KOLEHIYO NG LUNGSOD NG DASMARINAS
BRGY. BUROL MAIN, CITY OF DASMARIÑAS,
CAVITE, PHILIPPINES 4114
INSTITUTE OF NURSING
PERFORMANCE CHECKLIST
SURGICAL HANDSCRUBBING, GOWNING, GLOVING
Name: _______________________________
Yr/Sec: _________
Rating: _________
HANDSCRUBBING
A. TIME METHOD
CRITERIA
Performed
Not
Performed
Remarks
1.
2.
3.
Wet hands and forearms.
Apply antiseptic from dispenser to the hands
Wash hands and arms thoroughly to 2-3 inches
above elbow.
4. Rinse thoroughly under running water with hands
held higher than elbows.
5. Clean fingernails with a nail cleaner under running
water.
6. Take a sterile brush and apply ample amount of
antiseptic.
7. Scrub one hand for one (1) minute, starting from
the fingernails, all sides of finger (from the thumb
to the little finger), back of hand and palm of
hands.
8. Scrub one hand for one (1) minute (back, front and
sides) and 2-3 inches above the elbow for ½
minute.
9. Rinse thoroughly under running water with hands
held higher than the elbows.
10. Scrub the other hands and arms using the same
time, manner and anatomical pattern of scrubbing,
then, rinse as before.
11. Rescrub hands and arms, one minute for each part,
excluding the elbow, using the same manner and
pattern of scrubbing.
12. Rescrub both hands and arms, ½ minute for each
hand, using the same manner and pattern of
scrubbing.
13. Rinse thoroughly under running water, keeping the
hands higher than the elbows.
14. Rinse brush and discard it properly.
Total _____________
B. STROKE METHOD
CRITERIA
Performed
Not
Performed
Remarks
1.
2.
3.
Wet hands and forearms.
Apply antiseptic from dispenser to the hands
Wash hands and arms thoroughly to 2-3 inches
above elbow.
4. Rinse thoroughly under running water with hands
held higher than elbows.
5. Clean fingernails with a nail cleaner under running
water.
6. Take a sterile brush and apply ample amount of
antiseptic.
7. Scrub one hand with prescribed manner of strokes
• Fingernails – 30 strokes
• All sides of the finger (dorsal, ventral, lateral,
medial) – 20 strokes or 5 strokes side
• Back of the hand – 20 strokes
• Palm of the hand – 20 strokes
8. Scrub one arm with prescribed number of strokes:
• Each third of the arm (back, front, and sides) –
20 strokes
• 2 – 3 inches above the elbow – 6 strokes
9. Rinse thoroughly under running water with hands
held higher than the elbows.
10. Scrub the other hands and arms using the same
time, manner and anatomical pattern of scrubbing,
then, rinse as before.
11. Rescrub hands and arms with prescribed number of
strokes:
• Nails – 20 strokes
• Sides of finger – 10 strokes
• Back of the hand – 10 strokes
• Palm of the hand – 10 strokes
• Each third of the arm – 10 strokes
• Elbow - 3 strokes
- Using the same manner, then rinse as before
12. Rescrub both hands with prescribed number of
strokes, using the same manner:
• Nails – 10 strokes
• Sides of the finger – 5 strokes
• Back of the hand – 5 strokes
• Palm of the hand – 5 strokes
13. Rinse thoroughly under running water, keeping the
hands higher than the elbows.
14. Rinse brush and discard it properly.
Total _____________
GOWNING
1.
2.
3.
4.
5.
6.
7.
CRITERIA
Pick up the grown directly upward.
Step back away from the table.
Hold the folded gown in the opposite hand
and dry one hand on the bottom part of the
gown using an oscillating motion (starting
from fingers, hands and arms).
Dry the other hand and arm on the unused
area of the bottom part of the gown using
the same technique.
Locate the neckband and hold it at shoulder
level, then allow it to unfold keeping the
inside front of the gown towards the body.
Slip both arms into the armholes
simultaneously, either leaving hands inside
the sleeves (for open gloving).
Keep hands and arms between shoulder and
waist level as the circulating nurse pull the
inside shoulder and arm seams and tie it
securely at the neck and waist.
Performed
Not Performed
Remarks
TOTAL __________
CLOSE GLOVED TECHNIQUE
CRITERIA
1.
2.
3.
4.
5.
6.
7.
8.
Performed
Not
Performed
Remarks
Extend the right forearm with palm.
Place the palm of the right glove against the palm
of the right hand and hold it on the top edge of the
folded cuff to secure it.
Unfold the cuff by grasping the back of the cuff
and turning it over the end of the sleeves.
Pull the gloved hand over the extended fingers until
the cuff and sleeves is completely covered
Using the gloved hand, pick up the left glove by
inserting the fingers under the folded cuff and place
the palm against the palm of the left hand.
Grasp the back of the folded cuff and full it over
the left sleeve.
Fix by putting the sleeves up, and the tip of the
gloved fingers towards the hand, then keep the
hands away from the face and waist level,
After donning wipe gloves with wet sponge to
remove excess powder.
TOTAL: _______________
OPEN GLOVED TECHNIQUE
CRITERIA
1.
2.
3.
4.
5.
6.
Performed
Not
Performed
Remarks
Under the left hand, pick up the right glove by
grasping the folded cuff.
Insert right hand into the glove and pull it on by
holding the top edge of the folded cuff leaving it
turned well done over the hand.
Slip the fingers above of the gloved hand under the
folded cuff of the left glove.
Insert hand into the glove and then, pull it and turn
it over the hand.
With the fingers of the gloved right hand, pull the
cuff of the left glove over the sleeve.
• If the sleeve is loose, fold a pleat as you
release the cuff of the glove over the sleeve.
Fix by pulling the sleeves up, and the tip of the
gloved fingers towards the hand, then keep hands
away from the face and waist level
• After donning, wipe gloves with wet sponge to
remove excess powder.
TOTAL: _______________
ASSISTING IN GOWNING AND GLOVING ANOTHER PERSON
A. GOWNING ANOTHER PERSON
CRITERIA
1.
2.
3.
4.
5.
6.
Performed
Not
Performed
Remarks
Pick up a hand towel and unfold it, leaving the
upper part folded and facing the scrub nurse as
he/she offers it.
Pick up the gown and hold the bottom part and
offer it to the surgeon to dry his/her hands and
arms.
Hold the neck band and allow the gown to unfold.
Keep hands on the sterile part of the gown
Under the shoulder areas.
Offer the inside front of the gown as the surgeon
slip his/her arms into the armhole.
Release the gown carefully, avoiding the gloved
hand to come in contact with unsterile area (face
and neck)
TOTAL: _______________
B. GLOVING ANOTHER PERSON
CRITERIA
1.
2.
3.
4.
5.
Performed
Not
Performed
Remarks
Pick up right glove by grasping firmly with finger
under the folded cuff of the glove.
Hold it with the palm towards the person.
Stretch the cuff sufficiently, with your thumb out as
the person insert his/her hand.
Exert upward pressure as the person insert his/her
hand into the glove and unfold it over the sleeve,
then, release.
Glove the left hand in same manner/technique.
TOTAL: _______________
SCORING:
2 – Performed Correctly
1 – Performed Improperly
0 - Not Performed
_____________________________________
Student’s Signature over Printed Name
___________________________________
C.I.’s Signature over Printed Name