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Name: _________________________________ Date: _____________ Section/Group:________ Hand washing CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 1. Determine: Presence in client of factors increasing susceptibility to infection. Whether client uses immunosuppressives. Clients medications Recent diagnostic procedures of treatments that penetrated the clients skin or a body cavity. Clients current nutritional status. Signs and symptoms indicating the presence of an infection; Localized signs swelling, redness, pain or tenderness with palpation or movement, palpable heat at site, loss of function with affected body part, presence of exudates Systemic indications fever, increased pulse and respiratory rates, lack of energy, anorexia and enlarged lymph nodes. Determine: The location of running water and soap or soap substitutes Assemble the equipment: Soap Warm, running water Disposable or sanitized towels Assess the hands: Nails should be kept short. Remove all jewelry Check hands for breaks in the skin, such as hangnails or cuts. Procedure If you are washing your hands where the client can observe you, explain to the client can observe you, explain to the client what you are going to do and why is it necessary. Turn on the water, and adjust the flow: For knee levers, move with the knee to regulate flow and temperature. For foot pedals, press with the foot to regulate flow and temperature. For elbow controls, move the elbows instead of the hands. For infrared control, motion in front of the sensor causes water to start and stop flowing automatically. Be sure to adjust the flow so that water is warm. Wet the hands thoroughly by holding them under the running water, and apply soap to the hands. Hold the hands lower than the elbows, so that the water flows from the arms to the fingertips. If the soap is liquid, apply 2-4 ml (1 tsp). if it is bar soap, granules, or sheets, rub them firmly between the hands Thoroughly wash and rinse the hands. Use firm, rubbing and circular movements to wash the palm, back and wrist of each hand. Interlace the fingers and thumbs, and move the hands back and forth. Continue this motion for 10 seconds.

Rub the fingertips against the palm of the opposite hand.

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Rinse the hands. Thoroughly dry the hands and arms Dry hands and arms thoroughly with a paper towel. Discard the paper towel in the appropriate container. Turn off the water. Use a new paper towel to grasp a hand operated control. Variation : Handwashing Before Sterile Technique Procedure Apply the soap and wash as described in Step 4, but hold the hands higher than the elbows during this hand wash. Wet the hands and forearms under the running water, letting it run from the fingertips to the elbows so that the hands become cleaner than the elbows. Apply the soap and wash as described earlier in Step 6, maintaining the hands uppermost. After washing and rinsing, use a towel to dry one hand thoroughly in a rotating motion, from the fingers to the elbows. Use a new towel to dry the other hand and arm. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Donning and Removing Sterile Gloves (Open Method) CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 Assess client for latex allergies. Assemble equipments and supplies. Sterile gloves Ensures sterility of the package of gloves. Procedure Explain to the client what you are going to do, why is it necessary, and how he can cooperate. Wash hands and observe other appropriate infection control procedures. Provide for client privacy. Open the package of the sterile gloves. Place the package of gloves on a clean dry surface. If the gloves are packed in both an inner and an outer package, open the outer package without contaminating the gloves or the inner package. Remove the inner package from the outer package. Open the inner package as in Step 4 of procedure 29-3, or according to the manufacturers direction. If no tabs are provided, pluck the flap so that the fingers do not touch the inner surfaces. Put the first glove on the dominant hand. If the gloves are packaged so that they lie side by side, grasp the glove for the dominant hand by its folded cuff edge (on the palmar side) with the thumb and the first finger of the non dominant hand. Touch only the inside of the cuff; or , If the gloves are packaged one on top of the other, grasp the cuff of the top glove as above, using the opposite hand. Insert the dominant hand into the glove and pull the glove on. Keep the thumb of the inserted hand against the palm of the hand during insertion. Leave the cuff turned down. Put the second glove on the non dominant hand. 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 gloved palm. Pull on the second glove carefully. Hold the thumb of the gloved first hand as far as possible from the palm. Adjust each glove so that it fits smoothly, and carefully pull the cuffs up by sliding the fingers under the cuffs. Remove and dispose of used gloves. There is no special technique for removing sterile gloves. If they are soiled with secretions, remove them by turning them inside out. Document that sterile technique was used in the performance of the procedure. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Measuring Body Temperature CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Review medical record for baseline factors that influence vital signs. 2. Explain to the client that vital signs will be assessed. Encourage client to remain still and refrain from drinking, eating, and smoking to avoid mouth breathing, if possible. 3. Assess clients toileting needs and proceed as appropriate. 4. Gather equipment. 5. Provide for privacy. 6. Wash hands/hand hygiene and apply gloves, when appropriate. Oral temperature: 7. Repeat Actions 1-6. 8. Grasp top of probes stem. 9. Place tip of thermometer under the clients tongue and along gum line to posterior sublingual pocket lateral to lower jaw. 10. Instruct client to keep mouth closed around thermometer. 11. Thermometer will signal (beep) when a constant temperature registers. 12. Read measurement on digital display of electronic thermometer. 13. Inform client of temperature reading. 14. Remove gloves and perform hand hygiene. Rectal temperature. Repeat actions 1-6 Place client in Sims position with upper knee flexed. Adjust sheet to expose only anal area. Place tissues in easy reach. Apply gloves. Lubricate rectal probe tip. With dominant hand, grasp top of the probes stem. With other hand, separate buttocks to expose anus. Instruct client to take deep breath. Insert probe gently into anus. Repeat actions 11-14. Axillay temperature. Repeat actions 1-6 Remove clients arm and shoulder from one sleeve of gown. Avoid exposing chest. Make sure axillay skin is dry, if necessary, pat dry. Place probe into center of axilla. Fold clients upper arm straight down, and place arm across clients chest. Repeat actions 11-14

For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Assessing Pulse rate CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Wash hands/hand hygiene. 2. inform client of site(s) where pulse will be measures. 3. Flex clients elbow and place lower part of arm across chest. 4. Support clients wrist by grasping outer aspect of thumb. 5. Place index and middle fingers on inner aspect of clients wrist over the radial artery, and apply light but firm pressure until pulse is palpated. 6. Identify pulse rhythm. 7. Determine pulse volume. 8. Count pulse rate by using second hand of watch. Taking apical pulse. 9. Wash hands/hand hygiene. 10. Raise clients gown to expose sternum and left side of chest. 11. Cleanse earpiece and stethoscope diaphragm with an alcohol swab. 12. Put stethoscope around the neck. 13. locate the apex of the heart. With the client lying on left side, locate suprasternal notch. Palpate second intercostal space to left sternum. Place index finger in intercostal space, counting downward until fifth intercostal space is located. Move index finger along fourth intercostals left of sternal border and to fifth intercostals space, left of midclavicular line to palpate the point of maximal impulse (PMI) Keep index finger of nondominant hand on PMI. 14. Inform client that clients heart will be listened to. Instruct client to remain silent. 15. With dominant hand, put earpiece of the stethoscope in ears and grasp diaphragm of stethoscope in palm of the hand for 5-10 seconds. 16. Place diaphragm of stethoscope over PMI and auscultate for sounds S1 and S2 to hear lubdub sound. 17. Note the regularity of the rhythm. 18. Start to count while looking at second hand of watch. Count lub-dub sound as one beat. 19. Share findings with patient. 20. Record by site, rate,rhythm, and, if applicable, number of irregular beats. 21. Wash hands/hand hygiene. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Assessing Respiratory Rate CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Wash hands/hand hygiene. 2. be sure chest movement is visible. Remove clothing, if necessary. 3. Observe one complete respiratory cycle. 4. Start counting with first inspiration while looking at the second hand of watch. 5. Observe character of respiration. 6. Replace clients gown, if needed. 7. Record rate and character of respiration. 8. Was hands/hand hygiene. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Assessing Blood Pressure CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Wash hands/ hand hygiene. 2. determine which extremity is most appropriate for reading. 3. Select a cuff size appropriate for the client. 4. Rest clients bare arm on a support so the midpoint of the upper arm is at the level of the heart. Extend elbow with palm turn upward. 5. Make sure bladder cuff is fully deflated and pump valve moves freely. Place manometer at eye level and easily visible. 6. palpate brachial artery in antecubital space, and place cuff so that midline of bladder is over arterial pulsation. Wrap and secure off snugly around the clients bare upper arm. Lower edge of cuff should be 1 inch above antecubital fossa where head of stethoscope is to be placed. 7. Inflate cuff rapidly to 70 mmHg and increase by 10 mm increments while palpating radial pulse. Note level of pressure at which pulse disappears and subsequently reappears during deflation. 8. Insert stethoscope earpieces into ear canals. 9. Relocate brachial artery with nondominat hand, and place stethoscope bell over brachial artery pulsation. 10. With dominant hand, turn valve clockwise to close. Compress pump to inflate cuff rapidly and steadily until manometer registers 20-30 mmHg above the level previously determined by palpation. 11. Partially unscrew (open) valve counter clockwise to deflate bladder at 2mm/sec while listening for the 5 phases of the Korotkoff sounds. Note manometer reading for these sounds. 12. After the last Korotkoffs sound is heard, deflate cuff slowly for at least another 10 mmHg then deflate rapidly and completely. 13. Allow client to rest for at least 30 seconds and remove cuff. 14. Inform client of reading. 15. Record the BP reading. 16. if appropriate, lower bed, raise side rails, and place call light in easy reach. 17. Put all equipment in proper place. 18. Wash hands/hand hygiene. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Proper Body Mechanics, Safe Lifting, and Transferring CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Wash hands/hand hygiene. 2. Assess for obstacles, heavy clients, poor handholds, equipment or object. Assess for tubing or equipment connected to client. 3. Assess for slippery surfaces, including wet floors; slippery surface before lifting the client or object. 4. Assess for slippery surfaces, including client confusion, combativeness, orthostatic hypotension, drug effects, pain, or fear. 5. Maintain low center of gravity by bending at hips and knees. Squat down rather than bend over to lift and lower the client. 6. Establish a wide support base with feet spread apart. 7. Use feet to move, not a twisting or bending motion from the waist. 8. When pushing and pulling: Stand near object Stagger one foot partially ahead of the other 9. When pushing: Lean into the client or object and apply continuous light pressure. Lean away and grasp with light pressure. Never jerk or twist your body to force a weight to move. 10. When stopping to move an object: Maintain a wide base support with feet. Flex knees to lower body. Maintain straight upper body. 11. When lifting or carrying an object: Bend the knees in front of the object. Take a firm hold, and assume a standing position by using leg muscles and keeping back straight. 12. When rising up from a squatting position: Arch your back slightly. Keep the buttocks and abdomen tucked in. Rise up with your head first. 13. When lifting or carrying heavy objects, keep weight as close to your center of gravity as possible. 14. When reaching for a client or an object: Keep the back straight. If client or object is heavy, do not try to lift without repositioning yourself closer to the weight. 15. Use safety aids and equipment. Use gait belts, lifts, draw sheets, and other transfer assistance devices. Encourage clients to use handrails and grab bars. Wheelchair, cart and stretcher wheels should be locked when they are not being moved. 16. Wash hands/hand hygiene. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature:__________________ Evaluators Signature:__________________ Comments:_____________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Turning and Positioning a Client CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 1. Wash hands/hand hygiene. 2. Explain procedure to client. Elicit client cooperation and participation. 3. Gather all necessary equipment. Provide for client privacy. 4. Secure adequate assistance to complete task safely. 5. Adjust bed to comfortable working height. Lower side rail on side of bed closest to you. 6. Follow proper body mechanics guidelines: When moving a client in bed, position bed so that your legs are slightly bent at knees and hips. Maintain natural curves in your back while lifting. Position one foot slightly in front of other and spread feet apart to create a wide base for balance. When arms are placed under client, slowly lean backward onto your back leg using your body weight to help you lift client to one side of bed. Do not extend to rotate your back to move a client in bed. If you cannot move client easily, always ask for and obtain assistance for the safety of both you and the client. Be sure floor is not slippery and that bed is locked. Always use a turning sheet when rolling a client because this gives you better support and control of client. 7. Position drains tubes and IVs to accommodate clients new position. 8. Place or assist client into appropriate starting position. Monitor client status, and provide adequate rest breaks or support as necessary. Moving from Supine to Side-Lying Position 9. Move client from supine to side lying position: Slide your hands underneath client. Move client to one side of bed by lifting clients toward you in stages: First the upper trunk; Then the lower trunk; Finally, the legs Lift clients body; do not drag client across sheets. Roll client to side-lying position by placing clients inside arm next to clients body with palm of hand against hip. Cross clients outside arm and leg toward midline and logroll client toward you. Use clients outside shoulder and hip for leverage while maintaining stability and control of top arm and leg. Maintaining Side-Lying Position 10. Repeat Action 1-8. 11. Use pillows to support client: Place to support clients head and arms. Can be used topside leg, thigh, knee, ankle, and foot. Move lower arm forward slightly at shoulder and bend elbow for comfort. If client in unstable, placing a pillow against the back will provide additional support and keep the client from rolling supine. Moving from Side-Lying to Prone Position 12. Repeat Actions 1-8. 13. To move to Prone position: Remove positioning towels, pillows, or others support devices. Assess if clients position needs to be adjusted to accommodate continued movement into prone position. Move clients inside arm next to clients body with palm against hip. Roll client onto stomach using shoulder and hip as key points of control.

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Place the head in a comfortable position to one side without excessive pressure to sensitive areas. Place pillows under trunk, as needed, to relieve pressure and increase comfort. Place arms comfortably at clients side and uncross legs with feet approximately a foot apart. Maintaining Prone Position 14. To maintain prone: Use a shallow pillow or folded towel to support clients heat comfortably. Place pillow under abdomen to support back. Place an additional pillow under lower leg to reduce pressure of toes and forefoot against bed. Moving from Prone to Supine Position 15. Repeat Actions 1-8. 16. To move from prone to supine: Remove positioning towers or pillows. Slide your hands underneath client. Move client segmentally to one side of the bed to accommodate the new position. Position inside arm next to clients body with clients palm next to hip. Roll client to supine position by logrolling the client toward you using the clients outside shoulder and hip for leverage. Position client away from direction of roll to prevent undue pressure. When client reaches supine, uncross, the arms and legs and place into anatomic positions. Maintaining Supine Position 17. To maintain supine position: Use a footboard to support the foot. Use heel protectors or place a pillow between the heel and gastrocnemuis muscle to reduce the pressure on the heels. Assess and compare warmth, sensation, color, and movement of feet. Use a trochanter roll to prevent excessive external rotation of the lower extremity. For comport, place additional pillows to support clients head, arms, or lower back. 18. Place side rails in upright position. Return bed to low position. 19. Please call light within reach. 20. Move bedside table close. Place items of frequent use within reach. 21. Wash hands/hand hygiene. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Moving a Client in Bed CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Moving a Client up in Bed with One Nurse 1. Wash hands/hand hygiene. 2. Inform client of reason for the move and how to assist. 3. Elevate bed to just below waist height. Lower head of bed, if tolerated. Lower side rails on your side. 4. Remove the pillow. Place against headboard. 5. Have client fold arms across chest. 6. Have client hold on to overhead trapeze, if available. 7. Have client bend knees and place feet flat on bed. 8. Stand at an angle to head of bed with feet apart, facing head of bed, and knees bent. 9. Slide one hand and arm under clients shoulder, the other under clients thigh. 10. Rock forward toward head of bed, lifting client with you. Have client push with legs. 11. If client has trapeze, have client pull up holding onto trapeze as you move client upward. 12. Repeat these steps until client is moved up high enough in bed. 13. Returns clients pillow under the bed. 14. Elevate head of bed, if tolerated by client. 15. Assess client for comfort. 16. Adjust the clients bedclothes as needed for comfort. 17. Lower bed and elevate side rails. 18. Hand hygiene. Moving a Client up in Bed with Two or More Nurses 19. Hand hygiene. 20. Inform client of reason for the move and how to assist. 21. Elevate bed to just below waist height. Lower head of bed if tolerated by client. Lower side rails. 22. With two nurses, place turn or draw sheet under clients back and head. 23. Roll up draw sheet on each side until it is next to client. 24. Follow Actions 4-7. 25. The nurses stand on either side of bed, at an angle to head of bed, with knees flexed and feet apart in wide stance. 26. The nurses hold their elbows as close as possible to their bodies. 27. The lead nurse will give signal to move: 1-2-3 go. The nurses will lift up (off of bed) on turn or draw sheet and forward (toward head of bed) in one smooth motion. The move is coordinated to transfer client toward head of bed. Simultaneously, have client push with legs or pull using trapeze. 28. Repeat until client is moved upright enough in bed to be comfortable. 29. Return clients pillow under head. 30. Elevate head of bed, if tolerated by client. 31. Assess client for comfort. 32. Adjust clients bedclothes for comfort. 33. Lower bed and elevate side rails. 34. Wash hands/hand hygiene.

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For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Assisting from Bed to Wheelchair, Commode, or Chair CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Inform client about desired purpose and destination. 2. Assess client for ability to assist with transfer and presence of cognitive or sensory deficits. 3. Lock bed in position. Hand hygiene. 4. Place any splints, braces, or other devices on client. 5. Place shoes or slippers on clients feet. 6. Lower height of bed to lowest possible position. 7. Slowly raise head of bed if not contraindicated by clients condition. 8. Place one arm under clients legs and one arm behind clients back. Slowly pivot client so clients legs are dangling over edge of bed and client is in a sitting position on edge of bed. 9. Allow client to dangle for 2 to 5 minutes. Help support client, if necessary. 10. Bring chair or wheelchair close to side of bed. Place at 45 angle to bed. If client has a weaker side, place chair or wheelchair on clients strong side. 11. Lock wheelchair brakes and elevate foot pedals. For chairs, lock brakes, if available. 12. If using a gait belt to assist client, place it around clients waist. 13. Assist client to side of bed until feet are firmly on floor and slightly apart. 14. Grasp sides of gait belt or place your hands just below clients axilla. Using a wide stance, bend your knees and assist client to standing position. 15. Stand close to client, pivot until clients back is toward chair. 16. Instruct client to place hands on arm supports or place clients hand on arm supports of chair. 17. Bend at knees and ease client into a sitting position. 18. Assist client to maintain proper posture. Support weak side with pillow, if needed. 19. Secure safety belt, place clients feet on feet pedals, and release brakes if moving client immediately. Make sure tubes and lines, arms and hands are not pinched or caught between client and chair. If client is sitting in chair, offer a footstool, if available. 20. Wash hands/hand hygiene. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Assisting from Bed to Stretcher CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Transferring a Client with Minimum Assistance 1. Inform client about desired purpose and destination. Hand hygiene. 2. Raise the height of bed to 1 inch higher than the stretcher and lock brakes of bed. 3. Instruct client to move to side of bed close to stretcher. Lower side rails of bed and stretcher. Leave side rails on opposite side up. 4. Stand at outer side of stretcher and push it toward bed. 5. Instruct client to move onto stretcher providing assistance, as needed. 6. Cover client with sheet or bath blanket. 7. Elevate side rails on stretcher and secure safety belts about client. Release brakes of stretcher 8. Stand at head of stretcher to guide it when pushing. 9. Hand hygiene. Transferring a Client with Maximum Assistance 10. Repeat Actions 1 and 2. 11. Assess amount of assistance required for transfer. Usually 2 to 4 staff members are required for maximally assisted transfer. 12. Lock wheels of bed and stretcher. 13. Have one nurse stand close to clients head. 14. Logroll client (keep in straight alignment) and place a lift sheet under clients back, trunk and upper legs. The lift sheet can extend under head if client lacks head control abilities. 15. Empty all drainage bags (e.g., T-tube, Hemo Vac, Jackson-Pratt). Record amounts. Secure drainage system to clients gown before transfer. 16. Move client to edge of bed near stretcher. Lift client up and over to avoid dragging. 17. Because client is now on side of bed with side rail down, the nurse on nonstretcher side of bed holds stretcher side of lift sheet up ( by reaching across the clients chest) to prevent client from falling onto stretcher or off bed. 18. Place pillow or slider board to overlap bed and stretcher. 19. Have staff members grasp edges of lift sheet. Be sure to use good body mechanics. 20. On count of 3, have staff members pull lift sheet and client onto stretcher. 21. Position client on stretcher, place pillow under head, and cover with a sheet. 22. Secure safety belts and elevate side rails of stretcher. 23. If IV pole is present, move it from bed IV pole to stretcher IV pole after client transfer. 24. Wash hands/hand hygiene. For the next items, evaluate the students in general according to t2he criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Changing an Unoccupied Bed CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Assess: The clients health status, to determine that the person can safely get out of the bed The clients pulse and respirations, if indicated Note all the tubes and equipment connected The clients pulse and respirations, if indicated Note all the tubes and equipment connected to the client. 2.Assemble equipment And supplies: Two flat sheets, or one Fitted and one flat sheet, Cloth drawsheet, One blanket, One bedspread, Waterproof drawsheet, Or waterproof pads (optional), Pillowcases for the head Pillows, Plastic laundry bag or Portable linen hamper, If available. Procedure 1. Explain to the client what you are going to do, why it is necessary, and how she can cooperate 2. Wash hands and observe other appropriate infection control procedures 3. Provide for client privacy 4. Place the fresh linen on the clients chair or overbed table, do not use another clients bed. 5. Assess and assist the client out of bed. Make sure that this is an appropriate and convenient time for the client to be out of bed. Assist the client to a comfortable chair 6. Strip the bed. Check bed linens for any items belonging to the client, and detach the call bell or any drainage tubes from the bed linen. Loosen all bedding systematically, starting at the head of the bed on the far side and moving around the bed up to the head of the bed on the near side. Remove the pillowcases, if Soiled and place the pillows on the bedside chair near the foot of the bed. Fold reusable linens, such as the bedspread and top sheet of the bed, into fourths. First, fold the linen in half by bringing the top edge even with the bottom edge, then grasp it at the center of the middle fold and bottom edges. Remove the waterproof pad and discard it, if soiled. Roll all soiled linen inside the bottom sheet, hold it away from your uniform, and place it directly in the linen hamper. Grasp the mattress securely, using the lugs, if present, and move the mattress up to the head of the bed. 7. Apply the bottom sheet and drawsheet. Place the folded bottom sheet with its center fold on the center of the bed. Make sure the sheet is hem-side down for a smooth foundation. Spread the sheet out over the mattress and allow a sufficient amount of sheet at the top to tuck under the mattress. Miter the sheet at the top corner on the near side and tuck the sheet under the mattress, working from the head of the bed to the foot. If a waterproof drawsheet is used, place it over the bottom sheet so that the center fold is at the center line of the bed and the top and bottom edges extend from the middle of the clients back to the area of the mid thigh or knee. Fanfold the upper-most half of the folded drawsheet at the center or far edge of the bed, and tuck in the near edge. Lay the cloth drawsheet over the waterproof sheet in the same manner. Optional: Before moving to the other side of the bed, place the top linens on the bed hem-side up, unfold them, tuck them in, and miter the bottom corners. 8. Move to the other side and secure the bottom linens. Tuck in the bottom sheet under the head of the mattress, pull the sheet firmly, and miter the corner of the sheet. Pull the remainder of the sheet firmly so that there are no wrinkles.

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Complete this same process for the drawsheet(s). 9.Apply or complete the top sheet, blanket, and spread. Place the top sheet, hemside up, on the bed so that its center fold is at the center of the bed and the top edge is even with the top edge of the mattress. Unfold the sheet over the bed. Optional: Make a fold in the sheet to provide additional room forthe clients feet. vertical toe pleat: make a fold in the sheet 5-10 cm (2-4in) perpendicular to the foot of the bed. Horizontal toe pleat: Make a fold in the sheet 5-10 cm (2-4 in) across the bed near the foot. Follow the same procedure for blanket and the spread, but place the top edges about 15 cm (6in) from the head of the bed to allow a cuff of sheet to be folded over them. Tuck in the sheet, blanket, and spread at the foot of the bed, and miter the corner using all three layers of linen. Leave the sides of the top sheet, blanket, and spread hanging freely, unless toe pleats were provided. Fold the top of the top sheet down over the spread, providing a cuff. Move to the other side of the bed, and secure the top bedding in the same manner. 10.Put clean pillowcases On the pillows as required. Grasp the closed end of the pillowcase at the center with one hand. Gather up the sides of the Pillowcase and place them over the hand grasping the case. Then grasp the center of one short side of the pillow through the pillowcase. With the free hand, pull the pillowcase over the pillow. Adjust the pillowcase so that the pillow fits into the corners of the case and the seams are straight. Place the pillows appropriately at the head of the bed. 11.Provide for client comfort and safety. Attach the signal cord so that the client can conveniently use it. If the bed is currently being used by a client, either fold back the top covers at one side or fanfold them down to the center of the bed. Place the bedside table and the overbed table so that they are available to the patient. Leave the bed in the high Position if the client is returning by stretcher, or place in the low Position if the client is returning to bed after being up. 12. Document and report pertinent data. Variation : Surgical Bed Strip the bed. Place and leave the pillows on the bedside chair. Apply the bottom linens as for an unoccupied bed. Place a bath blanket on the foundation of the bed, if this is agency practice. Place the top covers on the bed as you would for an unoccupied bed. Do not tuck them in, miters the corners, or make a toe pleat. Make a cuff at the top of the bed as you would for an unoccupied bed. Fold the top linens up from the bottom. On the side of the bed where the client will be transferred, fold up the two outer corners of the top linens so they meet in the middle of the bed forming a triangle. Pick up the apex of the triangle, and fanfold the top linens lengthwise to the other side of the bed. Leave the bed in high position with the side rails down. Lock the wheels of the bed if the bed is not to be moved. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Changing an Occupied Bed CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Assess: Note specific orders or precautions for moving and positioning the client. Determine presence of incontinence or excessive drainage from other sources indicating the need for protective waterproof pad. Assess skin condition and need for special mattress, footboard, or heel protectors. 2. Assemble equipment and supplies: Two flat sheets, or one fitted and one flat sheet. Cloth drawsheet (optional) One blanket One bedspread Waterproof drawsheet or waterproof pads (optional) Pillowcases for the head pillows Plastic laundry bag or portable linen hamper, if available. Procedure 1. Explain to the client what you are going to do, why is it necessary and how she can cooperate. 2. Wash hands and observe other appropriate infection control procedures 3. Provide for client privacy. 4. Remove the top bedding. Remove any equipment attached to the bed linen, such as a signal light. Loosen all the top linen at the foot of the bed, and remove the spread and the blanket. Leave the top sheet over the client, or replace it with a bath blanket as follows: Spread the bath blanket over the top sheet. Ask the client to hold the top edge of the blanket. Reaching under the blanket from the side, grasp the top edge of the sheet and draw it down to the foot of the bed, leaving the blanket in place. Remove the sheet from the bed and place it in the soiled linen hamper. 5. Change the bottom sheet and drawsheet Assist the client to turn on the side facing away from the side where the clean linen is. Raise the side rail nearest the client. If there is no side rail, have another nurse support the client at the edge of the bed. Loosen the foundation of the linen on the side of the bed near the linen supply. Fanfold the drawsheet and the bottom sheet at the center of the bed, as close to the patient as possible. Place the new bottom sheet on the bed, and vertically fanfold the half to be used on the far side of the bed as close to the patient as possible. Tuck the sheet under the near half of the bed, and miter the corner if a contour sheet is not being used. Place the clean drawsheet on the bed with the center fold at the center of the bed. Fanfold the uppermost half vertically at the center of the bed, and tuck the near side edge under the side of the mattress. Assist the client to roll over toward you onto the clean side of the bed. Have the client roll over the fanfolded linen at the center of the bed. Move the pillows to the clean side for the patients use. Raise the side rail before leaving the side of the bed. Move to the other side of the bed, and lower the side rail. Remove the used linen and place it in the portable hamper. Unfold and fanfold bottom sheet from the center of the bed.

18
Facing the side of the bed, use both hands to pull the bottom sheet so that it is smooth, and tuck excess under the side of the mattress. Unfold the drawsheet fanfolded at the center of the bed and pull it tightly with both hands. Pull the sheet in three sections: Face the side of the bed to pull the middle section. Face the far top corner to pull the bottom section. Face the far bottom corner to pull the top section. Tuck the excess drawsheet under the side of the mattress. 6. Reposition the client in the center of the bed. Reposition the pillows at the center of the bed. Assist the client to the center of the bed. Determine what position the client requires or prefers, and assist the client to that position. 7. Apply or complete the top bedding. Spread the top sheet over the client, and either ask the client to hold the top edge of the sheet or tuck it under the shoulders, the sheet should remain over the client when the bath blanket or used sheet is removed. Complete the top of the bed. 8. Ensure the continued safety of the client. Raise the side rails. Place the bed in the low position before leaving the bedside. Attach the signal cord to the bed linen within the clients reach. Put items used by the client within easy reach. Bed making is not normally recorded. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Brushing and Flossing the Teeth CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Assess: The extent of the clients self care abilities The clients usual mouth care practices Inspect lips, gums, oral mucosa, and tongue for deviation from normal. For presence of oral problems such as tooth carries, halitosis, gingivitis, or lose or broken teeth. The client for bridge work or dentures. Assemble equipment and supplies: Brushing and flossing: Towel Disposable gloves Curved basin or emesis basin Tooth brush Cup of tepid water Toothpaste Mouthwash Dental floss (at least two pieces, 20cm or 8 inches in length) Floss holder (optional) Cleaning artificial dentures: Disposable gloves Tissue or piece of gauze Denture container Clean wash cloth Toothbrush or stiff brittle brush Toothpaste Tepid water Container of mouth wash Curved basin Towel Procedure Explain to the client what you are going to do, why it is necessary, and how she can cooperate. Wash hands and observe other appropriate infection control procedures. Provide for client privacy. Prepare the client and the environment. Assist the client to a sitting position in bed, if health permits. If not assist the client is a side lying position with the head turned. Prepare the equipment Place the towel under the clients chin. Put on clean gloves Moisten the bristles of the toothbrush with tepid water and apply the toothpaste to the toothbrush. Use a soft toothbrush and the clients choice of toothpaste. For the client who must remain in bed, place of hold the curved basin under the clients chin, fitting the small curve around the chin or neck. Inspect the mouth and teeth. Brush the teeth.

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Hand the toothbrush to the client, or brush the clients teeth as follows: Hold the brush against the teeth with the bristles at a 45 degree angle. The tips of the outer bristles should rest against and penetrate against the gingival. Move the bristle up and down, using a vibrating or jiggling motion from the sulcus to the crowns of the teeth. Repeat until all outer and inner surfaces of the teeth and sulci of the gums are cleaned. Clean the biting surfaces by moving the brush back and forth over them in short strokes. If the tongue is open, brush it gently with a toothbrush. Hand the client the water cap or mouthwash to rinse the mouth vigorously. Then ask the client and spit the water and excess toothpaste into the basin. Repeat the preceding steps until the mouth is free of toothpaste and food particles. Remove the curved basin and help the client wipe her/his mouth. Floss the teeth. Assist the client to floss independently, or floss the teeth as follows: Wrap one end of the cloth around the third finger of each hand. To floss the upper teeth, use your thumb and index finger to starch the floss. Move the floss up and down between the teeth from the tops of the crown to the gum and along the gum lines as far as possible. Make a C with the floss around the tooth edge being flossed. Star at the back on the right side and work around to the back of the left side, or work from the center teeth to the back of the jaw on either side. To floss the lower teeth, use your index fingers to stretch the floss and follow instructions as above. Give the client tepid water of mouth wash to rinse the mouth and a curved basin in which to spit the water. Assist the client in wiping the mouth Remove and dispose of equipment appropriately. Remove and clean the curved basin. Remove and discard the gloves. Document assessment of the teeth, tongue, gums, and oral mucosa. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Providing Special Oral Care CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Assess: Inspect lips, gums, oral mucosa, and tongue from deviations form normal Identify presence of oral problems such as tooth carries, halitosis, gingivitis, lose or broken teeth. Asses for gag reflex when appropriate Assemble equipment and supplies: Towel Tissue or piece of gauze to remove denture (optional) Denture container Rubber tipped bulb syringe Suction catheter with suction apparatus (optional) Foam swabs and clean solution for cleaning the mucus membranes Petroleum jelly Bite block to hold the mouth open and teeth apart (optionl) Disposable gloves Curved basin or emesis basin Tooth brush Cup of tepid water Toothpaste Mouthwash Procedure Explain to the client what you are going to do, why it is necessary, and how she can cooperate. Wash hands and observe other appropriate infection control procedures. Provide for client privacy. Prepare the client and the environment. Position the unconscious client in a side lying position, with the head of the bed lowered. Place the towel under the clients chin Place the curved basin against the clients chin and lower cheek to receive the fluid form the mouth Put on gloves Clean the teeth and rinse the mouth If the client has natural teeth, brush the teeth. If the client has artificial teeth, clean them as prescribe in the variation component***** Rinse the clients by drawing about 10 ml of water or alcohol free mouth wash into the syringe and injecting it gently into each side of the mouth. Watch carefully to make sure that all the rinsing solution has run out of the mouth into the basin. If not, suction the fluid from the mouth Repeat rinsing until the mouth is free form tooth paste if used. Inspect and clean the oral tissues If the tissues appear dry or unclean, clean them with the foam swabs or gauze and cleaning solution, following agency policy. Picking up moistened foam swab, wipe the mucous membrane of one cheek. If no foam swabs are available, wrap a small gauze square around a tongue blade and moisten it. Discard the swab or tongue blade in a waste container and, with a fresh one, clean the next area. Clean all the mouth tissues in an orderly progression, using separate applicators: the cheeks, roof of the mouth, base of the mouth, and tongue. Observe the tissues closely for inflammation and dryness. Rinse the clients mouth as prescribed in step 5.

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Remove and discard gloves Ensure the client comfort. Remove the basin, and dry around the clients mouth with the towels. Replace artificial dentures if indicated Lubricate the clients lips with petroleum jelly. If the client is on oxygen therapy, do not use petroleum jelly because it can cause burns to the clients mouth. Use another mouth care product that does not have petroleum in it. Document: Assessment of the teeth tongue, gums, and oral mucosa Any problems such as sores or inflammations or swelling of the gums. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Providing Perineal and Genital Care CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Assess for presence of: Irritation, excoriation, inflammation, swelling Excessive discharge Odor pain or discomfort Urinary or fecal incontinence Recent rectal or perineal surgery Indwelling catheter Determine: Perineal genital hygiene practices Self care abilities Whether the client is experiencing any discomfort in the perineal genital area. Assemble equipments and supplies: Perineal genital care provided in conjunction with a bed bath Bath towel Bath blanket Clean gloves Bath basin with water 43 46 degrees Celsius (110 115 Fahrenheit) Soap Wash cloth Special perineal genital care Bath towel Bath blanket Clean gloves Cotton balls or swabs Solution bottle, pitcher, or container filled with warm water or a prescribe solution. Bed pan to receive rinse water. Moisture resistant bag or receptacle for used cotton swabs Perineal pad Procedure Explain to the client what you are going to do, why it is necessary, and how she can cooperate. Wash hands and observe other appropriate infection control procedures. Provide for client privacy. Prepare the client and the environment. Fold the top bed linen to the foot of the bed and fold the gown up to exposed genital area. Place a bath towel under the clients hips. Position and drape the client and clean the upper and inner thighs For females Position in a back lying position with the knees flexed and spread well apart. Cover her body and legs with a 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. Put on gloves, and wash and dry the upper inner thighs.

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For males Position the male client in a supine position with knees slightly flexed and hips slightly externally rotated. Put on gloves, and wash and dry the upper inner thighs Inspect the perineal area Note particular areas of inflammation, excoriation, or swelling, especially between the labia in females or the scrotal folds in males. Also note excessive discharge or secretion from the orifices, and the presence of odors. Wash and dry the perennial genital area. For females Clean the labia majora. Then spread the labia to wash the folds between the labia majora and minora. Use separate quarters of the wash cloths for each stroke, and wipe from the pubis to the rectum. For menstruating women and clients with clients with indwelling catheters, use clean wipes, cotton balls, or gauze. Take a clean ball for each stroke. Rinse the area well. Dry the perineum thoroughly. For males Wash and dry the penis, using firm strokes. If the client is uncircumcised, retract the prepuce to expose the glans penis for cleaning. Replace the fore skin after cleaning the glans penis. Wash and dry the scrotum. The posterior folds of the scrotum may need to be clean in step 9 with the buttocks. Inspect the perineal orifices intactness Inspect particularly around the urethra in clients with indwelling catheter. Clean between the buttocks. Assist the client to turn on to the side facing away from you. Pay particular attention to the anal area and posterior folds in the scrotum in males. Clean the anus with toilet tissue before washing it, if necessary. Dry the area well. For post delivery or menstruating females, apply a perineal pad as needed, from front to back. Document: Any unusual findings such as redness excoriation, skin break down, discharge, or drainage. Any localized area of tenderness. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Bathing an Adult or Pediatric Client CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Assess: Condition of the skin Fatigue Presence of pain and need for adjunctive measures before the bath Range of motion of the joints Any other aspect of health that may affect the clients bathing process Assemble equipment and supplies: Basin or sink with warm water Soap and soap dish Linens: bath blanket, two bath towels, washcloth, clean gown, or pajamas or clothes as needed, additional bed linen and towels, if required Gloves, if appropriate Personal hygiene articles Shaving equipment for male clients Table for bathing equipment Laundry hamper Determine: The purpose and type of bath the client needs Self-care ability of the client Any movement or positioning precautions specific to the client Other care the client may be receiving Clients comfort level with being bathed by someone else Procedure Explain to the client what you are going to do, why it is necessary, and how she can cooperate. Wash hands and observe other appropriate infection control procedures. Provide for client privacy. Prepare the client and the environment. Invite a family member or significant other to participate, if desired Close windows and doors to ensure the room is a comfortable temperature. Offer the client a bedpan or urinal, or ask whether the client wishes to use the toilet or commode. Encourage the client to perform as much personal self-care as possible. During the bath, assess each area of the skin carefully. For a Bed Bath Prepare the bed and position the client appropriately. Position the bed at a comfortable working height. Lower side rail on the side close to you. Keep the other side rail UP. Assist the client to move near you. Place bath blanket over top sheet. Remove the top sheet from under the bath blanket by starting at clients shoulders and moving linen down towards clients feet. Ask the client to grasp and hold the top of the bath blanket while pulling linen to the foot of the bed. Note: If the bed linen is to be reused, place it over the bedside chair. If it is to be changed, place it in the linen hamper. Make a bath mitt with the washcloth. Wash the face. Place towel under the clients head.

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Wash the clients eyes with water only, and dry them well. Use a separate corner of the washcloth for each eye. Wipe from the inner to the outer canthus. Ask whether the client wants soap used on her face. Wash, rinse, and dry the clients face, ears and neck. Remove the towel from under the clients head. Wash the arms and hands. Place a towel lengthwise under the arm away from you. Wash, rinse and dry the arm by elevating the clients arm and supporting the clients wrist and elbow. Apply deodorant or powder if desired. Optional: place a towel on the bed and put a washbasin on it. Place the clients hands in the basin. Assist the client as needed to wash, rinse and dry her hands, paying particular attention to the spaces between her fingers. Repeat for hand and arm nearest you. Wash the chest and the abdomen. Place bath towel lengthwise over chest. Fold bath blanket down to the clients pubic area. Lift the bath towel off her chest, and bathe her chest and abdomen with your mitted hand, using long, firm strokes. Rinse and dry well. Replace the bath blanket when the areas have been dried. Wash the legs and feet. Expose the leg farthest from you by folding the bath blanket towards the other leg, being careful to keep the perineum covered. Lift leg and place the bath towel lengthwise under the leg. Wash, rinse and dry the leg, using long, smooth, firm strokes from the ankle to the knee to the thigh. Reverse the coverings and repeat for the other leg. Wash the feet by placing them in the basin of water. Dry each foot. Obtain fresh, warm, bathwater now or when necessary. Wash the back and then the perineum. 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. Wash and dry the clients back, moving from the shoulders to the buttocks, and upper thighs, paying attention to the gluteal folds. Perform a back massage now or after completion of bath. Assist the client to the supine position and determine whether the client can wash the perineal area independently. If she can not do so, drape the client and wash the area. Assist the client with grooming aids such as powder, lotion or deodorant. Use powder sparingly. Release as little as possible into the atmosphere. Help the client put on a clean gown or pajamas. Assist the client to care for hair, mouth and nails. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Administering an Intradermal Injection CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Assess: Appearance of injection site Specific drug action and expected response Clients knowledge of drug action and response Assemble equipment and supplies: Vial or ampule of the correct medication Sterile 1ml syringe calibrated into hundredths of a milliliter (i.e. tuberculin syringe) and a 25 to 27gauge needle hat is to 5/8 inch long Alcohol swabs 2 x 2 sterile gauze square (optional) Nonsterile gloves (according to agency protocol) Band Aid (optional) Epinephrine (a bronchodilator and antihistamine) on hand Check the MAR Check the label on the medication carefully against the MAR to make sure that the correct medication is being prepared. Follow the three checks for administering medications. Read the label on the medication: When it is taken from the medication cart Before withdrawing the medication After withdrawing the medication Organize the equipment. Procedure Wash hands and observe other appropriate infection control procedures. Prepare the medication from the vial or ampule for drug withdrawal. See Procedure 332 and 333. Prepare the client Check the clients identification band Explain to the client that he medication will produce a small wheal, sometimes called a bleb. Provide for client privacy Select and clean the site Select a site. Avoid using sites hat are tender, inflammed, or swollen, and those that have lesions Put on gloves. Cleanse the skin at the site using a firm circular motion, starting at the center and widening he circle outward. Allow the area to dry thoroughly. Prepare the syringe for he injection Remove he needle cap while waiting for the antiseptic to dry. Expel any air bubbles from the syringe. Grasp the syringe in your dominant hand, holding it between thumb and forefinger. Hold the needle almost parallel to the skin surface with the bevel of the needle up. Inject the fluid. With the nondominant hand, pull the skin at the site until it is taut. Insert the tip of the needle far enough to place the bevel through the epidermis into the dermis. The outline of the bevel should be visible under the skin surface. Stabilize the syringe and needle, and inject the medication carefully and slowly, so that it produces a small wheal on the skin. Withdraw the needle quickly at the same angle that it was inserted. Apply a Band Aid, if indicated. Do not massage the area.

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Dispose of the syringe and needle safely. Remove gloves. Circle the injection site with ink to observe for redness or induration per agency policy. Document all relevant information. Record the testing material given, the time, dosage, route, site and nursing assessments. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Administering an Subcutaneous Injection CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Assess: Allergies to medication Specific drug action, side effects, and adverse reactions Clients knowledge and learning needs about the medication Status and appearance of subcutaneous site for lesions, erythema, swelling, ecchymosis, inflammation, and tissue damage from previous injections. Ability of client to cooperate during the injection Previous injection sites used Assemble equipment and supplies: MAR or computer printout Vial or ampule of the correct sterile medication Syringe and needle Antiseptic swabs Dry sterile gauze for opening an ampule (optional) Disposable gloves Check the MAR. Check the label on the medication carefully against the MAR to make sure that the correct medications is being prepared. Follow the three checks for administering medications. Read the label on the medication: When it is taken from the medication cart Before withdrawing the medication After withdrawing the medication Organize the equipment. Procedure Wash hands and observe other appropriate infection control procedures. Prepare the medication from the ampule or vial for drug withdrawal. See procedure 332 (ampule) or 333 (vial) Provide for client privacy. Prepare the client. Check the clients identification band. Assist the client to a position in which the arm, leg, or abdomen can be relaxed, depending on the site to be used. Obtain assistance in holding an uncooperative client. Explain the purpose of the medication and how it will help, using language that the client can understand. Include relevant information about effects of the medication Select and clean the site. Select a site free of tenderness, hardness, swelling, scarring, itching, burning, and localized inflammation. Select a site that has not been used frequently Put on gloves As agency protocol indicates, clean the site with an antiseptic swab. Start at the center of the site and clean in a widening circle to about 5cm (2in). Allow the area to dry thoroughly Place and hold the swab between the third and fourth fingers of the nondominant hand, or position the swab on the clients skin above the intended site. Prepare the syringe for injection Remove the needle cap while waiting for the antiseptic to dry.

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Inject the medication. Grasp the syringe in your dominant hand by holding it between your thumb and fingers. With palm facing to the side or upward for a 45degree angle insertion, or with the palm downward for a 90degree angle insertion, prepare to inject. Using the nondominant hand, pinch or spread the skin at the site, and insert the needle, using the dominant hand and a firm steady push. When the needle is inserted, move your nondominant hand to the end of the plunger. Aspirate by pulling back on he plunger. If blood appears in the syringe, withdraw the needle, discard the syringe, and prepare a new injection. If blood does not appear, continue to administer the medication. Inject the medication by holding the syringe steady and depressing the plunger with slow, even pressure. Remove the needle Remove the needle slowly and smoothly, pulling along the line of insertion while depressing the skin with your nondominant hand. If bleeding occurs, apply pressure to the site with dry sterile gauze until it stops. Dispose of supplies appropriately. Discard the uncapped needle and attached syringe into designated receptacles Remove gloves. Wash hands. Document all relevant information. Document the medication given, dosage, time route, and any assessments. Many agencies prefer that medication administration be recorded on the medication record. Assess the effectiveness of the medication at the time it is expected to act. Variation: Administering a Heparin Injection Procedure Select a site o the abdomen away from the umbilicus and above the level of the iliac crests. Use a 3/8inch, 25 or 26gauge needle, and insert it at a 90degree angle. If a client is very lean or wasted, use a needle longer than 3/8inch, and insert it at a 45degree angle. The arms or highs may be used as alternate sites. Do not aspirate when giving heparin by subcutaneous injection. Do not massage the site after the injection. Alternate the sites of subsequent injections. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Administering an Intramuscular Injection CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Assess: Client allergies to medication(s) Specific drug action, side effects, and adverse reactions Clients knowledge of and learning needs about the medication. Tissue integrity of the selected site Clients age and weight, to determine site and needle size Clients ability or willingness to cooperate Determine: Whether the size of the muscle is appropriate to the amount of medication to be injected. Assemble equipment and supplies: MAR or computer printout Sterile medication (usually provided in an ampule or vial) Syringe and needle of a size appropriate for the amount of solution to be administered Antiseptic swabs. Disposable gloves Check the MAR. Check the label on the medication carefully against the MAR to make sure that the correct medication is being prepared. Follow the three checks for administering the medication and dose. Read the label on the medication: When it is taken from the medication cart Before withdrawing the medication After withdrawing the medication Confirm that the dose is correct. Procedure Wash hands and observe other appropriate infection control procedures. Prepare the medication from the ampule or vial for drug withdrawal. See Procedure 332 (ampule) or 333 (vial) Whenever feasible, change the needle on the syringe before the injection. Invert the syringe needle uppermost, and expel all excess air. Provide for client privacy. Prepare the client. Check the clients identification band. Assist the client to a supine, lateral, prone, or sitting position, depending on the chosen site. Obtain assistance in holding an uncooperative client. Explain the purpose of the medication and how it will help, using language that the client can understand. Include relevant information about effects of the medication. Select, locate ad clean the site Select a site free of skin lesions, tenderness, swelling, hardness, or localized inflammation, and one that has not been used frequently. If injections are to be frequent, alternate sites. Avoid using the same site twice in a row Locate the exact site for the injection. Put on clean gloves. Clean the site with an antiseptic swab. Using a circular motion, start at the center and move outward about 5 cm (2in). Transfer and hold the swab between the third and fourth fingers of your

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nondominant hand in readiness for needle withdrawal, or position the swab on the Clients skin above the intended site. Allow skin to dry prior to injecting medication. Prepare the syringe for injection Remove the needle cover without contaminating the needle. If using a prefilled unitdose medication, take caution to avoid dripping medication on the needle prior to injection. If this does occur, wipe the medication off the needle with sterile gauze. Inject the medication using a Ztrack technique. Use the ulnar side of the nondominant hand to pull the skin approximately 2.5 cm (1inch) to the side. Holding the syringe between the thumb and forefinger, pierce the skin quickly and smoothly at a 90degree angle, and insert the needle into the muscle. Hold the barrel of the syringe steady with your nondominant hand, and aspirate by pulling back on the plunger with your dominant hand. Aspirate for 5 to 10 seconds. If blood appears in the syringe, withdraw the needle, discard the syringe, and prepare a new injection. If blood does not appear, inject the medication steadily an slowly (approximately 10 seconds per milliliter) while holding the syringe steady. After injection, wait 10 seconds. Withdraw the needle. Withdraw the needle smoothly at the same angle of insertion. Apply gentle pressure at the site with a dry sponge. Do not massage the site. If bleeding occurs, apply pressure with dry sterile gauze until it stops. Discard the uncapped needle and attached syringe into the proper receptacle. Remove gloves. Wash hands. Document all relevant information Include the time of administration, drug name, dose, route, and the clients reactions. Assess effectiveness of the medication at the time it is expected to act. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Administering Cardiopulmonary Resuscitation [CPR] CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 CPR: One Rescuer- Adult, Adolescent 1. Assess responsiveness by tapping or gently shaking client while shouting, Are you OK? 2. Activate emergency medical system (EMS): In clinical setting, follow institutional protocol. In community or home environment, activate local emergency response system. 3. Position client in a supine position on hard, flat surface. 4. Apply gloves or face shield, if available. 5. Position self. Face client on knees parallel to client, next to head, to begin to assess airway and breathing status. 6. Open airway. If head or neck injury suspected, use jaw thrust method. 7. Assess for respirations. Look, listen, and feel for air movement (3-5 seconds). 8. If respiration is absent: Occlude nostrils with thumb and index finger of hand on forehead that is tilling head back. Form a seal over the clients mouth using either your mouth or the appropriate respiratory assist device (e.g., Ambu (r) - Bag and mask) and give two full breaths of approximately 0.5-2 seconds, allowing time for both inspiration and expiration. In serious mouth or jaw injury that prevents mouth-to-mouth ventilation, uses mouth-to-nose ventilation 9. Assess for rises and fall of chest: If chest rises and falls, continue to Action 10. If chest does not move, assess for excessive oral secretions, vomit, airway obstruction, or improper positioning. 10. Palpate carotid pulse (5-10 seconds): If present, continue rescue breathing at rate of 12 breaths/min. If absent, begin external cardiac compressions. 11. Perform cardiac compressions as follows: Maintain position on knees parallel to sternum. Position hands for compressions. a. With hand nearest to legs, use index finger to locate lower rib margin and quickly move fingers up to location where ribs connect to sternum. b. Place middle finger of this hand on notch where ribs meet sternum and index finger next to it. c. Place heel of opposite hand next to index finger on sternum. d. Remove first hand from notch and place on top of hand that is on sternum so that they are on top of each other. e. Extend or interface fingers and do not allow them to touch chest. f. Keep arms straight with shoulders directly over hands on sternum and lock elbows. g. Compress adult chest 3.89 5.0 cm (1/2-2 inches) at the rate of approximately 100. h. Heel of hand must completely release pressure between compressions, but should remain in constant contact with clients skin. i. Use the mnemonic one and, two and three and to keep rhythm and timing. j. Ventilates client as described in Action 8.

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12. Maintain compression rate for approximately 100 times/min, interjecting 2 ventilations after every 15 compressions. (compression: ventilation rate 15:2). 13. Reassess client after 4 cycles. CPR: Two Rescuers Adult, Adolescent 14. Follow steps above, with the following changes: One rescuer is positioned facing client parallel to head while other rescuer is positioned on opposite side facing client parallel to sternum next to trunk. Rescuer positioned at clients trunk is responsible for performing cardiac compressions and maintaining verbal mnemonic count. This is rescuer 1. Rescuer 2 positioned at clients head is responsible for monitoring respirations, assessing carotid pulse, establishing an open airway, and performing rescue breathing. Maintain compression rate for approximately 100 times/min, interjecting 2 ventilations after every 15 compressions (15:2 ratio) Rescuer 2 palpates carotid pulse with each chest compression during first full minute. Rescuer 2 is responsible for calling for a change when fatigued, following this protocol. Rescuer 1 calls for a change and completes 15 chest compressions. Rescuer 2 administers 2 breaths and then moves to a position parallel to clients sternum and assumes proper hand position. Rescuer 1 moves to rescue breathing position and checks carotid pulse for 5 seconds. If cardiac arrest persists, rescuer 1 says, continue CPR and delivers one breath. Rescuer 2 resumes cardiac compressions immediately after breath. CPR: One Rescuer Child (1-7 years) 15. Assess responsiveness, activate emergency medical system, position isolation, position child, apply appropriate body substance isolation, position self, open airway, and assess for respirations as described in Action 1 -7. 16. If respirations are absent, begin rescue breathing: Give two slow breaths (1 1 sec/ breath), pausing to take a breath in between. Use only amount of air needed to make chest rise. 17. Palpate carotid pulse (5 10 seconds). If present, ventilate at a rate of once every 4 seconds or 15 times/min. If absent, begin cardiac compressions. 18. Cardiac compressions (child 1 7 years): Maintain positions on knees parallel to childs sternum Position hands for compressions. a. Locate lower margin of rib cage using hand closest to feet and find notch where ribs and sternum meet. b. Pace middle finger of this hand on notch and then place index finger next to middle finger. c. Place heel of other hand next to index finger of first hand on sternum with heel parallel to sternum (1 cm above the xiphoid process). d. Keeping elbows locked and shoulders over child, compress sternum 2.5 3.8 cm (1 -1 inches) at appropriate rate of 100 times/min. e. Keep other hand on childs forehead. f. At end of every fifth compression, administer a ventilation (1 1 seconds). g. Re evaluate child after 20 cycles. h. A 1 minute CPR should be performed for infants and children up to age 8 before calling 911. In institutions, follow hospital protocol. CPR: One Rescuer Infant ( 1 12 months ) 19. Assess responsiveness, activate emergency medical system, position child, apply appropriate body substance isolation, position self, open airway, and assess for respirations as described in Action 1- 7. 20. If respirations are absent, begin rescue breathing:

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Avoid overextension of infants neck. Place a small towel or diaper under infants shoulders or use a hand to support neck. Make a tight seal over both infants nose and mouth and gently administer artificial respirations. Give two slow breaths (1 1 1/2 sec/breath), pausing to take a breath in between. Use only amount of air needed to make chest rise. 21. Assess circulatory status using brachial pulse: Locate brachial pulse on inside of upper arm between elbow and shoulder by placing thumb on outside of arm and palpating proximal side of arm with index finger and middle fingers. If pulse is palpated, continue rescue breathing 20times/min or once every 3 seconds. If pulse is absent, begin cardiac compressions. 22. cardiac compressions ( infant 1 12 months: Maintain position parallel to infant. Place small towel or other support under infants shoulders and neck. Position hands for compressions: a. Using hand closest to infants feet, locate intermammary line where it intersects sternum b. Place index finger 1 cm blow this location on sternum and place middle finger next to index finger. c. Using these two fingers, compress in a downward motion 1.3-2.5 cm (1/2-1 inch) at rate 100 times/min. d. Keep other hand on infants forehead. e. At end of every fifth compression, administer a ventilation (1-1 seconds). f. Reevaluate infant after 20 cycles. g. A 1-minute CPR should be performed for infants and children up to age 8 before calling 911. CPR: Two Rescuers Child (1-7 years) and Infant (1-12 months) 23. Follow Action 14 for two rescuer CPR for adults with the following changes: Utilize child or infant procedure for chest compressions. Change ratio of compressions to ventilation to 5:1. Deliver ventilation on upstroke of third compression CPR Neonate or Premature Infant 24. Follow infant guidelines with the following changes for chest compressions: Encircle chest with both hands. Position thumbs over midstrenum. Compress 1.3-1.8 cm (1/2-3/4 inch) at rate of 100- 120 times/min. 25 . If properly trained, use an automated external defibrillator (AED). AED are not recommended for children under 8 years of age. In hospital setting, use defibrillator as specified by institution protocol. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: __________________________Date: _____________ Section/Group:________ IV Insertion CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Verify written order for IV therapy, check prepared IVF and other needed (procedure 1-Aset up) 2. Explain the procedure and observe 10Rs 3.Wash hands before and after the procedure 4. Choose site for IV 5. Apply tourniquet 5 to 12cm. (2-6in.)above the injection site depending on the patients condition 6. Check the radial pulse below tourniquet 7. Prepare the site with effective topical antiseptic according to hospital policy or cotton balls with alcohol in circular motion and allow 30 sec. to dry (no touch technique) NOTE: CDC Universal precaution :Always wear gloves when doing any venipuncture 8. Using the appropriate IV cannula, pierce skin with needle positioned on 15-30 degree angle 9. Upon flashback visualization decrease the angle, advance the catheter and the stylet (1/4 inch.) into the vein. 10. Position the IV Catheter parallel to the skin. Hold the stylet stationary and slowly advance the catheter, until the Hub nearly meets the puncture site (by 1 hand tech or 2 hand tech). (Never insert the catheter cannula until the hub for patient safety.) 11. Slip sterile gauze under the hub. Release the tourniquet, remove the stylet while applying digital pressure over the catheter with 1 finger about inch from the tip of the inserted catheter 12. Connect the infusion tubing of the IVF prepared in to the procedure 1A setting, as aseptically to the catheter. 13. Open the clamp, regulate the flow rate. 14. Anchor the needle firmly in place with the use of: a. Transparent tape/dressing directly on the puncture site. b. Tape (using any appropriate anchoring style) 15. Tape a small loop of IV tubing for additional anchoring apply splint (if needed) 16. Calibrate the IVF bottle and regulate flow of infusion according to prescribed duration 17. Label on the IV, tape near the IV site indicate the date of insertion, type and gauze of IV catheter and countersign. 18. Label with plaster on the IV tubing to indicate the date when to change the tubing 19. Observe and report untoward effect. 20. Document in the patients chart and endorse to incoming shift. 21. Discard sharps and waste according to MMDA Ordinance No.16 22. Dressing. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature:__________________Evaluators Signature: __________________ Comments:_____________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Preparing an IV Solution CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Check prescribing practitioners order. 2. Wash hands/hand hygiene. Apply gloves, if needed. 3. Prepare new bag by removing protective cover from bag. 4. Inspect bag for leaks, tears or cracks. Inspect fluid for clarity, particulate matter, and color. Check expiration date. 5. Prepare label for IV bag: On label, note date, time, and your initials. Attach label to bag. Keep in mind bag will be inverted when hanging. Make sure label can be read when IV is hanging. 6. Store prepared IV solution in are assigned by institution. 7. Remove gloves and dispose with all used materials. 8. Wash hands/hand hygiene. 9. Document procedure. Hanging the Prepared IV 10. Wash hands/hand hygiene. 11. Obtain IV solution for client. Check label on IV bag to ensure matches order. 12. Inspect bag for leaks, tears or cracks. Inspect fluid for clarity, particulate matter, and color. 13. Check clients identification bracelet. 14. Prepare IV time tape for IV bag: On time tape, note rate solution is to infuse. Mark approximate infusion intervals. Attach time tape to bag. Because bag is inverted, place time so can be read when IV is hanging. 15. Make sure clamp on tubing is closed. Grasp port IV bag with nondominant hand, remove plastic tab covering the port, and insert full length of spike into bags port. 16. Compress drip chamber to fill halfway. 17. Loosen protective cap from needle or end of IV tubing; open roller clamp and flush tubing with solution. 18. Close roller clamp and replace cap protector. 19. When ready to initiate infusion, remove cap protector from tubing. Attach IV tubing to venipuncture catheter. 20. Open clamp and regulate flow or, if applicable, attach tubing to infusion device or rate controller, if used. Turn on pump and set flow rate. 21. Wash hands/hand hygiene. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Preparing the IV bag and Tubing CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Check prescribing practitioners order for IV solution. 2. Wash hands/hand hygiene. 3. Check clients identification bracelet. Gather equipment. 4. Prepare new bag by removing protective cover. Check expiration date on bag and assess for cloudiness or leakage. 5. Open new infusion set. Unroll tubing and close roller clamp. 6. Spike bag with tip of new tubing and compress drip chamber to fill halfway. 7. Open roller clamp, remove protective cap from end of tubing, and slowly flush solution completely through tubing. 8. Close roller clamp and replace cap protector. 9. Apply clean gloves. 10. Remove old tubing and replace with new tubing: Place sterile 2x2 gauze under IV catheter or heparin lock. Stabilize hub of catheter or needle and gently pull out old tubing. Quickly insert new tubing into catheter hub or needle. Open roller clamp to establish flow of IV solution. Apply new dressing to IV site. 11. Discard old tubing and IV bag. 12. Remove gloves and dispose with all used materials. 13. Apply a label with date, time of change to tubing. Calculate IV drip rates and begin infusion at prescribed rate. 14. Wash hands/hand hygiene. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Assessing and Maintaining an IV insertion Site CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Review prescribing practitioners order. 2. Review clients history for medical conditions or allergies. 3. Review clients IV site record and intake and output record. 4. Wash hands/hand hygiene. 5. Assemble equipment and obtain clients vital signs. 6. Check IV fluid for correct, additives, rate and volume at beginning of shift. 7. Check IV tubing for tight connections every 4 hours. 8. Check gauze IV dressing hourly to be sure is dry and intact. 9. If gauze is not dry and intact, remove dressing and observe site for redness, swelling, or drainage. 10. If occlusive dressing used, do not remove dressing when assessing site. 11. Observe vein tract of redness, swelling, warmth, or pain hourly. 12. Document IV site findings in nursing record or flow sheet. 13. Wash hands/hand hygiene. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Changing the IV Solution CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Check prescribing practitioners order for the IV solution. 2. Wash hands/hand hygiene. Don clean gloves. 3. Check clients identification bracelet. 4. Prepare new bag with additives as ordered by prescribing practitioner. Prepare bag at least 1 hour before needed. Change solution when IV bag is empty but there is still solution in drip chamber. 5. Be sure drip chamber is at least half full. 6. Change IV solution: Move roller clamp to stop flow of fluid. Remove old IV bag from IV pole and hang new bag. Spike new bag with tubing. Reestablish flow rate. 7. Check for air in tubing. If air present, close roller clamp. While stretching tubing, flick tubing with finger and which bubbles rise to drip chamber. If large amount of air in tubing, insert needle with empty syringe into port below air and allow air to enter syringe as it flow to client. 8. Empty remaining fluid from old IV, if needed. 9. Remove gloves and disposes of all used materials. 10. Apply label with time, date, and type of solution. 11. Wash hands/hand hygiene. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Setting the IV Flow Rate CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Check prescribing practitioners order for IV solution and rate of infusion. 2. Wash hands/hand hygiene. 3. Check clients identification bracelet. 4. Prepare to set flow rate: Have paper and pencil ready to calculate flow rate. Review calibration in drops per milliliter of each infusion set. 5. Determine hourly rate by dividing total volume by total hours. 6. Make length of tape placed on IV bag with hourly time periods, according to rate. 7. Calculate minute rate based on drop factor of infusion set. 8. Set flow rate using appropriate device: For regular tubing without a device: Count drops in drip chamber for 1 minute while watching second hand of watch and adjusts the roller clamp, as necessary. For an infusion pump: Insert tubing into flow control chamber, select desired rate (generally calibrated in cc/min), open roller clamp, and push start button. For a controller: Place IV bag 36 inches above IV site, select desired drops/min, open roller clamp, and count drops for 1 minute to verify rate. For volume control device: Place device between IV bag and insertion spike of IV tubing, fill with 1-2 hours amount of IV fluid, and count drops for 1 minute. 9. Monitor infusion rates and IV site for infiltration. 10. Assess infusion when alarm sounds. 11. Wash hands/hand hygiene. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ The Bag Technique CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Contents of the OB Bag Paper Lining Extra Paper For Making Waste Bag Apron Hand Towel Soap In A Soap Dish Digital Thermometer Suction Bulb Medicine Tray Forceps(Curve And Straight) Disposable Syringe (1ml, 3ml, 5ml) Hypodermic Needle Sterile Dressing Cotton Balls Cord Clamp Micropore Plaster Babys Scale Tape Measure Pair Of Sterile Gloves Alcohol Lamp Test Tube Holder Test Tube Mask Bonnet Tourniquet Hot water bag Medicine dropper Kidney Basin Specimen bottle Medicine cup straight catheter Penlight cotton tip applicator Tongue depressor Pairs Of Scissors (Surgical And Bandage Scissor) Solutions: Betadine, Spirit Of Ammonia, Acetic Acid, 70% Alcohol, Hydrogen Peroxide, Benedicts Solution *stethoscope and sphygmomanometer carried separately Preparation Be guided with the purpose and principles of home visit. Check the completeness of the public health bag including its arrangements. Procedure 1.Upon arrival, place the bag on the table lined with a clean paper. The clean side must be out and the folded part, touching the table. 2. Ask for a basin of water or a glass of a drinking water if tap water is not available. 3. Open the bag and take out the towel and soap 4. Wash hands using soap and water. Wipe to dry. 5. Take out the apron from the bag and put it on with the right side out. 6. Put out all the necessary articles needed for the specific care. 7. Close the bag and put it in one corner of the working area. 8. Proceed in performing the necessary nursing care and treatment. 9. After giving the treatment, clean all things that were used and perform hand washing. 10. Open the bag and return all things that were used in their proper places after cleaning them. 11. Remove apron, folding it away from the person, the soiled side in and the clean side out. Place it in the bag. 12. Fold the lining, place it inside the bag and close the bag. 13. Take the record and have a talk with the mother. Write down all the necessary data that were gathered, observations, nursing care and treatment rendered. Give instructions for care of patients in the absence of the nurse. 14. Make appointment for the next visit (either home or clinic) taking note of the date and time

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For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed.

Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________ __________

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Name: _________________________________ Date: _____________ Section/Group:________ Benedicts Test CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Preparation Be guided with the purpose and principles of home visit. Check the completeness of the public health bag including its arrangements. Procedure Identify the patient and explain the procedure. Instruct the patient to collect urine sample. Place the bag on the table lined with a clean paper. The clean side must be out and the folded part, touching the table. Open the bag and take out the towel and soap Wash hands using soap and water. Wipe to dry. Take out the apron from the bag and put it on with the right side out. Put out all the necessary articles needed for the test. Close the bag and put it in one corner of the working area. Take 5 ml (one teaspoon) of Benedict's solution in the test-tube. Holding the test-tube with the holder, heat it over a spirit lamp till the Benedict's Solution boils without overflowing. Drop 8 to 10 drops of urine into the boiling Benedict's solution. After again boiling the mixture, let it cool down. While cooling, determine the changes in the mixture color and interpret. After the test, clean all things that were used and perform hand washing. Open the bag and return all things that were used in their proper places after cleaning them. Remove apron, folding it away from the person, the soiled side in and the clean side out. Place it in the bag. Fold the lining, place it inside the bag and close the bag. Take the record and have a talk with the client. Write down all the necessary data that were gathered, observations, care rendered. Give instructions for care of the client in the absence of the nurse. 14. Make appointment for the next visit (either home or clinic) taking note of the date and time. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed.

Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________ __________

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Name: _________________________________ Date: _____________ Section/Group:________ Acetic Acid Test CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Preparation Be guided with the purpose and principles of home visit. Check the completeness of the public health bag including its arrangements. Procedure Identify the patient and explain the procedure. Instruct the patient to collect urine sample. Place the bag on the table lined with a clean paper. The clean side must be out and the folded part, touching the table. Open the bag and take out the towel and soap Wash hands using soap and water. Wipe to dry. Take out the apron from the bag and put it on with the right side out. Put out all the necessary articles needed for the test. Close the bag and put it in one corner of the working area. Take 5 ml (one teaspoon) of urine from the specimen bottle and place it in a test tube. Holding the test-tube with the holder, heat it over a spirit lamp it boils without overflowing. Drop 5 drops at a time of acetic acid into the boiling urine. After again boiling the mixture, let it cool down. While cooling, determine the changes in the mixture color and interpret. After the test, clean all things that were used and perform hand washing. Open the bag and return all things that were used in their proper places after cleaning them. Remove apron, folding it away from the person, the soiled side in and the clean side out. Place it in the bag. Fold the lining, place it inside the bag and close the bag. Take the record and have a talk with the client. Write down all the necessary data that were gathered, observations, care rendered. Give instructions for care of the client in the absence of the nurse. Make appointment for the next visit (either home or clinic) taking note of the date and time. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed.

Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________ __________

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Name: ___________________________Date: _____________ Section/Group:________ Leopolds Maneuver CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0

1. Prepare the client a. Identify the patient and introduce self. b. Does the history taking and measures the fundic height. c. Explain the procedure. d. Instruct the patient to empty her bladder. e. Position the woman supine with knees slightly flexed. Place a pillow or rolled towel under the right side. f. Wash your hands using warm water. g. Observe the womans abdomen for longest diameter and where fetal movement is apparent. 2. Perform the first maneuver a. Stand at the foot of the patient , facing her, and place both hands flat on her abdomen. b. Palpate the superior surface of the fundus. Determine consistency, shape and mobility. 3. Perform the second maneuver. a. Face the client and place the palms of each hand on either side of the abdomen. b. Palpate the sides of the uterus while the right hand palpates the opposite side of the uterus from top to bottom. Then hold the right hand steady, and repeat palpation using the left hand on the left side. c. Determine where to assess the fetal heart rate. 4. Perform the third maneuver. a. Gently grasp the lower portion of the abdomen just above the symphysis pubis between the thumb and index finger and try to press the thumb and finger together. Determine any movement and whether the part is firm or soft. 5. Perform the fourth maneuver. a. Place fingers on both sides of the uterus approximately 2 inches above the inguinal ligaments, pressing downward and inward in the direction of the birth canal. Allow fingers to be carried downward. 6. Explains the result of the procedure to the patient. 7. Documentation and after care. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

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Name: ___________________________Date: _____________ Section/Group:________ Monitoring of Labor CHECKLIST Legend: 3-Very Satisfactory 2- Satisfactory 0- Did not perform the procedure 1- Needs Improvement PROCEDURES 1. Prepare the client a. Identify the patient and introduce self. b. Does the history taking and measures the fundic height. c. Explain the procedure. d. Instruct the patient to empty her bladder. e. Position the woman supine with knees slightly flexed. Place a pillow or rolled towel under the right side. f. Wash your hands using warm water. g. Observe the womans abdomen for longest diameter and where fetal movement is apparent. PROCEDURE 1. Locate and assess for the fetal heart rate. 2. Locate the fundus of the uterus and determine the ff: a. duration of contraction b. interval c. frequency d. strength 3. Document the result and monitor as appropriate depending on the stage of labor. 4. Put on sterile gloves. 5. Inform the patient to breath though the mouth as you do the internal examination of the vagina. 6.Insert laterally your middle and index fingers of your dominant hand. 7. Assess for cervical dilatation, effacement and fetal station. 8. Once the examination is done, inform the patient to relax and do the aftercare. 9. Explain the result of the procedure to the patient. 10. Properly document the result of the monitoring to the appropriate sheet. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ 3 2 1 0

Comments: _________________________________________________________________________ ______________________________________________________________________________ _____

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Name: __________________________Date: _____________ Section/Group:________ Fetal- Placental Delivery CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 1. Prepare the necessary things needed. 2. Position the patient. Use eye-to-eye contact and a calm, relaxed manner. If there is someone else available, such as the circulating nurse, that person could help support the woman in position, assist with coaching and compliment her on her efforts. 3. Wash hands and put on gloves. 4. As the head begins to crown, you should do the following: a. Instruct the woman to pant. b. Place a napkin or an OS into the perineum for support. c. Place the flat side of your hand on the exposed fetal head and apply gently pressure toward the vagina to prevent the head from popping out. 5. After the birth of the head, check for an umbilical cord. If the cord is around the babys neck, try to slip it over the babys head or pull it gently to get some slack so that you can slip it over the shoulders. 6. Support the head as restitution (external rotation) occurs. After restitution, with one hand on each side of the babys head, exert gentle pressure downward so that the anterior shoulder emerges under the symphysis pubis and acts as a fulcrum; then as gentle pressure is exerted on the opposite direction, the posterior shoulder, which has passed over the sacrum and coccyx, emerges. 7. Be alert! Do the Mauricius maneuver. (downward then up) 8. Cradle the babys head and back in one hand and the buttocks in the other. Keep the babys head down to drain secretions. 9. Dry the baby quickly to prevent rapid heat loss. 10. Place the baby on the mother abdomen, cover the baby. Clamp the cord and cut. (when the pulsations stopped) 11. Wait for the placenta to separate. Do the Brant-Andrews maneuver. 12. Check for the placental membranes for its completeness or any abnormality. Remind the circulating nurse to check the patients blood pressure and to give methergine. 13. Check the firmness of the uterus. 14. Check for any lacerations and bleeding. 15. DO the after care and put the mothers diaper. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed.

Evaluators Signature: __________________ Students signature: __________________ Comments: _________________________________________________________________________ ______________________________________________________________________________ _____

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Name: _________________________________ Date: _____________ Section/Group:________ Suturing CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Prepare the necessary things needed. Identify the patient and introduce self. Explain the procedure to the mother. Position to the mother in a lithotomy position. Perform hand washing. Don sterile gloves. Flush the perineum and apply antiseptic solution. Assess the extent of laceration. Suture the vaginal mucosa, one centimeter (1 cm) above the angle. Pull the thread not too tight, not too loose. Make an interrupted suture in the skin edges, from the fourchette to align vaginal opening properly. When the laceration has been closed, inspect suture areas for any dead space. Do vaginal/ rectal examination. Clean and disinfect the area. Put a sterile pad and do the after care. Place the mother in a comfortable position and continue monitoring the mother. Document the procedure. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________

Comments: _________________________________________________________________________ ______________________________________________________________________________ _____

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Name: ___________________________Date: _____________ Section/Group:________ Newborn Care CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 Prepare the necessary things needed. Introduce self. Gather data about the health history of the mother. Essential Newborn care begins during the 2nd stage of labor, when perineum is bulging, with presenting part visible, the nurse/midwife should do the following: a. Ensure that delivery area is draft-free and room temperature between 25-28 degree Celsius. b. Wash Hands with clean water and soap. c. Double glove just before delivery.* Deliver the baby in prone position on the mothers abdomen, face turned to the side. Call out the time of birth. Dry the newborn thoroughly. Check the babys breathing while drying. Remove wet cloth. Do APGAR Scoring. Place the newborn on the mothers abdomen in skin-to-skin contact. Cover the back with dry blanket. Do not suction unless moth/nose are obstructed with secretions or other material. Do not ventilate unless the baby is floppy and not breathing. Do not remove the vernix!!! Spread. Remove first set of gloves. Clamp and cut the cord when pulsations have stopped (after 1-3 minutes for term babies/ 30 sec to 1 minute for preterm. Place the newborn on the mothers chest in skin to skin contact. Cover the babys head with a hat. Cover the mother and baby with a warm cloth. Do not separate the baby from the mother for at least 90 minutes unless in respiratory distress or maternal emergency. Initiate breastfeeding while maintaining skin-to-skin contact. Place identification band on the ankle, Do eye care. Dress the baby. Postpone bathing until the newborn is more than 6 hours of age. After 90 minutes of age (after the baby is detached from the breast): a. Examine the baby. Get anthropometric measurements (HC,CC,AC,MAC,TC, length, weight). b. Get the footprints of the baby. c. Get the vital signs. d. Check anal patency.* e. Inject Vit K IM, Hep B vaccine IM and f. BCG ID at right deltoid Place the baby in bassinet and should be kept warm. Document the procedure and findings Put the baby into the mothers breast if stable. Room in. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature:__________________ Evaluators Signature: __________________ Comments: _________________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Administering a Cleansing Enema CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement Goal: To introduce solution into the large intestine to promote expulsion of feces. PROCEDURES 3 2 1 0 .1 Assemble necessary equipment. Warm the solution in amount ordered and check temperature with bath thermometer, if available. If tap water is used, adjust temperature as it flows from the tap. 2. Explain the procedure to the patient and plan where he or she will defecate. Have bedpan, commode, or nearby bathroom ready for his or her use. 3. Perform hand hygiene. 4. Add enema solution to container. Release clamp and allow fluid to progress through tube before reclamping. 5. Position waterproof pad under patient. 6. Provide privacy. Position and drape patient on the left side (Sims position) with anus exposed or on back, as dictated by patient comfort and condition. 7. Put on disposable gloves. 8. Elevate solution so it is 45 cm (18 inches) above level of patients anus. Plan to administer solution slowly over a period of 5-10 minutes. Container may be hung on IV pole or held in the nurses hands at the proper height. 9. Generously lubricate the last 5-7 cm (2-3 inches) of the rectal tube. A disposable enema set may have a prelubricated rectal tube. 10. Lift buttock to expose anus. Slowly and gently insert rectal tube 7-10 cm (3-4 inches). Direct it in an angle pointing toward the umbilicus. 11. If the tube meet resistance while inserting it, permit a small amount of solution to enter, withdraw tube slightly, then continue to insert it. Do not force tube entry. Ask pt to take several deep breaths. 12. Introduce solution slowly over a period of 5-10 minutes. Hold tubing all the time solution being instilled. 13. Clamp tubing or lower container if patient has the desire to defecate or cramping occurs. Patient also may be instructed to take small fast breaths or to pant. 14. After solution has been given, clamp tubing and remove tube. Have paper towel ready to receive tube as it is withdrawn. Have patient retain solution until the urge to defecate becomes strong, usually in about 5-15 minutes. 15. Remove disposable gloves from inside out and discard. 16. When patient has a strong urge to defecate, place him or her in sitting position on bedpan or assist to commode or bathroom. 17. Record character of the stool and patients response to the enema, Remind patient not to flush commode before nurse inspects results of enema. 18. Assist patient, if necessary with cleaning of anal area. Offer washcloth, soap, and water to wash his or her hands. 19. Leave patient clean and comfortable. Care for equipment properly. 20. Perform hand hygiene.
For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________Evaluators Signature: ________________

Comments:_____________________________________________________________________

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Name: _________________________________ Date: _____________ Section/Group:________ Measuring Blood Glucose Levels CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 0 1. Review orders, identify client, and review manufacturers instructions for meter usage. 2. Wash hands/hand hygiene. 3. Assemble equipment at bedside. 4. Have client wash hands with soap and water and position client comfortably in a semi Fowlers position or upright in a chair. 5. Remove a reagent strip from container and reseal container cap. Turn on meter. 6. Following manufactures instructions, calibrate meter, if needed. 7. Remove unused reagent strip from meter and place on a clean, dry surface(paper towel) with test pad facing up. 8. Apply disposable gloves. 9. Select appropriate puncture site and perform skin puncture. 10. Wipe away first drop of blood from site. 11. Gently squeeze site to produce a droplet of blood 12. Transfer drop of blood to reagent strip by carefully moving site over strip. 13. Quickly press meter timer according to manufactures instructions. 14. Apply pressure to puncture site. 15. According to manufactures instructions, wipe blood from test pad with a cotton ball; place a strip into meter. Allow timer to continue. 16. Read meter for results found on the unit display. 17. Turn off meter and properly dispose of the test strip, cotton ball, and lancet. 18. Remove disposable gloves and place them in appropriate receptacle. 19. Wash hands/hand hygiene. 20. Review test results with client. 21. Notify prescribing practitioner of test results. 22. Wash hands/hand hygiene. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Students signature: __________________ Evaluators Signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________

53 REFERENCES: Delaune, Sue C. et al, Skills Checklist to Accompany Fundamentals of Nursing Standards and Practice, 3rd edition,Thomson Learning Asia.2006 Kozier, Barbara et.al, techniques in Clinical Nursing , Basic to Intermediate Skills, 5th edition, Pearson Publishing Company.2003