of the restraint through the slit
in the wrist portion or through the buckle
and ensure that the restraint is not too
tight
● Using a half-bow knot, attach the other
end of the restraint to the movable portion
83
of the bed frame.
5. Adjust the plan of care as required, for
example, to include releasing the restraint,
providing skin care, range-of-motion exercises,
and attending to the client’s physical needs by
providing fluids, nutrition, and toileting.
6. Document on the client’s chart the behavior(s)
indicating the need for the restraint, all other
interventions implemented in an attempt to avoid
the use of restraints and their outcomes, and the
time the primary care provider was notified of the
need for restraint
TOTAL SCORE
POST MORTEM CARE
1. Identify the client
2. Prepare equipment needed.
3. Wash hands and put on gloves.
4. Respect the family’s religious restrictions.
5. Place the body in supine position with a
pillow under his/her head.
6. Close the mouth.
7. Place bath blanket over the body and remove
the clothes.
8. Remove contraptions.
9. If the body has wounds, cover it with gauze.
10. Clean the body.
11. Place protective pad under the buttocks.
12. Allow the family to view the patient’s body.
13. Attach identification tag.
14. Put clean hospital gown.
15. Wrap the body with linen. Fasten and attach
name tag.
16. Prepare a checklist for the client’s belongings
and put all his/her belongings in a plastic bag
and give to the relatives.
17. Clean the room before transferring the client
to the morgue.
18. Wash hands and document.
TOTAL SCORE
84
MATERNAL AND CHILD CARE PROCEDURES
5 EXCELLENT. Carries out procedure/task efficiently, systematically and

independently
4 VERY SATISFACTORY. Carries out procedure/task efficiently, but requires
minimal guidance and supervision
1 POOR. Carries out the procedure/task inefficiently, unsystematically even after
close guidance and supervision
85
INTRAVENOUS THERAPY
1.Explain to the client what you are going to
do, why it is necessary and she can
cooperate.
2.Wash hand and observe other appropriate
3.Provide for client privacy.
4.Open and prepare the infusion set.
● Remove tubing from the container
and straighten it out.
● Slide the tubing clamp along the
tubing until it is just below the drip
chamber to facilitate its access.
● Close the clamp.
● Leave the ends of the tubing

covered with the plastic caps until
the infusion is started.
5.Spike the solution container.
● Remove the protective cover from
the entry site of the container.
● Remove the cap from the spike and
insert the spike into the insertion site
of the bag or bottle. Follow the
manufacturer instructions.
6. Apply the medication label to the solution
86
container if a medication was added.
7. Apply a timing label on the solution
container.
● The timing label may be applied at
the time of the infusion
Is started. Follow agency
practice.
8.Hang the solution container on the pole.
● Adjust the pole so that the container
is suspended about 1m 3 ( 3 feet )
above the clients head.
9.Partially fill the drip chamber with
solution.
● Squeeze the chamber gently until is
half full of solution.
10.Prime the tubing.
● Remove the protective cap and hold
the tubing over a container. Maintain
the sterility of the end of the tubing
● Release the clamp, and let the fluid
run through the tubing until all
bubbles are removed. Tap the tubing
with your fingers if necessary to
help the bubbles move.
● Reclamp the tubing and replace the
tubing cap, maintaining sterile
technique.
● For caps with air vents, do not
remove the cap when priming this
tubing.
● If an infusion control pump
electronic device, or controller is
being used , follow the
manufacturer’s directions for
inserting the tubing and setting the
infusion rate.
11.Wash your hands.
12.Select the venipuncture site.
● Unless contraindicated, use the
client’s non dominant arm.
● Check agency protocol about
87
shaving if the site is very hairy.
● Place a towel or bed protector under
the extremity to protect linens.
13.Dilate the vein.
● Place the extremity in a dependent
position.
● Apply a tourniquet firmly 15-20 cm
(6-8 in)above the venipuncture site.
● If the vien is not sufficiently dilated:
● Massage or stroke the vein distal to

the site and in the direction of
venous flow toward the heart.
● Encourage the client to clench and
unclench the fist.
● Lightly tap the vein with your
fingertips.
● If the preceding steps fail to distend
the vein so that it is palpable,
remove the tourniquet and apply
heat to the entire extremity for 10-15
minutes.
14.Don clean gloves and clean the
venipuncture site.
● Clean the skin at the site of entry
with a topical antiseptic swab,
25% chlorhexidine, or alcohol.
Check for allergies to iodine or
shellfish before cleansing skin
with Betadine or iodine products.
● Use a circular motion, moving
from the center outward for
several inches.
● Permit the solution to dry on the
skin.
15.Insert the catheter and initiate the
infusion
● If desired and permitted by policy,
inject 0.05 ml 1% lidocaine
intradermal over the site where you
88
plan to insert the IV needle. Allow
5-10 seconds for the anesthetic to
take effect.
● Use the non dominant hand to pull
the skin taut below the entry site.
● Holding the over-the-needle
catheter at a 15- to 30 degree angle
with the bevel up, insert the
catheter through the skin and into
the vein in one thrust.
● Once blood appears in the lumen
of the needle or you feel the lack
of resistance reduce the angle of
the catheter until it is almost
parallel with the skin , and advance
the needle and catheter
approximately 0.5-1 cm (about
1/4inch) further. Holding the
needle portion steady, advance the
catheter until the hub is at the
venipuncture site.
● Release the tourniquet
● Remove the protective cap from

the distal end of the tubing , and
hold it ready to attach to the
catheter, maintaining the sterility
of the end.
● Carefully remove the needle,
engage the needle safety device
and attach the end of the infusion
tubing to the catheter tub.
● Initiate the infusion.
16.Tape the catheter
● Tape the catheter by the “U’’
method. Using three strips of
adhesive tape, each about 7.5 cm (3
in) long.
● Place one strip, sticky-side up, under
the catheter’s hub.
● Fold each end over so that the sticky
sides are against the skin.
89
● Place second trip, sticky side down,
over catheter hub
● Place third strip, sticky side down
over catheter hub.
17.Dress and label the venipuncture site and
tubing according to agency policy.
● Cover venipuncture site according
to policy.
● Remove soiled gloves and discard
appropriately.
● Loop the tubing and secure it with
tape.
● Label the dressing with the date and
time of insertion, type and gauge of
needle or catheter used and your
initials.
18.Ensure appropriate infusion flow
● Apply a padded arm board to splint
the joint ,as needed.
● Adjust the infusion rate of flow
according to the order.
19. Label the IV tubing
● Label the tubing with the date and
time of attachment and your initials.
20. Document relevant data. Record:
● The time of the start of the infusion.
● The flow rate of the infusion
● The date and time of venipuncture
● The amount and type of solution

used , including any additives
● The type and guage of the needle or
catheter
● The venipuncture site
● The clients general response.

Total
90
INTERNAL EXAMINATION
1. Explained in simple terms the
procedure to the patient and made her
feel comfortable.
91
2. Put the patient in a dorsal lithotomy
position.
3. Washed or flushed the perineum.
4. Washed hands or used an antiseptic
hand rub.
5. Put on sterile gloves.
6. Inspected the vulva: for masses/
amniotic fluid/ blood and pus.
7. Lubricated two fingers of the right
hand with antiseptic or lubricating
jelly.
8. Separated the labia with the thumb and
little fingers of the hand.
9. Inserted the 2nd and 3rd fingers
sidewise deep into vagina in downward
direction.
10. Swayed the fingers on the wall of the
vagina till they come in contact with
the cervix. Assessed the following:
10.1. Vaginal :firm/distensible
10.2. Condition of the cervix:
firm/soft/closed/open/effacement
/dilatation.
10.3. Membranes:
intact/ruptured/character of amniotic
fluid.
10.4. Presentation of fetus:
cephalic/breech/shoulder/others.
10.5. Station of the presenting parts.
10.6. Pelvic architecture(optional)
11.6.1 Ischial spine: prominent, not
prominent
11.6.2 Diagonal conjugate: >11.5 cm/< 11.5
cm.
Post-procedure tasks
11. Removed gloves and discarded them in
a leak proof container or plastic bag
and disposed properly.
12. Washed hands thoroughly or used
antiseptic hand rub
14.documented procedure on monitoring
data of the woman’s record
Total
92
FUNDIC HEIGHT MEASUREMENT
1.Explain the procedure to the mother and gain
verbal consent.
2. Have a non-elastic tape measure to hand.
3. Ensure the mother is comfortable in a semi
recumbent position with an empty bladder.
4. Expose enough of the abdomen to allow a
thorough examination.
5. Ensure the abdomen is soft [ not contracting.
]
6. Perform abdominal palpation to enable
accurate identification of the uterine fundus.
93
7. Use the tape measure with the centimeters
on the underside to reduce bias.
8. Secure the tape measure at the fundus with
one hand.
9. Measure from the top of the fundus to the
top of the symphysis pubis.
10. The tape measure should stay in contact
with the skin.
11. Measure along the longitudinal axis
without correcting to the abdominal midline.
12. Measure only once.
13.Record the metric measurement and plot it
on the growth chart.
Total
PRENATAL
5 4 3 2 1 REMARKS
PREPARATION
1 Distinguishes the therapeutic and non-
therapeutic techniques of communication
while establishing rapport with the patient.
2 Outlines assessment procedure to pregnant
mothers.
3 Explains the importance of providing
privacy to clients during assessment.
4 Describes the condition of the mother after
assessment.
5 Identifies any deviations from normal
pregnancy.
6 Justifies result of assessment.
7 Explains how compute EDC and AOG.
94
8 Discuss the steps in performing Leopold’s
maneuver
9 Decides on the fetal position, engagement,
etc. after Leopold’s maneuver
10 Explains the importance of tetanus toxoid to
pregnant mothers.
11 Appreciates significance of accurate
recording and reporting of patient’s
condition
PROCEUDURE
1 Establishes a working relationship with

client and family
2 Assess the condition of the pregnant patient
correctly.
● Obtains complete obstetrical
history.
● Computes EDC and AOG
● Determine height, weight, vital

signs.
● Perform Leopold’s maneuver
● Auscultate fetal heart sounds
● Inspect feet, hands, and face for

edema
● Inspect teeth for dental carries
● Refer for dental checkup and other

relevant laboratory examinations
3 Promotes safety, privacy and comfort of
pregnant patient during physical assessment
4 Administer medication safely/ doctor’s
order
● Tetanus toxoid
● Vitamin A
● Folic Acid/ Ferrous sulfate

5 Provides health education to pregnant
patients regarding:
● Nutrition
● Rest and sleep
95
● Hygiene
● Exercise
● Birth plan
● Mino discomforts of pregnancy
● Possible complications
6 Evaluate condition of client
7 Refer patient for any sign of complication
8 Record pertinent data about patient’s

condition
9 Ensures a well-organized and accurate
record of client (HBMR)
10 Shows diligence and enthusiasm in
accomplishing given tasks.
Total
POST PARTUM
1 Identifies the different health related history
of pregnancy, labor and delivery of the
patient
2 Discusses the methods of physical
assessment including the Leopold’s
96
maneuver and Partograph and internal
examination
3 Identifies any deviation from normal during
assessment
4 Describes the mechanism of labor
5 Explains the 5 P’s of labor
6 Recognizes the responsibility of the midwife
in the care of patient in labor and delivery
7 Shows respect for the patient while on labor
8 Identifies the difference instruments and
supplies needed during labor and delivery
9 Explains the procedure of handling normal
spontaneous delivery
10 Describes the signs and symptoms of
placental separation
11 Identifies correct medication needed by the
patient
12 Enumerates the immediate post partum care
of patient
PROCEDURE
1. Gathers accurate data about health related
history of pregnancy, labor and delivery
2. Performs physical assessment systematically.
● Leopold’s Maneuver
● Internal examination
● General Assessment
3. Monitors progress of labor through
Partograph
4. Monitors Fetal Heart Beat of the fetus
correctly
5. Prepares patient for delivery
● Provides privacy
● Explains the procedure to the patient
● Assists patient to assume lithotomy

position
● Coaches the patient on proper
bearing down with concern
● Prepares perineal area aseptically
6. Prepares instrument and supplies aseptically
7. Assists/handles delivery of the fetus and
placenta
● Provides emotional support to patient
97
throughout the delivery
● Applies Ritgen’s maneuver correctly
to the perineum
● Handles head and body of the fetus
carefully during delivery
● Delivers the whole body of the
newborn correctly
● Places the newborn on the mother’s
abdomen
● Clamps cord after pulsation stops
● Delivers the placenta within required

time
●
Assesses the completeness of the
placenta
8. Checks for perineal laceration
● Inspects perineum for laceration
● Sutures episiotomy/lacerations
evenly
9. Assesses for the amount of blood loss
10. Maintains a well contracted uterus
11. Administers oxytocin/doctor’s order on the
third stage of labor
12. Cleanses the perineal area of the mother
13. Documents pertinent data about mother and
newborn
14. Performs after care of the equipment and the
delivery room
Total
98
ESSENTIAL NEWBORN CARE
1 Identifies the different interventions
needed by the newborn
2 Discusses the time-bound interventions
needed by the newborn
3 Describes the time-bound and non-
immediate interventions for the newborn
4 Recognize the importance of performing
the time bound interventions for the
newborn
5 Classify the time bound interventions and
the non-immediate interventions
6 Identifies any deviation from normal
during assessment
hypoglycemia, infection, brain hemorrhage
8 Explains the assessment procedures of the
newborn
9 Identifies correct medication needed by the
newborn
10 Enumerates the essential newborn care
11 Recognizes the responsibility of the
midwife in the care of newborn
PROCEDURE
1 Within 30 seconds, provides warmth,
prevent hypothermia to the newborn by:
- Drying thoroughly
- Removing wet cloth
- Quick check of NB’s breathing
- Covering w/ blanket and bonnet
- Do not remove vernix
2 Facilities bonding through Skin-To-Skin
contact to prevent infection and hypo
glycaemia by:
- Putting in prone on chest/ abdomen
of the mother for skin-to-skin
contact
- Place identification on ankle
- Do not separate
3 Up to 3 minutes post-delivery, reduces
incidence anemia in term and IVH in pre-
term by:
- Clamping and cutting cord after
cord pulsations stop (1-3 mins.)
- Not milking the cord
- Active management of labor
99
4 Within 90 minutes of age, facilitates
initiation of breastfeeding through
sustained skin-to-skin contact and eye care
by:
- Leaving the newborn on S-T-S
contact with the mother
- Observing the newborn for feeding
cues
- Counselling on positioning and
attachment
- Doing eye care
5 Administer the following to the newborn
- Vitamin K
- BCG
- Hepatitis B
6 Re-assessment of the newborn
- Weigh
- Look for malformations, etc.
- Feeding difficulties
7 Records pertinent data about the newborn
8 Performs after care of the equipment, and
materials
Total
POST NATAL CARE
PRERARTION 5 4 3 2 1 REMARKS
1 Explains the assessment procedures of
the mother
100
2 Enumerates the essential care of the
mother
3 Identifies the different interventions
needed by the patient
4 Discusses the importance of the
interventions for the patient
5 Recognize the importance of performing
the interventions to the mother
6 Classify interventions as to:
- Comfort measures
- Therapeutic measures
7 Identifies any deviation from normal
during assessment
complications
9 Identifies correct medication needed by
the newborn
10 Identify the correct medication needed
by the patient
11 Recognizes the responsibility of the
midwife in the care of newborn
PROCEDURE
1. Establishes interpersonal relationship
through therapeutic communication
2. Provides privacy, comfort and safety to
patients
3. Relates to the patient procedure to be
done
4. Performs assessment
- Prepare mother for assessment
- Check vital signs
- Palpate uterus for contractility
- Check amount and color of lochia
- Check breast for engorgement and
presence of milk
5. Plans care for the identified health
problems
- Prepare health care plan
6. Renders nursing care based on the
identified health problems
- Massage uterus until contracted
- Cold compress
- Perineal care
- Comfort measures
- Therapeutic measures
- Administer drugs based on the
doctor’s order.
7. Provides health education to mothers
regarding:
101
- Nutrition
- Breastfeeding
- Hygiene
- Elimination
- Rest and sleep
- Marital relation
- Family planning
- Post-partum check-up
8. Evaluates nursing care rendered
9. Performs daily newborn care
- Bathing
- Dressing
- Nutrition
- Routine assessment
- Cord observation
10. Documents nursing care rendered and
patient’s condition.
Total
COMPLICATIONS OF PREGNANCY AND POSTPARTUM
5 4 3 2 1 REMARKS
PREPARATION
1. Recognizes the need of establishing a
working relationship with the client and
family member
102
2. Understands the policies and guidelines
set by the institution related to patient
care and training of the students
3. Describes the conditions of the clients
based on the assessment of their health
status
4. Knows the different activities of health
center within the scope of midwifery
practice
5. Identifies the different programs of
DOH rendered by the health center
6. Learns to organize and prioritize work
7. Discusses the different health education

to client for promotion and maintenance
of health
8. Displays knowledge in promoting
safety, privacy, and comfort to client
9. Knows the importance of establishing
cooperation to students and other
members of health team
10. Utilizes principles of home visit and
bag technique during follow-up visit.
PROCEDURE
1. Establishes a working relationship with

the client and family member
2. Follows policies and guidelines set by
the institution related to patient care and
training of the students
3. Demonstrate beginning skills in the
assessment of health status of the client
4. Participates actively in different
activities of the health center
⮚ Per consultation
● Takes clinical history, vital

signs, weight and height
● Writes findings on client’s
record
⮚ Medical examination
● Assists client before, during and

after examination by the
physician
● Inform physician of relevant
103
findings gathered in pre-
consultation
● Ensures privacy, safety and
comfort of patient throughout
procedure
● Observes confidentiality
⮚ Post consultation conference
● Gives health education for

promotion and maintenance of
health
● Medication to be taken
● Follow-up clinic visit

5. Demonstrate honesty and accuracy in
recording and reporting significant data
6. Administers medications correctly
ordered
7. Demonstrates ability to organize and
prioritize work
8. Performs systematic prenatal
examination of pregnant mother during
home visit.
● Takes obstetrical history
● Physical examination including

Leopold’s Maneuver, fundic
height, fetal heart tone
● Assessment of the client in
regards to maternal discomfort
and complication during
pregnancy
● Interprets laboratory
examinations correctly
o Acetic Acid Test
o Benedict’s Test
9. Gives health education to client for
promotion and maintenance of health
10. Documents pertinent data about the
family about home visit
Total
104
POST PARTUM COMPLICATIONS
1. Describes patient’s condition based on
the assessment of the health status
2. Discusses the different types of
complications of post-partum
3. Enumerates some complication that may
arise during post-partum period
4. Identifies symptoms that need to be
reported or referred
5. Define physiological and psychological
diagnosis to a post-partum mother
6. Identifies abnormalities/complications
from physical assessment
7. Identifies procedure in the administration
of drugs as their preparations, indications,
classification of midwives responsibilities
8. Identifies appropriately the health care
rendered to the client
9. Displays knowledge on the topic
discussed during health education
10. Discusses the roles of the midwives in
providing health care
PROCEDURE
1. Establishes working relationship with the
mother, staff and co-group members
2. Provides privacy and comfort, and safety
at all times to the client
3. Prepares mother physically and
psychologically for the assessment and
intervention activities
4. Assesses patient heath status accurately
a. Monitor vital signs and record
accurately
b. Assesses characteristics of lochia
c. Maintain well contracted uterus
5. Reports/refer abnormalities/complications
after assessment
6. Administers medicines as order correctly
7. Implements accurate health care action to
the client
8. Provides health education to the client
a. Proper nutrition especially lactating
mother
105
b. Promotes elimination and proper
hygiene
c. Promoting rest and sleep
d. Instruct post-partum check-up after
discharge
e. Counseling about family planning
f. Resumption of sexual activities
g. Explain the importance of breast
feeding
h. Proper position during feeding and
how to burp the baby after each
feeding
i. Discuss the immunization to the baby
j. Discuss the importance of NB
screening
9. Shows consideration for the mother’s
newborn and significant others responses
accordingly
10. Monitors and evaluates client’s responses
or outcome of care given
11. Record and report significant findings,
merging diagnosis and intervention given
to the mother completely
12. Participate actively during the discussion
of post-partum complications
13. Participates actively and wisely in
conducting educational activities
14. Shows interest to learn and improve
competencies
Total
TOTAL PATIENT CARE
106
1. Recognize the different physical set-ups
and staff and personnel of the hospital
2. Identifies interviewing technique to
enhance communication both verbal and
non-verbal
3. Discuss factors affecting health and how
these factors contribute to the devt. of
illness
4. Analyze client response, verbal and non-
verbal
5. Identifies principles and responsibilities in
the preparation and performance of
different procedure in medical asepsis,
comfort measure and elimination
6. Discuss procedures in administration of
drugs, preparation and classification
7. Displays knowledge and proficiency in
performing physical assessment
8. Discuss roles of a midwife in the
management of the client
PROCEDURE
1. Utilizes proper approach develop and
maintain good rapport within the client,
staff and personnel
2. Demonstrate skills in effective
communication therapeutically
3. Perform physical assessment with
consideration to the client
4. Provide therapeutic environment to the
client
5. Utilizes health care process in the
management of client appropriately
6. Shows skills in performing procedure
positively
7. Practice medical aseptic technique
correctly
8. Monitor vital sign accurately
9. Shows skills in preparation and
administration of drugs safely
10. Use critical thinking to analyze what
procedure is needed by the client
11. Shows beginning skills in prioritizing
identified problems
12. Document significant data/observation
accurately
107
13. Displays self-reliance in working
independently
14. Demonstrate industry, punctuality, self-
discipline and respect to supervise others
15. Maintain good grooming appearance
Total
COMPLICATIONS OF PREGNANCY
108
1. Distinguishes the therapeutic and non-
therapeutic techniques of communication
while establishing rapport with the patient
2. Identifies assessment procedure for
mothers with complicated pregnancy
3. Enumerates significant data included in
assessment
4. Describes the condition of the mother
after assessment
5. Identifies any deviations from the normal
pregnancy
6. Differentiate normal from abnormal
findings
7. Enumerates the abnormal findings after
assessment
8. Identifies findings that need referral
9. Explains the procedure of home visit
10. Discusses the principles behind bag
technique
11. Appreciate significance of accurate
recording and reporting of patient’s
condition
PROCEDURE
1. Conducts case finding of mothers with
complicated pregnancy
● Formulates objectives for case
finding
●
Utilizes records/health care team
in identifying cases
2. Conducts home visits to patient and
family
● Formulates objectives for home
visit
● Explains to the family the purpose
of the visit
● Establishes a working relationship
with the family
● Respect family’s privacy and
safety
3. Performs family health assessment during
home visit
4. Utilizes bag technique in assessing and
109
rendering care to client and family
5. Performs systematic prenatal examination
of pregnant mother
● Take obstetrical history
● Physical examination including

Leopold’s Maneuver, fundic
height, fetal heart tone
● Assessment of the client in
regards to maternal discomfort
and complication during
pregnancy
● Interprets laboratory examinations
correctly
o Acetic acid test
o Benedict’s Test
6. Identifies health problems during
assessment
● Complications of pregnancy
● Family health problems

7. Plans care for the identified health
problems
● Refers mother with complication of
pregnancy
● Formulates plan of care for the
identified health problem of the family
● Formulates SMARTER objectives for
the identified health problems
8. Implements plan of care for the pregnant
mother and family.
● Conducts health education in relation
to identified health problems of the
mother and family
● Performs nursing procedures correctly
● Makes timely referrals if needed

9. Evaluates outcome of care rendered
10. Ensures a correct and accurate
documentation od relevant data in
patient’s family record
Total
110
IMMEDIATE CARE OF NEWBORN ( HOSPITAL SETTING)
1. Prepare all equipment at the cord dressing
room.
2. Wash hands with appropriate antiseptic
solution.
3. Receive the infant by placing one hand at the
back and the other hand around the legs and
place the infant on the crib in trendelenburg
position.
4. Rub the infant dry and wipes the mouth and
nose.
5. Establish patent airway by suctioning the
secretions in the mouth and nose.
6. Stimulate the baby to cry by tapping the
soles of the feet
7. Provide warmth by placing infant on a
heated crib under a droplight
8. Record the Apgar score.
9. Wash hands and puts on the sterile gloves.
10. Clamp the cord about 2 cm from the
umbilicus.
11. Cut the cord using sterile cord scissor
Check the number of vessels of the cord.
12.Put alcohol on the cord newborn baby.
13.Get the anthropometric
measurements( head, chest, length and weight).
14.Apply 2 drops of ophthalmic solution or
tetracycline on both eyes in lower eyelid as
Crede’s prophylaxis.
15. Inject 0.1 cc of vitamin K on the antero
lateral thigh / vastus lateralis.
16.Check the patency of the anus.
17.Dress and wrap the newborn and put name
tag.
Total
111
LEOPOLD’S MANEUVER
1. Instruct woman to empty her bladder first.
2. Place woman in dorsal recumbent position,
supine with knees flexed to relaxabdominal
muscles. Place a small pillow under the head for
comfort.
3. Drape properly to maintain privacy.
4. Explain procedure to the patient.
5. Warms hands by rubbing together. (Cold
hands can stimulate uterine contractions).
6. Use the palm for palpation not the fingers.
7. Using both hands, feel for the fetal part lying
in the fundus.
8. One hand is used to steady the uterus on one
side of the abdomen while the other hand moves
slightly on a circular motion from top to the
lower segment of the uterus to feel for the fetal
back and small fetal parts. Use gentle but deep
pressure.
9. Using thumb and finger, grasp the lower
portion of the abdomen above symphisis pubis,
press in slightly and make gentle movements
from side to side.
10. Facing foot part of the woman, palpate fetal
head pressing downward about 2 inches above
the inguinal ligament. Use both hands.
11. Document result of procedure.
Total
FETAL HEART TONE AUSCULTATION
112
1. Prepare the client.
A. Explain the procedure.
B. Position the woman lying
comfortably with her arms by her
sides.
C. Exposes the abdomen of the patient.
2. While facing the woman palpate the
woman’s abdomen with both hands
3. With both hands moving down, identify the
fetal back where the bell of the stethoscope
is placed to determine.
4. The stethoscope should be moved about
until the point of maximum intensity is
located where the fetal heart is heard.
5. Take the woman’s pulse at the same time
listening to fetal heart.
6. Assess heart rate if uterine shuffle or
funic shuffle.
7. Count fetal heart in one full minute.
8. Document result of procedure. Continues
to monitor FHT. Notify physician if there
is irregular with the findings.
Total
INTRAMUSCULAR INJECTION OF TETANUS TOXOID
1. Prepared material to be used.
113
2. Checked the patient identification.
3. Explained in simple terms the procedure to
the patient and made her comfortable.
4. Organized correct and adequate lighting.
5. Washed hands or used an antiseptic hand
rub to prevent infection or cross-
contamination.
PROCEDURE
6. Asked the patient to sit comfortably.
7. Identified the deltoid muscle
7.1. Found/palpated the knobbly top of the
arm (acromion process)
7.2. Marked the top border of an inverted
triangle about 2.5-5cm (1-3 finger
breadths) below the lower edge of
acromion process.
7.3. Chose the thickest portion of this area.
8. Disinfected the entry site using a cotton ball
with alcohol and allowed to dry. Did not
repalpate.
9. Stretched the skin and then bunched up the
muscle.
10. Inserted the needle at a right angle to the
skin in the center of the inverted triangle.
11. Aspirated and checked for backflow.If there
was blood,retracted and re-injected at
another site.
12. Injected the tetanus toxoid.
13. Removed the needle at the same angle as it
went in.
14. Applied pressure on the site with a dry
cotton ball.
Post-Procedure Tasks
15. Discarded the needle in a sharps container.
16. Washed hands or use an antiseptic hand rub
as prescribed.
17. Documented the procedure in the womans’
record.
18. Observed the injection site for bleeding or
swelling.
19. Instructed the patient to watch out for rash
or itching,shortness of breath or swelling of
the mouth ,lips or face and consulted
immediately.
Total
114
INTRAMUSCULAR INJECTION OF OXYTOCIN
1. Prepared material to be used together with
115
the other materials for delivery in a linear
arrangement.
2. After calling out the time of delivery and
sex of the baby,explained to the patient in
simple terms that you would be injecting a
drug to prevent postpartum bleeding.
PROCEDURE
acromion process.
3.4. Disinfected the entry site using a cotton
ball with alcohol and allowed to dry.
Did not repalpate.
3.5. Stretched the skin and then bunched up
the muscle.
4. Alternatively used the anterolateral thigh
muscle (vastus lateralis)
4.1. Found/palpated the area of the thigh
between the greatest trochanter and the
knee.
4.2. marked the lateral middle third of this
area as the injection site.
skin in the center of the inverted triangle if
using the deltoid or inserted the needle into
the lateral middle third of the thigh if using
the vastus lateralis.
another site.
7. Injected the oxytocin.When using the
anterolateral thigh muscle,lifted the vastus
lateralis muscle away from the bone while
injecting.
went in.
cotton ball.
as prescribed.
record.
116
swelling.
immediately.
Total
INTRAMUSCULAR INJECTION OF DEXAMETHASONE
Getting Ready
117
1. Prepared material to be used.
contamination.
PROCEDURE
6. Asked the patient to sit comfortably.
acromion process.
repalpate.
9. Stretched the skin and then bunched up the
muscle.
skin in the center of the inverted triangle.
another site.
12. Injected the dexamethasone.
went in.
cotton ball.
16. Removed gloves and washed hands or use
an antiseptic hand rub as prescribed.
record.
swelling.
immediately.
Total
118
INTRAMUSCULAR INJECTION OF AMPICILLIN
1. Prepared material to be used .
119
contamination.
PROCEDURE
6. Asked the patient to lie down comfortably.
7. Identified the ventrogluteal area
7.1. Placed the heel of your hand on the
greater trochanter.
7.2. Formed a “V” by separating your first
finger from the other 3 fingers.
7.3. Put your first (pointer) finger on the
anterior superior iliac spine (ASIS) and
the second (middle) finger with the
other fingers toward the iliac crest.
7.4. Identified the injection site at the center
of the ‘V” between the knuckles of the
pointer and middle fingers below the
level of the ASIS.
repalpate.
9. Using the Z-track method,inserted the
needle at a right angle to the skin in the
center of the “V” identified.
another site.
11. Injected the ampicillin.
went in.
cotton ball.
as prescribed.
record.
swelling.
immediately.
Total
120
INTRAMUSCULAR INJECTION OF MAGNESIUM SULFATE
121
contamination then wear protective gloves.
PROCEDURE
6. Placed the patient in left lateral position
with the anterior leg reflexed and other leg
straight.
7. Identified the ventrogluteal area
7.1. Placed the heel of your hand on the
greater trochanter.
7.2. Formed a “V” by separating your first
finger from the other 3 fingers.
7.3. Put your first (pointer) finger on the
anterior superior iliac spine (ASIS) and
the second (middle) finger with the
other fingers toward the iliac crest.
7.4. Identified the injection site at the center
of the ‘V” between the knuckles of the
pointer and middle fingers below the
level of the ASIS.
repalpate.
9. Spread the skin at the ventro-gluteal
injection site using the Z-track
method,inserted the needle perpendicularly
into the skin and deep intramuscular (IM)
another site.
11. Injected the magnesium sulfate slowly
(within 10-15 minutes when there was a
physician supervising but within 15-20
minutes when carrying out the physician’s
order alone).Waited for about 10 seconds
before withdrawing the needle.
went in.
cotton ball.
15. Removed gloves and wash hands or use an
antiseptic hand rub as prescribed.
16. Monitored the vital signs and urine output
and the appearance of the injection
site.Watched out for respiratory depression
or convulsions.Recorded all findings.
Total
122
INTRAMUSCULAR INJECTION IN NEWBORN
the mother
123
contamination .
6. Checked vaccine identification label
7. Checked the vial for any irregularities.
8. Wiped the top of the vial with 70% alcohol.
9. Reconstituted the vaccine ( as needed)
10. Aspirated the vaccine from the vial.
PROCEDURE
11. Asked the mother to cuddle the newborn or
positioned the patient supine on the
examining table.
12. Located the junction of the upper and
middle thirds of the vastus lateralis thigh
muscle.
13. Positioned the limb to relax the muscle.
14. Stretched the skin flat then pierced the skin
at an angle of 90 degree.
skin using a quick thrusting motion.
16. Injected the vaccine slowly.
17. Removed the needle rapidly without
aspiration.
cotton.
as prescribed.
21. Documented the procedure in the
medication chart or child’s health record.
swelling.
INTRADERMAL INJECTION IN NEWBORN
PREPARATION 5 4 3 2 1
3. Explained in simple terms the procedure to the mother
5. Washed hands or used an antiseptic hand rub to prevent
124
infection or cross-contamination .
6. Checked vaccine identification label
7. Checked the vial for any irregularities.
8. Wiped the top of the vial with 70% alcohol.
9. Reconstituted the vaccine ( as needed)
10. Aspirated the vaccine from the vial.
PROCEDURE
11. Asked the mother to cuddle the newborn or positioned the
patient supine on the examining table.
12. Identified the injection site in the newborn’s left upper arm.
13. Stretched the skin between a finger and thumb and inserted the
bevel into the dermis, bevel uppermost, to a distance of about
2mm.
14. Injected the BCG vaccine ,slowly forming a raised bleb about
7mm in diameter.
15. Removed the needle slowly.
17. Washed hands or use an antiseptic hand rub as prescribed.
18. Documented the procedure in the medication chart or child’s
health record.
19. Observed the injection site for bleeding or swelling.
REPAIR OF FIRST DEGREE LACERATION
the patient and made her feel comfortable.
3. Asked about allergies to antiseptics and
125
anesthetics.
4. Washed hands or used an antiseptic hand rub
to prevent infection or cross-contamination .
PROCEDURE
5. Inspected the tear/s to be repaired.
6. Identified the apex in the vagina, the
hymenal tags, the junction of the vaginal
mucosa and the outside skin, the wound
edges and the perineal apex of the tear.
7. Administered the local anesthetic.
7.1. Cleaned the perineum with antiseptic
solution.
7.2. Filled the syringe with 10ml of lidocaine.
7.3. Inserted the whole length of the needle
beneath the vaginal mucosa and beneath
the skin of the perineum.
7.4. Aspirated by drawing the plunger back
slightly to make certain the needle is not
penetrating a blood vessel.
7.5. Injected the lidocaine solution into the
vaginal mucosa, beneath the skin of the
perineum.
7.6. Waited 2 minutes then pinched the
incision site with forceps.
7.7. If the woman felt the pinch, waited 2
more minutes then retested.
8. Sutured the laceration/s
8.1. Sutured the vaginal mucosa, using a
continuous or continuous interlocking
suture starting about 1 cm above the apex
of the wound.
8.2. Tied the stitch with 3 cm alternating
knots.
8.3. Continued the suture ,placing each suture
about 1 to 1.5 cm from the last.
8.4. Ensured that the stitches included equal
amounts of tissue from each side and the
tension neither too loose or too tight.
8.5. Sutured the perineal skin using simple
interrupted or continuous suture starting
at the vaginal opening from the
fourchette.
9. Did vaginal and rectal examination
10. Washed the perineal area with antiseptic
solution, pat dried the area, cleaned away all
soiled linen and put a clean sanitary pad over
the vulva and perineum.
11. Put the mother in comfortable position.
12. Before removing the gloves, disposed of the
126
waste materials in a leak-proof container or
plastic bag. Disposed of all bloody linens in a
closed or closeable container for laundry.
13. Placed all the instruments in 0.5% chlorine
solution for decontamination.
14. Removed the gloves and discarded them in a
leakproof container or plastic bag and
disposed properly.
15. Washed hands thoroughly or used antiseptic
hand rub.
16. Continued to provide supportive care to
mother and baby.
17. Monitored vital signs of mother and baby.
18. Document procedure and monitoring data on
the woman’s records.
REPAIR OF SECOND DEGREE LACERATION
the patient and made her feel comfortable.
3. Asked about allergies to antiseptics and
anesthetics.
127
contamination .
PROCEDURE
5. Inspected the tear/s to be repaired.
6. Identified the apex in the vagina, the
hymenal tags, the junction of the vaginal
mucosa and the outside skin, the wound
edges and the perineal apex of the tear.
7. Administered the local anesthetic.
7.1. Cleaned the perineum with antiseptic
solution.
7.2. Filled the syringe with 10ml of
lidocaine.
7.3. Inserted the whole length of the needle
beneath the vaginal mucosa and beneath
the skin of the perineum.
7.4. Aspirated by drawing the plunger back
slightly to make certain the needle is not
penetrating a blood vessel.
7.5. Injected the lidocaine solution into the
vaginal mucosa, beneath the skin of the
perineum.
7.6. Waited 2 minutes then pinched the
incision site with forceps.
7.7. If the woman felt the pinch, waited 2
more minutes then retested.
8. Sutured the laceration/s
8.1. Sutured the vaginal mucosa, using a
continuous or continuous interlocking
suture starting about 1 cm above the
apex of the wound.
8.2. Tied the stitch with 3 cm alternating
knots.
8.3. Continued the suture ,placing each
suture about 1 to 1.5 cm from the last.
8.4. Ensured that the stitches included equal
amounts of tissue from each side and
the tension neither too loose or too tight.
8.5. Identified the perineal muscles that had
been torn.
8.6. Laid aside the suture and needle used
for the repair of the vaginal mucosa
earlier and proceeded to get another
suture with needle to repair the perineal
muscle layer first,using simple
interrupted or figure of 8 sutures.
8.7. Closed the subcutaneous tissue with
continuous suture from just below the
128
vaginal opening up to the edge of the
posterior tear ( using the needle and
suture set aside from the repair of the
vaginal mucosa,passed from behind the
hymenal ring via deep layer to reach the
perineum.
8.8. Sutured the perineal skin using
subcuticular starting at posterior
perineal tear and ran back up to the
vaginal opening.Passed the needle
through deep tissue and tied the suture
behind the hymen.
9. Did vaginal and rectal examination
10. Ensured that no stitches penetrated the
rectum. If there were, they were removed.
11. Washed the perineal area with antiseptic
solution, pat dried the area, cleaned away all
soiled linen and put a clean sanitary pad
over the vulva and perineum.
12. Put the mother in comfortable position.
13. Before removing the gloves, disposed of the
waste materials in a leak-proof container or
plastic bag. Disposed of all bloody linens in
a closed or closeable container for laundry.
14. Placed all the instruments in 0.5% chlorine
solution for decontamination.
15. Removed the gloves and discarded them in
a leakproof container or plastic bag and
disposed properly.
16. Washed hands thoroughly or used antiseptic
hand rub.
17. Continued to provide supportive care to
mother and baby.
18. Monitored vital signs of mother and baby.
19. Document procedure and monitoring data
on the woman’s records.
129
OPERATING ROOM TECHNIQUE
PROCEDURE CHECKLIST
RUBRIC FOR RETURN DEMONSTRATION

5 EXCELLENT. Carries out procedure efficiently, systematically and independently
4 VERY SATISFACTORY. Carries out procedure efficiently, but requires minimal
1 POOR. Carries out the procedure inefficiently, unsystematically even after close
PERFORMING PREOPERATIVE SKIN PREP
2. After the patient is anesthetized and
positioned on the operating room table, the
preoperative skin prep is done by the
130
surgeon, assistant surgeon, or circulator.
3. Expose the skin area to be cleaned by folding
back the sheet. Double-check the operative
site and procedure against the patient’s chart
and operative permit.
4. Washed hands or used an antiseptic hand rub
to prevent infection or cross-contamination .
5. Don surgical gloves using the open method
6. Place sterile towels above and below the
operative area to isolate the area and to
protect gloved hands while performing the
prep.
PROCEDURE
7. Wet sponge with antiseptic solution and
squeeze out excess. Using the wet sponge
scrub the skin, starting at the site of incision,
with a circular motion in an ever
widening circle to the outer portion of the
exposed area. You must use
sufficient pressure and friction to remove dirt
and microorganisms from skin and pores.
8. Discard the sponge after reaching the outer
edge. NEVER bring a soiled sponge back
toward the center of the area
9. Repeat the scrub with a separate sponge for
each round. Scrub for a minimum of five
minutes, blot the area dry with towel, and
apply the antiseptic solution in accordance
with local policy . This step completes the
preoperative skin prep.
10. The soiled sponges are discarded into the
kick bucket. All unused sponges and those
used and discarded into the kick bucket must
be removed before the case (surgical
procedure) begins.
Total
SURGICAL HANDWASHING
16. Remove all jewelries.
18. Wear shoe cover, cap, mask, and protective
eyewear.
131
PERFORMANCE
19. Position yourself on the sink with hands
higher than the elbow. Turn on the faucet.
20. Do initial handwashing. (up to elbow)
21. Apply cleansing agent to brush or sponge.
22. Wet hands and arms. Keep hands above
elbows.
23. Scrub the non-dominant hand using the
appropriate pattern:
● Fingertips and fingernails – 20
circular strokes
● Thumb – 5 downward stroke
● Interdigitals – 5 strokes each
● Palm – 10 circular strokes
● Dorsum – 10 circular strokes
● Wrist to forearm (4 angles) – 5

circular strokes
● Elbow – 5 circular strokes
24. Rinse the brush. Put liquid soap. Repeat step 9
to the dominant hand.
25. With hands higher than the elbows. Drop

brush into the sink.
26. Rinse the first hand and arm from the finger
tips to the elbow thoroughly with hands higher
than the elbows. Follow the same procedure to
the next hand.
27. Turn of the faucet.
28. Move to the sterile area to dry hands.
TOTAL SCORE
DONNING AND REMOVING STERILE GLOVES (OPEN METHOD)
132
21. Check client record, and ask the client about
latex allergies.
23. Insure the sterility o f the packaged gloves.
24. Remove jewelries.
PROCEDURE (APPLYING GLOVES)
going to do, why it is necessary, and how the
client can cooperate.
27. Observe other appropriate infection control
procedures.
29. Perform handwashing before opening the
sterile package on a clean, dry surface above
your waist.
30. Open the outside wrapper by carefully
peeling back the top of the package or as
directed by the manufacturer without
contaminating the gloves or the inner
package. Remove the inner package, making
sure you are handling only the outside part of
it.
31. Lay the inner package on clean, flat, dry
surface about waist level. Carefully open the
inner package and expose the gloves with the
cuff close to you.
32. Grasp the glove for the dominant hand by its
folded cuff edge, with the thumb and first
finger of the non dominant hand. Touch only
the inside of the cuff. Position your dominant
hand.
33. Insert your dominant hand into glove. Keep
hands in front of you and away from your
uniform so that nothing touches the gloves.
34. Pick up the other glove with the sterile
gloved hand, inserting the gloved fingers
under the cuff and holding the gloved thumb
close to the thumb.
35. Insert your second hand carefully.
36. Keeping hands above waist, adjust each
glove so that it fits smoothly, touching only
sterile areas.
PROCEDURE
(REMOVING AND DISPOSE OF USED
GLOVES)
37. Grasp the glove of the non-dominant hand
near the cuff end and remove it by inverting
133
with the dominant hand without touching
exposed wrist.
38. Slide the fingers of the ungloved hand inside
the remaining glove. Grasp the glove from
the inside and remove by turning inside out
over the hand and other glove.
39. Discard gloves into appropriate receptacle
and perform handwashing.
40. Document the procedure and sterile

technique used.
TOTAL SCORE
DONNING A STERILE GOWN AND GLOVES (CLOSED METHOD)
134
23. Gather equipment.
24. Insure the sterility of the package.
25. Observe appropriate infection control
procedure.
PROCEDURE (DONNING A STERILE GOWN)
26. Unwrap the sterile gown pack.
27. Open the package of sterile gloves. Remove
the outer wrap from the sterile gloves, and
leave the gloves in their inner sterile wrap on
the sterile field.
28. Wear shoe covers, cap that covers the hair,
face mask and protective eye wear.
29. Perform hand hygiene. (Surgical scrub)
30. Put on sterile gown. Grasp the sterile gown at
the crease near the neck; hold it away from
you, and permit it unfold freely without
touching anything, including the uniform.
31. Put the hands inside the shoulders of the
gown, and work the arms partway into the
sleeves without touching the outside of the
gown. Work the hands down the sleeves only
to the proximal edge of the cuffs.
32. Have a coworker grasp the neck tie without
touching the outside of the gown, and pull
the gown upward to cover the neckline of
your uniform in front and back. (Gowning
continues at step 21 )
PROCEDURE
(DONNING STERILE GLOVES - CLOSED
METHOD)
33. Open the sterile glove wrapper while the
hands are still covered by the sleeves.
34. With the dominant hand, pick up the opposite
glove with the thumb and index fingers,
handling it through the sleeve.
35. Lay the glove on the opposite gown cuff,
thumb side down, with the glove opening
pointed toward the fingers. Position the
dominant hand palm upward inside the
sleeve.
36. Use the non dominant hand to grasp the cuff
of the glove through the gown cuff, and
firmly anchor it.
37. With dominant hand working through its
sleeve, grasp the upper side of the gloves
cuff, and stretch it over the cuff of the gown.
38. Pull the sleeve up to draw the cuff over the
wrist as you extend the fingers of the non-
dominant hand into the glove’s finger.
135
39. Put the glove on the non-dominant hand.
Place the fingers of gloved hand under the
cuff of the remaining glove.
40. Place the glove under the cuff of the second
sleeve.
41. Extend the fingers into the glove as you pull
the glove up over the cuff.
PROCEDURE (COMPLETION OF GOWNING)

42. Have a coworker take the two ties at each
side of the gown, and tie them at the back of
the gown, making sure that your uniform is
completely covered.
43. When worn, sterile gowns should be
considered sterile in front from the waist to
the shoulder. The sleeves should be
considered sterile from 2 inches above the
elbow to the cuff since the arms of a
scrubbed person must move across a sterile
field.
44. Remove protective devices: remove gloves
first, then the mask, gown, the eye wear or
goggles, cap and shoe cover.
TOTAL SCORE
ESTABLISHING AND MAINTAINING A STERILE FIELD
27. Ensure that the package is clean and dry; if
136
moisture is noted on the inside of a plastic-
wrapped package or the outside of a cloth-
wrapped package, it is considered
contaminated and must be discarded
28. Check the sterilization expiration dates on the
package, and look for any indications that it
has been previously opened. Spots or stains
on cloth or paper-wrapped objects may
indicate contamination, and the objects
should not be used.
29. Follow agency practice for disposal of
possibly contaminated packages
PROCEDURE
33. Open the package. If the package is inside a
plastic cover, remove the cover.
To Open a Wrapped Package on a Surface
● Place the package in the work area so that the
top flap of the wrapper opens away from you
● Reaching around the package (not over it),
pinch the first flap on the outside of the
wrapper between the thumb and index finger.
● Repeat for the side flaps, opening the
topmost one first. Use the right hand for the
right flap, and the left hand for the left flap
● Pull the fourth flap toward you by grasping
the corner that is turned down
Opening a Wrapped Package While Holding It
● Hold the package in one hand with the top
flap opening away from you..
● Using the other hand, open the package as
described above, pulling the corners of the
flaps well back. Tuck each of the corners into
the hand holding the package so that they do
not flutter and contaminate sterile objects.
Opening Commercially Prepared Packages
● If the flap of the package has an unsealed
137
corner, hold the package in one hand, and
pull back on the flap with the other hand.
● If the package has a partially sealed edge,
grasp both sides of the edge, one with each
hand, and pull apart gently..
Establish a sterile field by using a drape
● Open the package containing the drape as
described above.
● With one hand, pluck the corner of the drape
that is folded back on the top touching only
one side of the drape
● Lift the drape out of the cover, and allow it to
open freely without touching any objects
● With the other hand, carefully pick up
another corner of the drape, holding it well
away from you and, again, touching only the
same side of the drape as the first hand
● Lay the drape on a clean and dry surface,
placing the bottom (i.e., the freely hanging
side) farthest from you
● Add necessary sterile supplies, being careful
not to touch the drape with the hands
To Add Wrapped Supplies to a Sterile Field
● Open each wrapped package as described in
the preceding steps.
● With the free hand, grasp the corners of the
wrapper, and hold them against the wrist of
the other hand
● Place the sterile bowl, drape, or other supply
on the sterile field by approaching from an
angle rather than holding the arm over the
field
● Discard the wrapper.
Adding Commercially Packaged Supplies to a Sterile
Field
● Open each package as previously described
● Hold the package 15 cm (6 in.) above the

field, and allow the contents to drop on the
field.
138
Adding Solution to a Sterile Bowl
● Obtain the exact amount of solution, if
possible
● Before pouring any liquid, read the label
three times to make sure you have the correct
solution and concentration (strength). Wipe
the outside of the bottle with a damp towel to
remove any large particles that could fall into
the bowl or field.
● Remove the lid or cap from the bottle and
invert the lid before placing it on a surface
that is not sterile
● Hold the bottle so that the label is against the
palm of the hand
● Hold the bottle of fluid at a height of 10 to 15
cm (4 to 6 in.) over the bowl and to the side
of the sterile field so that as little of the bottle
as possible is over the field
● Pour the solution gently to avoid splashing
the liquid
● Tilt the neck of the bottle back to vertical
quickly when done pouring so that none of
the liquid flows down the outside of the
bottle
● If the bottle will be used again, replace the lid
securely and write on the label the date and
time of opening.
34. Use sterile forceps to handle sterile supplies
● If forceps tips are wet, keep the tips lower
than the wrist at all times, unless you are
wearing sterile glove
● Hold sterile forceps above waist or table
level, whichever is higher
● Hold sterile forceps within sight
● When using forceps to lift sterile supplies,

be sure that the forceps do not touch the
edges or outside of the wrapper
● When placing forceps whose handles were
in contact with the bare hand, position the
139
handles outside the sterile area
● • Deposit a sterile item on a sterile field
without permitting moist forceps to touch
the sterile field when the surface under the
absorbent sterile field is unsterile and a
barrier drape is not used.
35. Document that sterile technique was used in
the performance of the procedure.
TOTAL SCORE
140
REFERENCES
American Academy of Pediatrics. 2015. How to Take a Child’s Temperature. Retrieved from
https://www.healthychildren.org/English/health-issues/conditions/fever/Pages/How-to-Take-a-
Childs-Temperature.aspx
BCCampus. No year. Clinical Procedures for Safer Patient Care. Retrieved from
https://opentextbc.ca/clinical skills/chapter/6-7-intradermal-subcutaneous-and-intramuscular-
injections/
Berma, Audrey et al. 2008. Kozier and Erb’s Fundamentals of Nursing Checklist,8th Edition,
Pearson Education
Berma, Audrey et al. 2010. Kozier and Erb’s Fundamentals of Nursing, Concepts, Process, and
Practice, 10th Edition, Vol 1. and 2 Pearson Education
Cafasso, Jacquelyn. 2017. What are Intramuscular Injections? Healthline. Retrieved from
https://www.healthline.com/health/intramusculas-injection
Clayton, Stock, and Cooper. 2010. Basic Pharmacology for Nurses, 15th Edition. Elsevier
Singapore
Department of Health,2016 Harmonized Module on Basic Emergency Obstetric and Newborn

Care Training for Midwives
Frazer ,Daie M., Coopler ,Margaret A.,2003 Myles Textbook for Midwives, 14th
Edition,Churchill,Livingstone
Lampert, Lynda. 2016. How to Insert a Nasogastric Tube. Ausmed. Retrieved from
https://www.ausmed.com/articles/insert-nasogastric-tube/
141
Mona, Maria. 2017. Occupied Bed Making Purposes | Occupied Bed Making Procedures.
Retrieved from http://nursingexercise.com/occupied-bed-making-purpose-procedure/
Mona, Maria. 2017. Principles of Closed Bed Making in Nursing | Procedure of Closed Bed in
Nursing. Retrieved from http://nursingexercise.com/closed-bed-making-procedure-principles/
Mona, Maria. 2017. Types of Bed Making in Nursing | Purpose of Bed Making | Principles of
Bed Making. Retrieved from http://nursingexercise.com/bed-making-nursing-purpose-principles/
My Cleveland Clinic. 2016. Thermometers: How to Take Your Temperature. Eucid Avenue,
Cleveland, Ohio. Retrieved from https://my.clevelandclinic.org/health/articles/9959-
thermometers-how-to-take-your-temperature
Padilla, Maria Teresa. 2008. Fundamentals of nursing Checklist. C and E Publishing Inc.
Pillitteri, Adele R.,2014 Maternal and Child Health Nursing : Care of the Childbearing and
Childbearing Family, 7th Edition, Lippincott Williams & Wilkins
Scribd. 2019. Nasogastric Tube Feeding. Retrieved from
https://www.scribd.com/doc/17490558/Nasogastric-Tube-Feeding
Shlamovitz, Gil. Z, 2016. Urethral Catheterization in Men. Medscape. Retrieved from

https://emedicine.medscape.com/article/80716-overview
Shlamovitz, Gil. Z, 2018. Nasogastric Intubation Technique. Medscape. Retrieved from

https://emedicine.medscape.com/article/80925-technique
The Royal Children's Hospital Melbourne. 2017. Indwelling urinary catheter - insertion and
ongoing care Retrieved from
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Indwelling_urinary_
catheter_insertion_and_ongoing_care/
Udan, Josie, 2004, Mastering Fundamentals of Nursing: Concepts and Clinical Application, 2nd
edition, Educational Publishing House
World Health Organization. 2009. Newborn care Until the First Week of Life Clinical Practice
Guide. WHO Press
142
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CHECKLIST 2022 2023

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PREFACE

● EXCELLENT. Carries out procedure efficiently, systematically and independently

● VERY SATISFACTORY. Carries out procedure efficiently, but requires minimal

● FAIR, but requires close guidance and supervisions

RUBRIC FOR RETURN DEMONSTRATION

● Interdigitals – 5 strokes each

● Palm – 10 circular strokes

● Dorsum – 10 circular strokes

● Wrist to forearm (4 angles) – 5

11. With hands higher than the elbows. Drop

20. Document the procedure and sterile

PROCEDURE (COMPLETION OF GOWNING)

● Hold the package 15 cm (6 in.) above the

● When using forceps to lift sterile supplies,

10. Ensure the suppository comes in contact with

● If an infusion control pump electronic device, or controller is

● Check agency protocol about shaving if the site is very

● Apply a tourniquet firmly 15-20 cm (6-8 in)above the

● Massage or stroke the vein distal to the site and in the

● Lightly tap the vein with your fingertips.

● If the preceding steps fail to distend the vein so that it is

● Remove the protective cap from the distal end of the

● Place third strip, sticky side down over catheter hub.

● Remove soiled gloves and discard appropriately.

● Loop the tubing and secure it with tape.

● Adjust the infusion rate of flow according to the order.

● The flow rate of the infusion

● The date and time of venipuncture

● The amount and type of solution used , including any

● The venipuncture site

● The clients general response.

Cannula – put over the client’s face, with the

Facemask – Apply from nose downward.

Face tent – place the tent over the client’s

● Observe the progression of the seizure,

● Use equipment to suction the oral airway

● Perform hand hygiene.

● Use a half-bow knot (a type of quick-

● Ensure that the client is positioned

5 EXCELLENT. Carries out procedure/task efficiently, systematically and

● Leave the ends of the tubing

● Massage or stroke the vein distal to

● Remove the protective cap from

● The flow rate of the infusion

● The date and time of venipuncture

● The amount and type of solution

● The clients general response.

7 Explains how compute EDC and AOG.

1 Establishes a working relationship with

● Determine height, weight, vital

● Auscultate fetal heart sounds

● Inspect feet, hands, and face for

● Refer for dental checkup and other

● Folic Acid/ Ferrous sulfate

● Rest and sleep

● Mino discomforts of pregnancy

7 Refer patient for any sign of complication

8 Record pertinent data about patient’s

● Explains the procedure to the patient

● Assists patient to assume lithotomy

● Delivers the placenta within required

7. Discusses the different health education

1. Establishes a working relationship with