Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Villa Lucinda Campus, Brgy. Binauganan, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph
Performance Evaluation Checklist
HAND WASHING (HAND SCRUB)
Name of Student: _______________________________________
Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ___First Semester ____Second Semester ___ Summer
Inclusive Dates of Clinical Rotation: __________________
Instructor: _____________________________________________
Purposes:
1. To reduce the number of microorganisms on the hands.
2. To reduce the risk of transmission of microorganisms to clients.
3. To reduce the risk of cross contamination among clients.
4. To reduce the risk of transmission of infectious organisms to oneself.
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Assessment
Determine the client’s:
 Presence of factors increasing susceptibility to infection and
possibility of undiagnosed infection (e.g. HIV)
 Use of immunosuppressive medications
 Recent diagnostic procedures or treatments that penetrated the
skin or body cavity
 Current nutritional status
Planning
 The location of running water and soap or soap substitutes.
Assemble equipment:
 Soap
 Warm, running water
 Disposable or sanitized towels/paper towel
Implementation
Preparation:
Assess the hands.
 Nails should be kept short.
 Remove all jewelry.
 Check the hands for breaks in the skin, such as hangnails or cuts.
Performance:
If you are washing your hands where the client can observe you,
introduce yourself and explain to the client what you are going to do
and why it is necessary.
Turn on the water and be sure to adjust flow so that water is warm.
There are five common types of faucet controls:
 Hand-operated handles
 knee levers.
 foot pedals.
 Elbow controls. Move these with the elbows instead of the hands.
 Infrared control. motion in front of the sensor causes water to start
and stop flowing automatically.
Wet the hands and wrist thoroughly by holding them under the
running water.
Hold the hands lower than the elbows so that the water flows from
the arms to the fingertips.
SCORE
2 1 0
REMARKS
Apply soap to the hands. If the soap is liquid, apply 4–5 mL (1 tsp).
If it is bar soap, granules, or sheets, rub them firmly between the
hands.
9 Thoroughly wash and rinse hands.
Use firm rubbing and circular movements to wash the palm, back,
and wrist of each hand. Be sure to include the heel of the hand.
Interlace the fingers and thumbs, and move the hands back and
forth.
210 The WHO recommended these steps:
a. Right palm over left dorsum with interlaced fingers and vice
versa
b. Palm to palm with fingers interlaced.
c. Back of fingers to opposing palms with fingers interlocked
d. Rotational rubbing of left thumb clasped in right palm and vice
versa.
Continue this motion for at least 30 seconds.
11 Rub the fingertips against the palm of the opposite hand. Rinse
hands.
12 Thoroughly pat dry the hands and arms. Dry hands and arms
thoroughly with a paper towel or clean hand towel without
scrubbing.
13 Discard the paper towel in the appropriate container.
14 Turn off the water.
Use a new paper towel to grasp a hand-operated faucet.
8
Variation: Hand Washing Before Sterile Skills
15 Wet the scrub brush and apply a liberal amount of antimicrobial
soap into your hands and lather well to 2 inches above the elbow,
but hold the hands higher than the elbows during this hand wash.
Let water run from the fingertips to the elbows so that the hands
become cleaner than the elbows
16 Using a circular motion, scrub all the surfaces of one hand and arm.
Start at the fingers. Scrub at least 10 strokes each on nail, all sides
of fingers and both sides of hands. Scrub the arm using 10 strokes
each of the lower, middle, and upper areas of the forearm. Keep
arms higher than the elbows.
17
Rinse the surgical brush and reapply antimicrobial soap. Repeat the
scrub on the second hand and arm. Normally the scrub takes at
least 2-6 minutes.
18
After washing and rinsing, use a towel to dry one hand thoroughly in
a rotating motion from the fingers to the elbow. Use a new towel to
dry the other hand and arm.
Apply sterile gloves before touching any sterile items.
Evaluation
Ensure that both hands are clean and dry properly.
TOTAL
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20
Shown to me by:
________________________________
Signature over Printed Name
Clinical Instructor
Shown to me:
________________________________
Signature over Printed Name
Student
Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Villa Lucinda Campus, Brgy. Binauganan, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph
Performance Evaluation Checklist
DONNING AND REMOVING STERILE GLOVES (OPEN METHOD)
Name of Student: _______________________________________
Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ___First Semester ____Second Semester ___ Summer
Inclusive Dates of Clinical Rotation: __________________
Instructor: _____________________________________________
Purposes:
1. To enable to handle or touch sterile objects freely without contaminating them.
2. To prevent transmission of potentially infective organisms from the nurse’s hands to clients
at high risk for infection.
Assessment
1
 Review the client’s record and orders to determine exactly what
procedure will be performed that require sterile gloves.
 Check the client’s record and ask about latex allergies. Use nonlatex
gloves whenever possible.
Planning
 Think through the procedure. Plan which step need to be completed
before applying the gloves
 Determine what additional supplies needed for the procedures. Have
an extra pair of gloves available.
 Assemble equipment: Packages of sterile gloves
Implementation
Preparation:
3  Determine the correct size of the sterile gloves. The gloves should be
snug but not tight.
 Ensure sterility of the package of gloves.
Performance:
4
Prior to performing the procedure, introduce yourself and verify client’s
identity. Explain to the client what you are going to do and why it is
necessary and how the client can cooperate.
5
Perform hand hygiene and observe other appropriate infection control
procedures.
6
Provide for client’s privacy
7
Open the outer wrapper and place the inner glove package on a clean
dry surface.
8
Open the inner glove package so that the glove cuffs are closest to you
and carefully open the flaps of the package so that they do not fold back
over and contaminate the gloves.
9 Put the first glove on the dominant hand.
10 Grasp the inner surface of the glove for the dominant hand by lifting the
folded cuff edge with the thumb and first finger using the nondominant
hand.
11 Slide your dominant hand into the glove, keeping your hand and fingers
above your waist and away from your body.
2
SCORE
2
1
0
REMARKS
12 Put the second glove on the nondominant hand.
13 Pick up the other glove with the sterile gloved hand by inserting the
fingers under the cuff of the glove.
14 Lift the glove up and away from the table and away from your body.
15 Slide your nondominant hand into the glove, being careful to avoid
contact with your gloved hand.
16 Adjust both gloves to fit your fingers. If necessary, pull the fingers of the
gloves down so that no excess is at the finger tips.
17 Keep your hands between shoulder and waist level infront of you.
18 Remove and dispose used gloves. There is no special technique for
removing sterile gloves. If they are soiled with secretions, remove them
by turning them inside out. Perform hand hygiene.
19 Document that sterile technique was used in the performance of the
procedure.
Evaluation
20 Conduct any follow-up indicated during your care of the client. Ensure
that adequate numbers and types of sterile supplies are available for the
next health care provider.
TOTAL
Shown to me by:
________________________________
Signature over Printed Name
Clinical Instructor
Shown to me:
________________________________
Signature over Printed Name
Student
Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Villa Lucinda Campus, Brgy. Binauganan, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph
Performance Evaluation Checklist
DONNING A STERILE GOWN AND GLOVES (CLOSED METHOD)
Name of Student: ____________________________
Year/Clinical Group: __________________________
School Year: ____________________
Term: ___1st Semester __ 2nd Semester __ Summer
Inclusive Dates of Clinical Rotation: ______________
Instructor: __________________________________
Purposes:
1. To enable to work close to the sterile field and handle sterile objects freely.
2. To protect client’s from becoming contaminated with microorganisms on the nurse’s hands,
arms and clothing.
Assessment
1
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12
 Review the client’s record and orders to determine exactly what
procedure will be performed that require sterile gloves.
 Check the client’s record and ask about latex allergies. Use
nonlatex gloves whenever possible.
Planning
 Think through the procedure. Plan which step need to be
completed before applying the gloves
 Determine what additional supplies needed for the procedures.
Always have an extra pair of gloves available.
 Assemble equipment:
Sterile pack containing a sterile gown and Sterile gloves
Implementation
Preparation:
Ensure the sterility of the gown and package of gloves.
Performance:
Prior to performing the procedure, introduce yourself and verify
client’s identity. Explain to the client what you are going to do and
why it is necessary and how the client can cooperate.
Perform hand hygiene and observe other appropriate infection
control procedures.
Provide for client’s privacy
Applying a Sterile Gown
Open the package of sterile gloves. Remove the outer wrap from
the sterile gloves and leave the gloves in their inner sterile wrap
on the sterile field.
Unwrap the sterile gown pack.
Perform proper hand hygiene.
Put on the sterile gown.
Grasp the sterile gown at the crease near the neck, hold it away
from you, and permit it to unfold freely without touching anything,
including the uniform.
Put the hands inside the shoulders of the gown, and work the
arms partway into the sleeves without touching the outside of the
gown.
Keep the sleeves of the gown above waist level
SCORE
2 1 0
REMARKS
13
Work the hands down the sleeves only to the proximal edge of the
cuffs;
14 Have a coworker grasp the neck ties without touching the outside
of the gown and pull the gown upward to cover the neckline of
your uniform in front and back. The coworker ties the neck ties.
Donning Sterile Gloves (Closed Method)
15 Open the sterile wrapper containing the sterile gloves.
16 Open the sterile glove wrapper while the hands are still covered by
the sleeves.
17 Put the glove on the nondominant hand.
18 With the dominant hand, pick up the opposite glove with the thumb
and index finger, handling it through the sleeve.
19 Lay the glove on the opposite gown cuff, thumb side down, with
the glove opening pointed toward the fingers. Position the
dominant hand palm upward inside the sleeve.
20 Use the nondominant hand to grasp the cuff of the glove through
the gown cuff, and firmly anchor it.
21 With the dominant hand working through its sleeve, grasp the
upper side of the glove’s cuff, and stretch it over the cuff of the
gown.
22 Pull the sleeve up to draw the cuff over the wrist as you extend the
fingers of the nondominant hand into the glove’s fingers.
23 Put the glove on the dominant hand.
24 Place the fingers of the gloved hand under the cuff of the
remaining glove. Place the glove over the cuff of the second
sleeve.
25 Extend the fingers into the glove as you pull the glove up over the
cuff.
Completion of Gowning
26 Have a coworker hold the waist tie of your gown, using sterile
gloves or a sterile forceps or drape. Have a coworker take the two
ties at each side of the gown and tie them at the back of the gown,
making sure that your uniform is completely covered.
27 When worn, sterile gowns should be considered sterile in front
from the waist to the shoulder. The sleeves should be considered
sterile from 2 inches above the elbow to the cuff, since the arms of
a scrubbed person must move across a sterile field.
28 There is no special technique for removing sterile attire. If they are
soiled, remove them by turning them inside out.
29 If appropriate, document that sterile technique was used in the
performance of the procedure.
Evaluation
30 Conduct any follow-up indicated during your care of the client.
Ensure that adequate numbers and types of sterile supplies are
available for the next health care provider.
TOTAL
Shown to me by:
________________________________
Signature over Printed Name
Clinical Instructor
Shown to me:
________________________________
Signature over Printed Name
Student