PAMANTASAN NG LUNGSOD NG MAYNILA

COLLEGE OF NURSING

Medical- Surgical Nursing 1

SKILLS LABORATORY CHECKLIST

Procedure: DONNING STERILE GOWN

(for surgical procedure)

Reyes, Anna Sofia M. December 19, 2020

Name: _______________________________________ _Date:______________________________
BSN 3 - 2
Year Level and Block:_______________________ Clinical Instructor:________________
Rating scale:
3 Performed correctly, systematically according to standard with correct rationale.
2 Performed correctly, with correct rationale but not systematic.
1 Performed correctly, but not systematic and with inadequate rationale.

0 Performed incorrectly.
I.
Performance Remarks
Procedure Rationale
3 2 1 0
1. Do surgical scrubbing (surgical - To eliminate some of the
handwashing) prior to entering the controllable sources of
OR/ theater. contamination in the
performance of aseptic
procedures
2. Once at the OR, dry hands with - Ineffective hand drying results
sterile towel (following the steps sited wet hands are an infection risk
at the surgical handwashing checklist) increasing the potential for
cross-infection.
3. The circulating nurse standing at the - Circulating nurse must
opposite side of the table will assist maintained the principle of
the scrub nurse in opening the sterility by having contact with
wrapper of the sterile gown. unsterile surfaces only and by
distancing at least 1 foot from
- The circulating nurse should only the sterile field or to any sterile
be touching the folds of the personnel.
wrapper.
- After the wrap was opened the
circulating nurse moves back away
from the area, then the scrub
nurse approach the table.
Picking up the Gown
3. With one hand, pick up the entire - Maintains sterility of the gown
folded gown from the wrapper by and positions it for donning.
grasping the gown through all layers,
being careful to touch only the inside
top layer which is exposed.

2. Once your hands are securely - To avoid contaminating outer

pinching the gown. Hold the gown surface, ungloved hands can
near the gown's neck and only touch the exposed layer of
allow it to unfold. the gown.

3. Step back from the shelf and allow - Be careful and do not let the
the gown to drop. Make sure the gown touch anything unsterile
gown does not touch any surrounding as it drops.
 unsterile objects.
4. Grasp the inside shoulder seams
and open the gown with the armholes
facing you.
Inserting your arms into the sleeves of the gown
5. Carefully insert your arms part way
into the gown one at a time, keeping
hands at shoulder level away from the
body.
6. Slide the arms further into the gown - Shrug your arms into the
sleeves and when the fingertips are level
with the proximal edge of the cuff, grasp
the inside seam at the cuff hem using
thumb and index finger. Be careful that
no part of the hand protrudes from the
sleeve cuff.
Fastening the gown
7. A theatre assistant/ circulating nurse
will fasten the gown behind you,
positioning it over the shoulders by
grasping the inside surface of the gown
at the shoulder seam. The theatre
assistant’s hands should only ever be in
contact with the inside surface of the
gown.
8. The theatre assistant/ circulating
nurse then prepares to secure the gown
at the neck and upper back. Gowns
differ in how they are secured, but most
with have either ties, buttons or Velcro
tabs.
9. The circulating person then ties the
gown at waist level at the back.
Note: before the final tie of the gown the
scrub nurse must first perform the sterile
close gloving procedure.
Final tie of the gown
10. The scrub person will take hold of
the belt tab which is securing the belt
ties. Keeping hold of the left side tie with
the left hand pull the tab with the right-
hand ties still secured and hand the tab
to the circulating person.
Variation: in the absence of the belt tab,
the scrub nurse may use a sterile forceps
to hold the tip of the belt. The forceps
will then be handed to the circulating
nurse. The circulating nurse must only
hold on to the forceps, careful not to
touch any part of the tie.
11. The circulating person will take hold
- Proper identification of the
armholes provide a smooth and
easy access of inserting the gown.
- Keep hands inside the cuffs to
prevent contamination and a
preparation for closed gloving.
sleeves while keeping your
hands wrapped into the cuffs
until you get your gloves.
- Prevents any part of the gown
from touching a non-sterile
object provides complete
coverage of undergarments.
- This adheres to the sterile-
sterile,
unsterile-unsterile movements
and, to avoid contaminating
the front of the gown that is
already considered sterile.
- Gowns of the surgical team are
considered sterile in front from
the chest to the level of the
sterile field.
- Secure the closure of the gown
by assisting the circulating
nurse in handling the tab while
still preventing contact with
them.
- Circulating nurses should only
come contact with unsterile
items and areas. Contact with
unsterile surgical team could
contaminate gown and gloves.
Gown must enclose
undergarments.
- Unsterile personnel keep in
 of the tab/ forceps being very careful
not to touch the tie and will move to the
side or behind the scrub person. The
scrub person will then turn if necessary,
to enable them to reach and retrieve the
tie.
12. When the scrub person is properly
positioned they will then take hold of
the belt tie only being careful not to
touch the tab or forceps and pull on the
tie leaving the circulating person with
only the tab/ forceps in their hand The
circulating person must hold on tightly
to the tab/ or release clamp of the
forceps so that when the scrub person
pulls on the tie the tab/ forceps doesn't
come with it and contaminate them.
13. Finally the scrub practitioner will
secure the ties on left side.
Evaluated By:
________________________________
Signature over Printed Name
Clinical Instructor
References :
https://geekymedics.com/surgical-scrubbing-gowning-gloving-guide/
https://www.newcastle-hospitals.org.uk /Infection
%20Control/SurgicalScrubGownandGloveProceduresPolicy201706.pdf
contact with unsterile items
and areas and must be
knowledgeable on the
proximity to the sterile field and
personnel to avoid
contamination.
- Sterile OR personnel come in
direct contact with persons who
wears gowns and gloves only.
The
items that they will touch are the
sterile equipment. Any supply
brought by an unsterile staff
should transfer the item in a
sterile manner.
- Securing the ties properly
provides complete coverage of
undergarments from being
exposed.
ANNA SOFIA M. REYES
________________________________
Signature over Printed Name of Student