College of Nursing - Clinical Nursing Skills Checklist

College of Nursing | Clinical Nursing Skills Checklist 1
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Foreword
This edition of the Clinical Nursing Skills Checklists contains the well-selected
nursing procedures that the students need to be familiar with in preparation for the actual
clinical and community nursing practice. These nursing procedures can be the students’
springboard to gain knowledge, to develop right attitude in the care of patients and to hone
their nursing skills, a Licean Student Nurse should possess. Thus, these skills checklists will
prepare the students to be both technically proficient and personally caring.
The skills checklists follow each step of the skill to provide a complete evaluative
tool. Students can use the checklists to facilitate self-evaluation, and faculty will find them
useful in measuring and recording student performance. The checklists are designed to record
an evaluation of each step of the skill.
The Authors

Nursing Procedures Performance Rating Scale
Criteria: (One point each)
1. States the step correctly. Able to express oneself confidently.
2. Demonstrates the step accurately. Very organized and with outstanding effort.
3. States the rationale correctly with scientific basis.
4. Basic nursing considerations are observed.
5. Displays confidence and compassion when performing the step.
5 Excellent All criteria are met.

4 Above Average 4 out of 5 criteria are met.
3 Average 3 out of 5 criteria are met.
2 Below Average 2 out of 5 criteria are met.
1 Poor Only 1 criterion is met.
TABLE OF CONTENTS
ANTEPARTAL EXERCISE 5 ASSESSING PERIPHERAL PULSE 11
ASSESSMENT OF APICAL PULSE 7 ASSESSING BLOOD PRESSURE 12
ASSISTING IV INFUSION 8 ASSESSING BODY TEMPERATURE 14
ASSESSING RESPIRATIONS 10 APPLICATION OF ABDOMINAL

BINDER 16 LUMBAR PUNCTURE 66
ASSISTING ENDOTRACHEAL MAKING OF HOMEMADE SALT

TUBE INSERTION 17 AND SUGAR SOLUTION 68
ADMINISTERING OXYGEN 19 MEASURING INTAKE AND OUTPUT 69
ASSISTING PHYSICIAN IN NGT MEDICAL HANDWASHING 70

INSERTION/GAVAGE 21
MORNING CARE 71
OCCUPIED BED 73
BREAST CARE 23
OFFERING AND REMOVING A
BASIC PERINEAL CARE 24 BEDPAN AND URINAL 75
BASIC CLEANING PROCEDURE 26 OPEN BED 77
BAG TECHNIQUE 29 OPEN GLOVING 79
BLOOD TRANSFUSION 30 PER OREM MEDICATION 80
BANDAGING 31 PHYSICAL ASSESSMENT 82
CARDIO PULMONARY RESUSCITATION 33 POSITIONING AND DRAPING

THE PATIENT 99
CARING FOR CLIENT ON ISOLATION 35 POST MASTECTOMY EXERCISES 101
CATHETERIZATION 37 POST MORTEM CARE 103
CENTRAL VENOUS PRESSURE READING 39 POSTPARTUM EXERCISE 105
CHECKING BLOOD GLUCOSE 40 PREPARATION OF AKAPULKO

OITMENT
CLEANSING BED BATH 41 106
SUPPOSITORY INSERTION ANAL

CLOSED BED 43
/VAGINAL 107
CONDUCT OF NORMAL LABOR 45 SPECIAL MOUTH CARE 108
CRUTCH WALKING 47 SELF-BREAST EXAMINATION 109
EAR IRRIGATION 49 SHAMPOO ON BED 111
ESSENTIAL INTRAPARTUM AND TAKING ELECTROCARGIOGRAM 112

NEWBORN CARE 51
TEPID SPONGE BATH 113
ESTIMATING GESTATIONAL AGE 54
TESTICULAR EXAMINATION 114
EYE DROP INSTILLATION/ EYE
TRACHEOSTOMY CARE 115
OINTMENT APPLICATION 55
USING PULSE OXIMETER 117
FBS AND INSULIN ADMINISTRATION 56 USER AUTONOMY CHECKLIST FOR
THE MUCUS METHOD 119
GLASGOW COMA SCALE 58
HOME VISIT 59 URINALYSIS 120
HOT WATER BAG APPLICATION 60 WOUND DRESSING 121
ICE CAP / ICE BAG APPLICATION 61 SPUTUM COLLECTION\ANDSMEARING 126
INTRADERMAL/INTRAMUSCULAR 62
OPERATING ROOM PROCEDURES:
INTRAMUSCULAR INJECTION 63
DONNING STERILE GOWN AND 122
INTRADERMAL INJECTION 64 CLOSED GLOVING
SURGICAL HAND ANTISEPSIS 124

LEOPOLD’S MANEUVER 65
Name of Student: _________________________________________________________
ANTEPARTAL EXERCISE

Retur 1 2 PE
STEPS n
Demo
1. Pelvic tilting or pelvic rocking relieves backache during
pregnancy and strengthens back and abdominal muscle.
Standing- Buttocks are tucked and flattened out the bottom
of the lower back. Hold for 3 seconds then relax allowing
hips to move to former position.
While down on hands and knees, arch back and drop
abdominal wall forward.
Lie supine without pillow on head, arch lower back upward
so that abdomen rises, then relax and repeat.
2. Knee-chest Twist
Lying on back, knees are pulled to the chest and arms
stretched straight to the side. Knees are rolled to one side
while the head is turned to the opposite side. Sides are
rotated and switched.
3. Leg Raising
Alternate raising of the legs while lying on the floor,
without bending the knees. This strengthens the abdominal
muscles and improves tone.
4. Tailor Sitting
Sitting on the floor with one foot in front of the other,
tucked inward towards the perineum and press the knees
with hands downward toward the floor.
5. Rib-cage Lifting
Tailor sitting position to help muscles of the thigh, hips and
lower back. Inhale while extending the right arm with
elbows slightly flexed above the head with arms extended.
Exhale. Inhale again and return to starting position.
6. Shoulder Circling
Either standing or sitting, keep back, head and neck straight
throughout the exercise and allow arms to hang loosely in
the side. Slowly rotate the shoulder up and back in circular
motion. Inhale as shoulder is rotated and exhale as the
circle is completed.
7. Knee-Bending
Deep knee-bend using a chair for stabilization. With feet
slightly apart, inhale when bending. Exhale when standing.
8. Calf Stretching
Stand with feet slightly apart. Hands at the back of the chair
for support. Inhale and slide foot or right leg sideward as
far as possible without letting the heel leave the floor. Bend
knee of the other leg, return to first position. Exhale and
relax.
9. Ability to answer questions:
A.
B.

Total Score
Equivalent Grade
Final Grade
Signature of C.I.
Signature of Student

Name of Student: _______________________________________________________
ASSESSMENT OF APICAL PULSE
Steps Ret 1 2 3 PE
Dem
1. Wash your hands.
2. Prepare the equipment.
3. Identify the patient and explain the procedure.
4. Provide Privacy.
5. Clean the earpieces and diaphragm of the stethoscope with cotton
balls soaked with alcohol.
6. Position the client in a comfortable position (supine or sitting
position).
7. Warm the diaphragm with your hands. Expose the area of the chest
over the apex of the heart.
8. Locate the site, on the left mid-clavicular line in between the 5 th and
6th ICS and place the diaphragm correctly.
9. Auscultate and count heartbeats and assess any observable
characteristics for full minute.
10. Record the pulse rate.
11. Replace patient’s clothing and fix the top linen.
12. Make patient comfortable.
13. Wash your hand.
14. Ability to answer questions.
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of C.I.

Name of Student: ___________________________________________________________
ASSISTING IN IV INFUSION
STEPS Return 1 2 3 PE
Demo
1. Check the doctor’s order.
2. Explain the procedure to the patient.
3. Gather all equipment. Wash your hands.
4. Inspect the solution on the following: kind/type, volume,
and clearness and expiration date.
5. Open the vacodrip set. Follow the instruction accompanying
the set.
6. Prepare the prescribed bottle of the solution accompanying
the instructions.
7. Open the regulator and let a little amount of fluid run
through the tube. Be sure that no air present in the tube.
8. Carry the needed equipment to the bedside.
9. Hang IV bottle/pack to the IV stand. Prepare the strips of
plaster.
10. Un-sleeve the arm involved.
11. Place the padded arm board or splint, and tourniquet under
arm.
12. Open the tray.
13. The doctor applies the tourniquet. Offer the cotton ball with
alcohol to the doctor. Instruct the patient to make a fist.
14. Remove the cover of the IV catheter and offer the needle to
the doctor (the doctor inserts the needle). Once back-flow of
blood is present, release and removethe tourniquet and open
the regulator.
15. Offer the plaster to the doctor and assist in anchoring.
16. Adjust the arm board or splint, bandages, and anchor
securely.
17. Regulate the flow of the solution as ordered.
18. Instruct the patient or watcher to call when there is a change
in the rate of flow when the solution stops flowing, when
the site is painful and bulging, when the solution is almost
consumed and when there is air or blood in the tubing.
19. Leave the patient in a comfortable position.
20. Carry the tray to the utility room. Wash your hands.
21. (When venoclysis is out) Clamp the tubing when the bottle
is almost empty.
22. Remove the adhesive tape.
23. Apply the pressure using Zephiran pledget or cotton ball
with alcohol over point of insertion ad withdraw the needle
quickly.
24. Dry the area with cotton ball and apply the adhesive tape.
25. Leave the patient comfortable and tidy the unit.
26. Bring the vacoliter with tubing to the utility room and put it
to its proper place.
27. Chart: date, time, solution used, bottle/pack number,
amount, rate per minute, site, and the doctor who inserted
the needle. In numbering bottles/packs used, ascertain
whether the number is for the whole series or one-day
series. Record the unusual reaction of the patient to the
treatment, if there is any.
28. Ability to Answer Questions:
A.
B.
Total Score:
Equivalent Grade
with patient
Final Grade
Signature of CI

Name of Student ___________________________________________________________
ASSESSING RESPIRATIONS
STEPS Return 1 2 PE
Demo
1. Introduce self, identify the patient and explain the
procedure.
2. Wash hands before starting the procedure.
3. Provide for client privacy.
4. Observe or palpate and count the respiratory rate.
 The client’s awareness that the nurse is counting the
respiratory rate could cause the client to alter the
respiratory pattern. If you anticipate this, place a hand
against the client’s chest to feel the chest movements
with breathing, or place the client’s arm across the
chest and observe the chest movements while
supposedly taking the radial pulse.
 Count the respiratory rate for one full minute. An
inhalation and an exhalation count as one respiration.
5. Observe the depth, rhythm, and character of respirations.
 Observe the respirations for depth by watching the
movement of the chest.
 Observe the respirations for regular or irregular
rhythm.
 Observe the character of respirations – the sound they
produce and the effort they require.
6. Make the patient feel comfortable and wash your hands.
7. Document the respiratory rate on the client’s record.
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of C.I.
Signature

Name of Student ___________________________________________________________
ASSESSING PERIPHERAL PULSE
STEPS Return 1 2 PE
Demo
1. Introduce self, identify the patient and explain the procedure.
2. Wash hands.
4. Select the pulse point. Normally, the radial pulse is taken unless
it cannot be exposed or circulation to another body area is to be
assessed.
5. Assist the client to a comfortable resting position. When the
radial pulse is assessed, with the palm facing downward, the
client’s arm can rest alongside the body or the forearm can rest
at a 90-degree angle across the chest. For the clients who can sit,
the forearm can rest across the thigh, with the palm of the hand
facing downward or inward.
6. Palpate and count the pulse. Place two or three middle
fingertips lightly and squarely over the pulse point. Count for
one full minute.
7. Assess the pulse rhythm and volume.
 Assess the pulse rhythm by noting the pattern of the intervals
between the beats. Normally, it has equal time periods
between beats.
 Assess the pulse volume. A normal pulse can be felt with
moderate pressure, and the pressure is equal with each beat.
A forceful pulse volume is full; an easily obliterated pulse is
weak. Record the rhythm and volume on your worksheet.
8. Make the patient comfortable and wash your hands.
9. Document the pulse rate, rhythm, and volume in the client
record.
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of C.I.
Signature

Name of Student ___________________________________________________________
ASSESSING BLOOD PRESSURE
STEPS Return 1 2 PE
Demo
1. Introduce self, identify the patient and explain the procedure.
2. Wash hands.
4. Position the client appropriately.
 The adult client should be sitting unless otherwise specified.
Both feet should be flat on the floor.
 The elbow should be slightly flexed with the palm of the
hand facing up and the forearm supported at heart level.
 Expose the upper arm.
5. Wrap the deflated cuff evenly around the upper arm. Locate the
brachial artery. Apply the center of the bladder directly over the
artery.
 For an adult, place the lower border of the cuff
approximately 2.5cm (1 in.) above the antecubital space.
6. If this is the client’s initial examination, perform a preliminary
determination of systolic pressure.
 Palpate the brachial artery with the fingertips.
 Close the valve on the bulb.
 Pump up the cuff until you no longer feel the brachial pulse.
Note the pressure on the sphygmomanometer at which pulse
in no longer felt.
 Release the pressure completely in the cuff, and wait 1 to 2
minutes before making further measurements.
7. Position the stethoscope appropriately.
 Cleanse the earpieces with antiseptic wipe.
 Insert the ear attachments of the stethoscope in your ears so
that they tilt slightly forward.
 Ensure that the stethoscope hangs freely from the ears to the
diaphragm.
 Place the bell side of the amplifier of the stethoscope over
the brachial pulse site.
 Place the stethoscope on the skin, not on clothing over the
site.
 Hold the diaphragm with the thumb and index finger.
8. Auscultate the client’s blood pressure.
 Pump up the cuff until the sphygmomanometer reads 30
mmHg above the point where the brachial pulse
disappeared.
 Release the valve on the cuff carefully so that the pressure
decreases at the rate of 2 to 3 mmHg per second.
 As the pressure falls, identify the manometer reading at
Korotkoff phases.
 Deflate the cuff rapidly and completely.

 Wait 1 to 2 minutes before making further determinations.
 Repeat the above steps to confirm the accuracy of the
reading.
9. If this is the client’s initial examination repeat the procedure on

the client’s other arm.
10. Make the patient feel comfortable.
11. Clean the earpieces of the stethoscope.
12. Do the aftercare of the equipment and wash your hands.
13. Document the BP reading on the client’s record.
14. Ability to answer questions
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of C.I.

Name of Student ___________________________________________________________
ASSESSING BODY TEMPERATURE
STEPS Return 1 2 PE
Demo
1. Check that the equipment is functioning normally.
2. Introduce self, identify the patient and explain the
procedure.
3. Wash hands before starting the procedure. Don gloves if
performing a rectal temperature.
5. Place the client in the appropriate position. (Sitting or
supine position for oral and axillary, Sim’s or lateral
position for inserting a rectal thermometer).
6. Place the thermometer.
a. Oral – Place the bulb on either side of the frenulum.
b. Rectal – apply clean gloves. Instruct the client to take a
slow deep breath during insertion. Never force the
thermometer if resistance is felt, insert 3.5 cm (1 ½ in
adults)
c. Axillary – pat the axilla dry if very moist. The bulb is
placed in the center of the axilla.
d. Tympanic – pull the pinna slightly upward and
backward for adults. Point the probe slightly anteriorly,
toward the eardrum. Insert the probe slowly using a
circular motion until snug.
e. Temporal artery – brush hair aside if covering the TA
area. With the probe flush on the center of the forehead,
depress the red button. Keep depressed. Slowly slide the
probe midline across the forehead to the hair line, not
down the side of the face. Lift the probe from the
forehead and touch on the neck just behind the earlobe.
Release the button.
 Apply a protective sheath or probe cover if appropriate.
 Lubricate a rectal thermometer.
7. Wait for the appropriate amount of time. Electronic and
tympanic thermometers will indicate that reading is
complete through a light or tone.
8. Remove the thermometer and discard the cover or wipe
with a tissue if necessary.
9. Read the temperature and record it on your worksheet.
10. Wash the thermometer if necessary and return it to the
proper place.
11. Document the temperature in the client record.
A.
B.
Total Score
Equivalent Grade

Final Grade
Signature of C.I.

Name of Student_____________________________________________________________
APPLICATION OF ABDOMINAL BINDER
STEPS Return 1 2 PE
Demo
2. Prepare equipment and bring to bedside.
3. Wash hands. Lower patient if on backrest.
4. Expose the abdomen. Centralize the binder under the
lumbar area.
5. Adjust sides of binder evenly and determine general fitness
by inserting two fingers.
6. Place pins horizontally at the sides or more pins for perfect-
fitting
7. Adjust gown. Make patient comfortable.
8. Chart.
A.
B.
TOTAL SCORE
EQUIVALENT GRADE
 With patient
FINAL GRADE
SIGNATURE OF C.I.
SIGNATURE OF STUDENT

Name ___________________________________________________________________
ASSISTING ENDOTRACHEAL TUBE INSERTION
STEPS Return 1 2 PE
Demo
Assessment: 1. Monitor the patient’s heart rate, level of
consciousness and respiratory status.
Planning/Implementation:
1. Prepare equipment
a. Ensure function of resuscitation bag with mask, and
suction.
b. Assemble the laryngoscope-make sure the light bulb is
tightly attached and functional.
c. Select an endotracheal tube of appropriate size.
d. Place the endotracheal tube on sterile towel.
e. Inflate the cuff to make sure it assumes a symmetrical
shape and holds volume without leakage. Then deflate
maximally.
f. Lubricate the distal end of the tube liberally with a
sterile anesthetic water-soluble jelly.
g. Insert the stylet into the tube.
2. Remove the patient’s dental bridgework and plates.
3. Remove headboard of bed, if applicable.
4. Aspirate stomach contents if nasogastric tube is in place.
5. If time allows, inform the patient of impending inability to
talk and discuss alternate means of communication.
6. If patient is confused, it may be necessary to apply soft
wrist restraints.
7. Put on goggles and gloves.
8. If cervical spine is not injured, place patient’s head in a
sniffing position or place rolled towel.
9. Spray the back of the patient’s throat with an anesthetic
spray if time is available inhibits gag reflex.
10. Ventilate and oxygenate the patient with the resuscitation
bag and mask 10L, 100%, for maximal lung inflation to
prevent hypoxia.
11. Hold the handle of the laryngoscope in the dominant hand
and hold the patient’s mouth open with the other hand by
placing crossed fingers on the teeth.
12. Insert the curved blade of the laryngoscope along the right
side of the tongue, push the tongue to the left and use right
thumb and index finger to pull patient’s lower lip away
from the lower teeth.
13. Lift laryngoscope upward and forward at a 45-degree
angle to glottis and visualize vocal cords.
14. Once vocal cord is visualized, insert the tube into the right
corner of the mouth and pass the tube.
15. Gently push the tube through the triangular space formed
by the vocal cords and back wall of the trachea.
16. Stop insertion just after the tube cuff has disappeared from
view beyond the cords.
17. Withdraw the laryngoscope while holding endotracheal
tube in place. Disassemble mask from resuscitation bag
and ventilate the patient.

18. Inflate cuff with minimal amount of air required to occlude
the trachea.
19. Insert bite block if necessary.
20. Ascertain expansion of both sides of the chest by
observation and auscultation of breath sounds.
21. Record distance from proximal end of the tube to the point
where the tube reaches the teeth.
22. Secure the tube to the patient’s face with adhesive tape or
apply a commercially available endotracheal tube
stabilization device.
23. Obtain chest x-ray.
24. Document the procedures done, time, tube, size, exit mark,
reaction of the patient and ventilator settings.
25. Ability to answer question:
A.
B.
Total Score:
Equipment Grade
Performed with Actual Patient
Equivalent Grade
Clinical Instructor’s signature
Student’s signature

Name of Student ________________________________________________________
ADMINISTERING OXYGEN
STEPS Return 1 2 PE
Demo
I. Nasal Cannula
1. Check doctor’s order and secure needed equipment.
2. Place “No Smoking” sign on the patient’s door and in the
view of patients and visitors.
3. Explain the procedure to the patient and show the nasal
cannula.
4. Make sure that the humidifier is filled to the appropriate
mark.
5. Crack the gauge and test flow meter.
6. Attach the connecting tube from the nasal cannula to
humidifier outlet.
7. Set the flow meter at a rate prescribed in liters/minute. Feel
to determine if oxygen is flowing through the tips of the
cannula.
8. Place the tipoff the cannula in the patient’s nose.
9. Adjust the flow meter.
10. Determine patient’s comfort with oxygen use.
11. Record flow rate and patient’s response.
II. Mask
1. Check doctor’s order and secure needed equipment.
2. Place “No Smoking” sign on the patient’s door and in the
view of patients and visitors.
3. Explain the procedure to the patient and show the venturi
mask.
4. Connect the mask by lightweight tubing to the oxygen
source.
5. Crack gauge and turn on the oxygen flow meter and adjust
to the prescribed rate (usually indicated on the mask). Check to
see the oxygen is flowing out of the vent holes in the mask.
6. Place venturi mask over the patient’s nose and mouth and
under the chin. Adjust elastic strap.
7. Check to make sure holes for air entry are not obstructed by
the patient’s beddings.
8. Determine patient’s comfort with oxygen use.
9. Record flow rate and patient’s response.
10. Ability to answer the questions
A.
B.
Total Score
Equivalent Grade
*with patient

Final Grade
Signature of the CI
Signature of student
Name of Student _________________________________________________________
ASSISTING PHYSICIAN IN NGT INSERTION/GAVAGE

STEPS Return 1 2 PE
Demo
1. Check doctor’s order.
3. Wash hands.
4. Assemble equipment at bedside and place on side of bed
nearest to the nurse.
5. Pull curtain around the bed or close room door.
6. Stand on client’s right side if right-handed; left side if
left-handed.
7. If NG tube is too pliable, place in emesis basin and cover
with ice (optional)
8. Place bath towel over client’s chest; give facial tissues to
client.
9. Offer gloves to the physician.
10. Instruct client to relax and breathe normally while
occluding one nostril. Then repeat this action for other
nares. Select nostrils with greater air flow.
11. Assist the physician in measuring distance to insert tube
by placing tip of tube at client’s nose and extending tube
first to tip of earlobe and then from earlobe down to the
xiphoid process of sternum.
12. Mark length of tube to be inserted with piece of tape or
note distance of point from next tube marking.
13. Curve 4-6 inches (10-15cm) of end of the tube tightly
around index finger then release.
14. Lubricate 3-4 inches (7.5-10cm) of end of the tube with
water soluble lubricating jelly.
15. Initially instruct client to extend his neck back against
pillow; assist the physician in inserting the tube slowly
through nares with curves end pointing downward.
16. Continue to pass the tube along floor of nasal passage
aiming down toward ear. When resistance is felt, apply
gentle downward pressure to advance tube (do not force
past resistance)
17. If resistance is met, withdraw tube to allow client to rest,
re-lubricate tube and insert into other nares.
18. Continue insertion of tube until just past nasopharynx by
gently rotating tube toward opposite nares.
a. Stop tube advancement, allow client to relax, and provide
tissue paper.
b. Explain to client that the next step requires him to
swallow.
19. With tube just above oropharynx, instruct client to flex
head forward and dry swallow or suck in air through
straw. Advance tube 2.5-5cm (1-2inches) with each
swallow. If client has trouble swallowing and is allowed
fluids, offer a glass of water. Advance tube with each
swallow of water.
20. If client begins to cough, gag, or choke, withdraw

slightly and stop tube advancement. Instruct client to
breathe easily and take sips of water.
21. If client continues to cough during insertion, pull tube
back slightly.
22. After client relaxes, continue to advance tube to the
desired distance.
Checking Tube Placement
1. Ask client to talk.
2. Check posterior pharynx for presence of coiled tube.
3. Attach syringe to end of NG tube. Place diaphragm of
stethoscope over upper left quadrant of abdomen just
below costal margin. Inject 10-20cc air while
auscultating abdomen.
4. Aspirate gently back on syringe to obtain gastric contents
(optional- check pH of gastric content).
Anchoring Tube
1. After tube is properly inserted, either clamp end or
connect it to drainage bag or suction machine.
2. Tape NG tube to client’s nose; avoid putting pressure
on nares. Cut 4 inches (10cm) long piece of tape.
Place one end of tape over nose and wrap opposite
split ends around tube as it exits the nose.
Gavage
1. Warm feeding.
2. Kink tubing then connect funnel or asepto-syringe.
3. Give the fluid/feeding slowly keeping the tube filled at
all times during the feeding. (Asepto syringe or funnel
should be at least one foot above the edge of bed when
feeding).
4. Rinse with water after feeding.
5. Clamp the tube tightly until next feeding.
6. Wash all equipment with soap and water and return to
proper place.
7. Chart procedure done, calories fed, amount of water used
for rinsing, and reaction of patient.
a.
b.
Total Score
Equipment Grade
with patient
Final Grade
Signature of CI
Name of Student: __________________________________________________________
BREAST CARE

Retur 1 2 3 PE
STEPS n
Demo
2. Bring the prepared equipment to the bedside.
3. Screen the bed and provide privacy.
4. Wash your hands thoroughly first.
5. Expose the farther breast and drape.
6. Using clean forceps and sterile cotton ball with sterile
water, clean the breast including the nipple going outward in
rotary motion until clean.
7. Dry the area with sterile cotton balls using the same
strokes as in step number 6.
8. Cover the area with a clean towel.
9. Follow the same procedure for the other breast.
10. Chart the date, time, procedure done and any
observations.
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of C.I.
Name of Student ___________________________________________________________

BASIC PERINEAL CARE
STEPS Return 1 2 PE
Demo
FOR FEMALE CLIENT
2.Secure the tray and check if the equipmentis complete.
3. Bring the bedpan and perineal tray to the bedside.
4. Screen the patient.
5. Place the rubber sheet and cotton draw sheet under the
patient’s buttocks. Put the towel over the hypogastrium.
6. Position the patient in dorsal recumbent position with leg
flexed. Do diagonal draping.
7. Offer the bedpan. Line the edge of the bed with towel. Let the
patient wash her hands.
8. Place the waste receptacle in a convenient area.
9. Pour water over vulva. The pitcher should be 6 inches above
the vulva.
10. Using each perineal ball, moistened with soap, clean the
vulva in the following manner: Mons pubis with S stroke, center
without touching the anus, farther labia minora, nearer labia
minora, farther labia majora, nearer labia majora, thighs (start
with farther then nearer thigh), clitoris to vaginal orifice then
vaginal orifice to anus.
11. Flush the vulva and dry with sterile dry cotton balls or cherry
balls in the same sequence.
12. Remove the bedpan and turn the patient to the side, dry the
buttocks with a towel from the hypogastrium.
13. Fix the bedding and make the patient comfortable.
14. Do after care of the equipment.
15. Chart the discharges noted, its type, color, odor, and
condition of the perineum.
FOR MALE CLIENT
1. Position the male client in a supine position with knees
slightly flexed and hips slightly externally rotated.
2. Put on gloves.
3. Retract foreskin (prepuce) of penis if uncircumcised.
4. Wash around the urinary meatus in a circular motion using
clean surface of the perineal ball for each stroke and around the
head of penis in circular motion.
5. Wash down the shaft of penis toward the thighs changing
perineal ball position with each stroke.
6. Wash the scrotum from front to back.
7. Wash inner thighs.
8. Rinse with perineal ball or peri-bottle using warm water in
same sequence.
9. Dry with clean perineal ball in the same sequence.
10. Replace foreskin as appropriate.
11. Turn patient on side to wash anus from front to back and dry.
12. Fix the bedding and make the patient comfortable.
13. Do the after care of the equipment.
14. Chart any unusual observation.
A.

B.
Total Score
Equivalent Grade
Final Grade
Signature of the CI
Name of Student: _________________________________________________________

BASIC CLEANING PROCEDURE
Return 1 2 3 PE
STEPS
Demo
CLEANING A ROOM
1. Remove all things like tables, chairs and other articles,
which can be moved to one side.
2. Clean the ceiling by removing the cobwebs and pay
attention to the cracks.
3. Dust the furniture.
4. Clean and return all the things in the proper places.
DUSTING
1. Bring the dusting tray to the room and place either on a
table or a chair over newspaper lining.
2. To begin, move the furniture on one side of the room, cover
the surfaces with newspaper and begin dusting at the ceiling of
the entrance then proceed to the other areas.
3. Use long straight strokes to prevent overlapping of strokes
and sipping corners and edges.
4. In dusting the walls, start from the highest point then down
towards the floor using the brush or broom.
5. Use the damp cloth. If necessary, use soap and water on the
dust cloth or brush on the wall.
6. Dust all furniture with damp cloth and move them to clean
area. Never use damp cloth on articles/ surfaces that will be
destroyed by moisture.
7. In using dusting bar slates or rods, hold them with the
folded dust cloth and rotate from the top to bottom.
8. To remove the dust in between the bars or crevices or if the
area is too small for hands to enter, wrap the end of the stick
with a piece of cloth and insert.
9. Never forget to dust all the parts of the bed and the articles
inside the drawer.
10. Inspect your work.
11. After dusting, tidy the room and clean, dry the instrument
and return to their proper places.
SWEEPING
1. Bring the equipment to the area to be swept.
2. Move the pieces of furniture away from the area to be
swept.
3. Start sweeping the floor areas opposite to the door.
4. Sweep with the proper long stroke towards the center of the
room.
5. When dust is heavy on the rough surface, tap the brush
broom on the floor at the end of each stroke to free from dirt.
6. Inspect your work.
7. Sweep the accumulated dirt into the dustpan and deposit it
into the dustbin.
8. Proceed to the other cleaning procedure as washing,
mopping, scrubbing and waxing.
9. Dust them including their drawers, doors and sides and
move them to their proper place.
10. Clean the equipment and return them in their proper place.

WASHING
1. Bring the tray to the area to be cleaned.
2.Protect the floor from drippings, by lining the floor with a
newspaper.
3. Wipe away loose dirt with a damp cloth.
4. Dip the cloth into the cleaning solution. Wrench the cloth
and wrap it around the hand to prevent from dangling.
5. Wash small areas in a circular motion.
6. Rinse cloth, and then dry the area with another wash cloth.
7. Continue washing, rinsing and drying the entire area.
8. Change the water as frequent as necessary.
9. To wash the receptacles and containers, wash out the dirt
from the inner surfaces with running water. Use a separate
dust cloth for the surfaces soiled with body waste and
discharges.
10. Prevent yourself from contamination by using a handled
brush or a rod with apiece of cloth wrapped at one end. In
cleaning the surfaces soiled with body waste and discharges.
Do thorough cleansing.
11. Return the furniture and equipment to their proper places.
MOPPING
1. Sweep the floor to be mopped. `
2. Soak the mop with disinfectant or detergent solution.
3. Through gloved hand, wring the mop and the mop floor
using side to side stroke in general floor areas.
4. Start mopping from the rear part of the room. Pass the mop
parallel to the baseboard when mopping the floor areas.
5. Soak the mop with disinfectant and with gloved hand, wring
the mop dry.
6 Change the disinfectant or detergent solution as necessary.
7. Dry the surface using another mop.
8. Sweep again.
SCRUBBING
1. Use the brush and solution in removing hard dirt that
attached to the floor by scrubbing vigorously.
2. Do the final mopping.
WAXING
1. Mop the floor dry, and then apply wax. Use dry mop to
apply wax in wide areas. Follow waxing with polishing.
2. Use the appropriate wax for the right floor material.
A.
B.
Total Score
Equivalent Grade

Final Grade
Signature of C.I.

Name ______________________________________________________________________
BAG TECHNIQUE
Steps Retur 1 2 PE
n
Demo
1. Upon arrival at the patient’s home, 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
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/ 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.
15. Ability to answer question
Score
Equivalent
Signature of Clinical Instructor

Name of Student: _____________________________________________________
BLOOD TRANSFUSION
Retur 1 2 PE
Steps n
Demo
1. Check order and explain the procedure to the patient.
2. Get blood in the laboratory and check for blood type,
cross matching, Rh, serial number, amount and VDRL.
Warm the blood by wrapping with towel. After it is
warmed, attach blood set into the blood pack and let blood
flow into the tubing only until 2 inches away from the tip of
the tube.
3. Attach butterfly and bring equipment to beside.
4. Place patient flat on bed. Obtain and record baseline vital
signs.
5. Prepare infusion site. Select a large vein that allows
patient some degree of mobility.
6. Assist doctor in venipuncture. (Same in assisting the
doctor in intravenous infusion).
7. Regulate flow rate to 10-15 drops per minute for 15-30
minutes. If there are no signs of adverse reactions or
circulatory overloading the infusion rate is regulated
according to the doctor’s order.
8. Observe patient closely and check vital signs every 15
minutes for the first one hour and then hourly.
9. Recheck vital signs one hour after transfusion and report
to the physician immediately.
10. Recheck vital signs one hour after transfusion.
11. Record the following information on the patient’s chart:
Blood type and volume transfused.
Serial number.
Time transfusion started and ended.
Patient’s reaction or patient’s immediate response.
Physician who started the transfusion.
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of C.I.

Name of Student __________________________________________________________
BANDAGING
Demo
1. Explain procedure to patient.
2. Prepare needed equipment after assessing part of the
body to be supported.
A. APPLYING ELASTIC-STOCKINGS
1. Wash hands.
2. Provide privacy and position patient.
3. Slide hand into stocking to the foot.
4. Turn leg of stocking down over hand.
5. Pull foot stocking onto patient’s foot with heel of
stocking over heel of foot
6. Turn stocking right side out unto leg.
7. Repeat for other stocking.
8. Make sure the stocking is smooth and the foot is
correctly positioned.
9. Question patient regarding comfort.
10. Wash hands.
11. Chart: time, type of bandage, area to which applied,
data on circulation, motion and sensation.
B. APPLYING T-BINDERS
1. Wash hands.
3. Remove soiled or used T-binder (if present) and save
pins.
4. Have patient lift mid-section or turn patient side to side,
and place binder smoothly under patient with waist band
at proper level and tail or tails downward at midline.
5. Bring waist end upward and around patient’s abdomen.
6. Bring lower tail or tails between patient’s legs, over
dressings.
7. Secure with pin or pins.
8. Examine for neatness.
9. Question the patient regarding comfort.
10. Wash your hands.
11. Chart: time, type of bandage, areas to which applied,
data on circulation, motion and sensation.
C. APPLYING AN ARM SLING
1. Wash hands.
3. Remove soiled or used arm sling (if present).
4. With patient facing you, place end of triangle over
shoulder on unaffected side.
5. Bring long straight side down smoothly under hand of
affected side.
6. Loop sling up around arm, placing other end of triangle
over shoulder of affected side.
7. Tie or pin to one side, not directly behind neck.

8. Pie at or fold sling at elbow, and pin.
9. Examine for neatness.
10. Check for circulation, motion and sensation of hand.
11. Question the patient regarding comfort.
12. Wash hands.
13. Chart: date, time, type of bandage, areas to which
applied, circulation, motion and sensation.
A.
B.
Total Score
Equivalent Grade
 With patient
Final Grade
Signature of C.I.

Name of Student ___________________________________________________________
CARDIO PULMONARY RESUSCITATION
STEPS Return 1 2 PE
Demo
1. Scene Survey
a. Before you approach the victim, ensure your safety and the
victim’s safety. Look up, down, left and right. Go around the
victim.
b. Get some idea what happened. See if the scene is safe.
2. Check for unresponsiveness. Simultaneously check for
breathing.
a. Kneel beside the victim. The victim’s shoulder should be
somewhere in between your knees.
b. Gently tap the victim’s shoulder and ask “hey are you okay? “
c. Also check for No Breathing or No Normal Breathing, e.g.
gasping
3. Activation of Emergency Response System
a. If the victim is unresponsive, call for help.
b. Get AED / defibrillator.
4. Check for Pulse
a. Palpate for the carotid artery on the side nearest you to check
for the pulse. Do this for no more than 10 seconds.
b. If there is no pulse, start chest compression. Perform 30
effective, uninterrupted chest compressions. The rate should
be at least 100 per minute. The depth should be at least 2
inches (5cm).
5. Airway / rescue Breaths
a. Open the airway using the head-tilt chin-lift method. Jaw
Thrust, if there is suspected neck injury.
b. Give 2 rescue breaths after the 30 compressions.
6. 30 compressions: 2 breaths cycle
a. Continue cycles of 30 compressions and 2 rescue breaths until
AED arrives/Advanced airway is placed/ROSC/Resuscitative
efforts are terminated.
7. AED Defibrillation: Look for Shock able Rhythm
a. For shock able rhythm – give 1 shock, then resume CPR
immediately for 2 minutes
b. For non-shock able – resume CPR immediately for 2 minutes,
check for rhythm every 2 minutes
c. Continue until ACLS provider take over / Victim starts to
move
8. Recovery Position
a. If the victim is already breathing normally and has effective
circulation but remains unresponsive, place the victim in the
recovery position.
b. Extend the victim’s arm nearest you above the victim’s head.
c. Pull the victim on that side.
d. The position should be stable, near a true lateral position, with

the head dependent and no pressure on the chest to impair
breathing.
e. Monitor the victim.
a.
b.
Total Score
Equivalent Grade
Final Grade
Signature of CI

Name of Student ___________________________________________________
CARING FOR CLIENT ON ISOLATION
STEPS Return 1 2 PE
Demo
1. Check physician’s order for the type of
precaution and review precaution in infection
control manual.
2. Plan nursing care activities before entering
the room.
3. Prepare a lining (a piece of paper) BP
apparatus, stethoscope, cotton balls with
alcohol, a piece of paper for data to be
gathered.
4. Provide instructions to patient, family
members and visitors.
5. Perform hand hygiene.
6. Put on gown, gloves, mask, protective
eyewear:
a. Put on gown by inserting hands and
arms into sleeves touching only the
inside part of the gown.
b. Tie gown securely at neck and waist
(obtain water proof gown if soiling is
likely)
c. Use clean disposable gloves. If worn
with gown, draw glove cuffs over gown
sleeves.
7. Enter client’s room with necessary
equipment. Place paper over table and put on
equipment.
8. Take vital signs. Follow procedure in taking
TPR. Record the data with the use of wrapped
pen, in a piece of paper provided for.
9. For BP taking, put on to client’s left arm
(long sleeves touching only the outside portion
of the client’s gown).
10. Place stethoscope on top of client’s gown
and then put on BP cuff on top of client’s
gown.
* Take the BP
*Record data with the use of a wrapped pen
11. Remove client’s gown holding only the
outer portion of it and hang in the patient’s
12. Administer medication, collect specimen or
perform necessary procedures.
13. After the procedure, return equipment to
the tray and discard lining on the client’s table
by grasping the middle part of the lining. Put

inside waste basket together with the waste
receptacle.
14. Make client comfortable.
1. When patient care is completed; untie waist
strings of the gown first. Then remove
gloves. Drop in appropriate container.
16. Remove mask:
a. For surgical mask: untie mask and drop
by strings into waste container.
b. Elastic strap: lift strap from behind
head and drop by strap into waste
container.
17. Remove gown:
Untie neck strings of gown.
a. Remove gown without touching outside
of gown by slipping the index finger
under the gown.
b. Draw the left sleeve by grasping it with
the right hand covered with the right
sleeve. Remove gown holding the
inside part of the gown.
18. Hang the gown on a stand with the
shoulder seams together and only the
contaminated (outer) portion is exposed to the
environment.
19. If the gown is hung outside of the client’s
unit, the clean portion is exposed outside the
environment.
20. Remove eyewear last and clean according
to agency policy.
21. Perform hand hygiene. Remove cover of
pen without touching contaminated part. Place
paper in appropriate container.
22. Record data gathered and procedures done.
A.
B.
Total Score
Equivalent Grade
*with patient
Final Grade
Signature of C.I

Name of Student: _______________________________________________________
CATHETERIZATION
Retur 1 2 3 PE
STEPS n
Demo
1. Verify the doctor’s order. Identify the patient and explain
the procedure.
2. Get the tray, wash your hands, and then check the tray for
the needed articles. Open the tray using the aseptic
technique.
3. Saturate the cotton balls with aseptic solution.
4. Remove the catheter aseptically from the bag container.
Place it in the sterile tray and drop enough amount of KY
jelly. Close the tray and carry it to the bedside.
5. Provide privacy. Place the rubber sheet and draw sheet
under the patient’s buttocks.
6. Place the patient in dorsal recumbent position. Do the
diagonal draping. For the female patient, check if she needs
preliminary care.
Give the bedpan and do perineal care/ flushing.
Remove the bedpan.
7. Place the tray between the thighs facing the vulva.
8. Adjust the light. Place the waste receptacle at a
convenient area.
9. Open the tray by bringing the edge of the cover under the
buttocks.
10. Put on gloves.
11. Drape the patient with catheterization sheet.
12.
For female patient, disinfect the area using the sterile
procedure. Clean it with cotton balls with antiseptic solution
in the following order: urinary meatus, farther from the labia
minora,nearer the labia minora, farther from the labia
majora, nearer the labia majora, then the urinary meatus
(center) and always with one downward stroke.
For the male patient: Keep the skin foreskin retracted.
Wash off the glans penis around the urinary meatus with
cotton balls soaked in an antiseptic solution using the
forceps to hold the cleansing sponger cotton balls. (Disinfect
starting from the urinary meatus going outward).
13. Place the kidney basin or bowl near the patient’s
buttocks.
14. Lubricate the catheter about 2 inches from the tip for the
female patient about 6-10 inches for the male patient.
15. Place the end part of the catheter inside the bowl before
inserting the tip into the meatus.
16. For the female patient: Separate the labia minora to
expose the meatus and insert the catheter into the urethra
about 2-3 inches or until the urine flows.
For the male patient: Grasp the shaft of the penis (with the
left hand) raising it almost straight up and insert the catheter
into the urethra 6-10 inches or until the urine flows.
17. If the catheter is not to be indwelled (if you are using a
straight catheter), pinch the catheter and remove it slowly as
soon as the desired specimen is obtained or until the urine
ceases to flow.
Dry the vulva with sponge using the forceps.
Remove the gloves and the catheterization sheet and place
them on a tray.
18. For indwelling (If you are using the Foley bag catheter),
inject the needed amount of distilled water with the use of a
syringe to inflate the balloon (as indicated by the
manufacturer’s instructions).
Remove the catheterization sheet and connect it to the
urobag. Remove the gloves.
Anchor it surely to the inner thigh.
19. Turn off the light. Undrape the patient. Remove the
rubber sheet and remake the top sheet.
20. Remove the screen and open the windows. Bring all the
equipment to the utility room.
21. Measure the amount of urine.
22. Wash all the equipment with soap and water. (Return to
CSR). Return the rest of the equipment in their proper
places.
23. Chart: time of procedure, amount of urine, character of
urine whether the urine is sent to the laboratory, specify if
indwelled and the reaction of the patient.
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of C.I.

Name of Student ___________________________________________________________
CENTRAL VENOUS PRESSURE READING
STEPS Return 1 2 PE
Demo
1. Explain procedure and place patient flat in bed.
3. Place pillow under patient’s right arm so that it will be at
the level of the right atrium.
4. Prepare area for cut down.
5. Assist physician.
6. To read:
a. Confirm zero point. Position patient in a position of
comfort. This is the baseline position used for
subsequent readings.
b. Position the zero point of the manometer at the level of
the right atrium.
c. Mark the midaxillary line on the patient with indelible
pencil.
d. Turn stopcock so that the IV solution flows into the
manometer filling to about 20-25 cm. level. Then turn
stopcock so that solution in the manometer flows to
patient. Closing the IV line.
e. Observe the fall in the height of the column of fluid in
manometer. Record the point at which solution
stabilizes or stops moving downward.
Note: the level at which the fluid remains stationary on the
manometer tube is read as the central venous pressure.
7. Turn stopcock again to allow IV solution to flow from the
bottle into patient’s veins.
8. Inspect site.Change dressing PRN as prescribed.
9. Chart: reading of CVP.
A.
B.
Total Score
Equivalent Grad
 With patient
Final Grade
Signature of CI

Name of Student ___________________________________________________________
CHECKING BLOOD GLUCOSE
STEPS Return 1 2 PE
Demo
1. Wash hands.
2. Identify the correct patient and explain the procedure.
3. Assemble the equipment and put on gloves.
4. Match the code on the test strips to the number on the
meter, check the expiration date on the test strips.
Discard them if they have expired. The code number
may need to be reset. Follow the meter’s instructions.
5. Remove a test strip from the container, and then close it.
Do not touch the white area on the strip.
6. Use a disposable lancet or insert the lancet into the
Penlet.
7. Place the end of the lancet firmly on the side of the
patient’s finger-tip. Press the button on top of the Penlet.
8. Squeeze the finger gently to obtain a large drop of blood.
9. Slowly draw the blood up into the disposable pipet.
Apply the blood sample to the test strip. This prevents
cross-contamination of body fluids between patients. An
alternative is to drop the blood directly onto the test strip
if the machine is used for only one patient.
10. Wait the indicated amount of time for the results to
appear on the meter.
11. Apply a bandage to the patient’s finger.
12. Clean and dispose the equipment as necessary.
13. Document and report the results to the RN or preceptor.
A.
B.
Total Score:
Equivalent Grade:
Final Grade
Signature of CI:
Signature of Student:

Name of Student: ________________________________________________________
CLEANSING BED BATH
Retur 1 2 PE
STEPS n
Demo
1. Wash your hands.
3. Screen the bed (if in general ward).
4. Adjust the temperature. Inspect the bedding.
5. Clear the bedside table. Place a paper lining and arrange
the needed articles within reach. Prepare a glass of drinking
water. Place lining on chair where the basin will be placed.
6. Loosen the top linen at the foot part of the bed. Replace
the top sheet with the bath blanket if it is to be reused.
7. Move the patient closer to you. Remove his clothing,
keeping him covered with the bath blanket.
8. Fill the bath basin with ½ to 2/3 of comfortably warm
water.
9. Place the bath towel under the head and face towel under
the chin.
10. Wet the wash cloth and squeeze out the excess water.
Wrap the wash cloth around the palm and fingers to form a
“mitten”.
11. Wash the region around the eyes with clear water.
Clean from the inner to outer canthus.
12. Wash the face, ear, and neck with soap and water.
Rinse and dry with bath towel. Remove the towels and
place them on the rack.
13. Spread the towel lengthwise under the farther arm.
Wash, soap, rinse and dry, paying particular attention to the
axilla, using long firm strokes. Cover the part with bath
blanket.
14. Do the same with the nearer arm. Line the bed with the
towel and place the basin with water. Wash both hands
paying attention to the fingernails and creases in between
the fingers and dry.
15. Cover the chest and abdomen with the bath towel and
fold the bath blanket down the pubic area. Wash, soap,
rinse and dry giving special attention to the area beneath
the breast and umbilicus.
16. Turn the patient in his side away from you. Place the
bath towel along his side and expose the back. Wash, soap,
rinse and dry from the nape to the posterior upper things,
using long and firm strokes.
17. Apply lotion or powder if desired. Put on his gown and
place the patient on a supine position.
18. Bathe the thighs and legs in the same manner and order
as in the arms. Place the towel under the leg, and drape. In
long firm strokes, wash, soap, rinse and dry giving
particular attention to the inguinal and popliteal area.
19. Flex both knees and drape. Put the bath towel under the
feet. Place the basin on the towel.
20. Place the farther foot flat into the basin. Wash it with
soap and water, rinse, dry using towel. In rinsing, pour
water from the pitcher over the foot and rinse thoroughly.
Do the same procedure with the nearer foot. If the basin is
big enough, both feet maybe washed at the same time.
21. In another basin with clean water, clean the pubic and
perineal areas. If the patient is female, finish the bath by
inserting the thumbless mitten into the patient’s hand using
the rinsing towel. Leave the buzzer or bell and instruct the
patient to call once it is finished. If the patient is male,put
the equipment within reach and ask him to finish the bath.
Wash his hands afterwards.
22. Put on the rest of the clothing. Put the bath towel under
the head and assist with hair care.
23. Fix the bedding. Make necessary adjustment. Replace
the bath blanket with top sheet.
24. Place the tissue paper under the patient’s hands and
trim his fingernails, PRN.
25. Place the patient in comfortable position.
26. Remove the screen. Clean and return the used
equipment to the utility room. Discard the dirty linens into
the
27. hamper.
Ability to answer questions:
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of C.I.

Name of Student: __________________________________________________________
CLOSED BED
Return
STEPS 1 2 PE
Demo
1. Wash your hands.
2. Prepare the necessary linens. Fold them
accordingly and arrange in order of use.
3. Bring the linens to the bedside.
4. Straighten the mattress and turn PRN.
5. Place the bottom sheet on the mattress, wrong
side up and put the center fold of the sheet over
the center of the mattress, the edge of the bottom
sheet should be in line with the edge of the foot
part of the bed.
6. Draw the top fold towards the head of the bed,
while facing the foot part of the bed.
7. Lift the top most side of the sheet and fanfold
towards the center of the bed.
8. Tuck the head end of the sheet well under the
mattress, miter the corner tuck the sides
smoothly towards the foot part.
9. Place the center fold of the rubber sheet which is
folded crosswise, wrong side up across the bed at
least 2 feet from the head part of the mattress.
Lift the top most side of the sheet and fanfold
towards the center of the bed.
10. Place the center fold of the cotton draw sheet
which is folded crosswise wrong side up on top
of the rubber sheet. Lift the top most side of the
sheet and fanfold it towards the center, tuck them
together, starting from the center to the sides.
11. Place the top sheet folded right side up starting at
the edge of the head part of the bed.
12. Draw the top folds toward the foot of the bed
while facing the head part of the bed. Get the top
most side and fanfold toward the center of the
bed.
13. Tuck the top sheet under the mattress at the foot
part, miter the corner and leave the side
untucked.
14. Fold back the top sheet about 18 inches from the
edge of the head part of the mattress.
15. Fold back the side of the top sheet towards the
center of the bed. The folded edge should be in
line with the mattress.

16. Place the bedspread 6-8 inches which is folded
wrong side up beyond the edge of the mattress at
the head part of the bed.
17. Draw the top folds towards the foot of the bed
while facing the head part of the bed. Lift the top
most side of the sheet and fanfold towards the
center. Tuck the bedspread at the foot part and
miter the corner leaving the side hanging. Fold
the head end of the bedspread at least 15 inches.
18. Place the pillow case into the pillow and place it
into the finished part of the bed.
19. Move to the other side to finish the bed.
20. Pull and straighten the bottom sheet. Then tuck
the upper part and miter the corner. Pull the
rubber sheet and cotton draw sheet accordingly.
21. Straighten the top sheet. Tuck and miter the
corner. Fold the side of the top sheet towards the
center of the bed. The folded edge should be in
line with the mattress.
22. Pull and straighten the bedspread. Tuck and
miter at the foot part of the bed leaving the sides
hanging.
23. At the folded end of the bedspread place the
pillow over riding 1/8 of the folded part. Cover
the pillow with the bedspread, while maintaining
a fold under the pillow.
24. Make necessary adjustment. Cover the entire bed
with the bedspread.
A.
B.
Total Score:
Equivalent Grade:
Final Grade
Signature of CI:

Name of Student _________________________________________________________
CONDUCT OF NORMAL LABOR
Demo
1. Welcome client and partner, introduce self.
2. Change client’s dress and place personal belongings in
safe place or give to partner.
3. Review prenatal records and check significant data.
4. Assess when labor started, has the membranes ruptured,
is there bloody show, are there complications that may
require treatment, client’s psychologic response during
this phase.
5. Put client to bed if membranes have ruptured.
6. Assess progress of labor.
A. Check fetal presentation, position, engagement.
(Leopold’s Maneuver)
B. Contractions: time began duration, intensity,
frequency and regularity.
C. Check vital signs.
D. Complete vaginal examination.
E. Recheck for allergies, edemas.
F. Check dietary intake for the last 2 hours.
G. Check bladder distention every 2 hours.
H. Observe character of amniotic fluid, discharges if
rupture of bag of waters (BOW) has occurred.
7. Provide comfort measures.
A. Clean vulva after vaginal examination.
B. Shave perineum.
C. Give enema if ordered.
D. Check lights in labor room.
E. Provide touch.
8. Teach (or coach) proper breathing techniques and
bearing down efforts.
9. Take note of the following indicating the beginning of
second stage of labor.
A. Increase in bloody show.
B. Feeling of pressure in the perineum.
C. Frequent regular close contractions.
D. Increase in perspiration, client cries.
E. Complete dilatation of cervix.
F. Bulging of the perineum.
10. Take/transfer client to Delivery Room (DR) table
when above signs are noted. Call physician.
A.

B.
Total Score
Equivalent Grade
 With patient
Final Grade
Signature of C.I.

Name of Student
CRUTCH WALKING
STEPS Return 1 2 PE
Demo
1. Inform the client you will be teaching crutch ambulation.
2. Assess the client for strength, mobility, ROM, visual acuity,
perceptual difficulties and balance. Note: nurse and therapist often
collaborate on this assessment.
3. Adjust crutches to fit the client. With the client supine, measure
from the heel to the axilla. With the client standing, set the crutch
position at a point 4-5 inches lateral to the client and 4-6 inches in
front of the client. The crutch pad should fit 1.5-2 inches below the
axilla (3 finger width). The hand grip should be adjusted to allow
for the client to have elbows bent at 30° flexion.
4. Lower the height of the bed.
5. Have the client dangle legs. Assess for vertigo.
6. Instruct the client to position crutches lateral to and forward to
feet. Demonstrate correct positioning.
7. Apply the gait belt around the client’s waist if needed.
8. Assist the client to standing position with crutches.
Four-Point Gait:
9. a. Position crutches to the side and in front of each foot.
b. Move the right crutch forward 4 to 6 inches.
c. Move the left foot forward, even with the left crutch.
d. Move the left crutch forward 4 to 6 inches.
e. Move the right foot forward, even with the left crutch.
f. Repeat the four-point gait.
Three-Point Gait:
10. a. Advance both crutches and the weaker leg forward
together.
b. Move the stronger leg forward, even with crutches.
c. Repeat two-point gait.
Two-Point Gait
11. a. Move left crutch and right leg forward 4-6 inches.
b. Move right crutch and right leg forward 4-6 inches.
c. Repeat two-point gait.
Walking UP stairs:
12. a. Instruct the client to position the crutches as if walking.
b. Place the strong leg on the first step.
c. Pull weak leg up and move the crutches up to the first step
d. Repeat for all steps.
Walking DOWN stairs:
13. a. Position the crutches as if walking.
b. Place weight on the strong leg.
c. Move crutches down the next lower step.
d. Place partial weight on hands and crutches.
e. Move the weak leg down to the step with crutches.
f. Put total weight on arms and crutches.
g. Move strong leg same step as weak leg and crutches.
h. Repeat for all steps.
14. Set realistic goals.
15. Consult with a physical therapist.
15. Wash hands.
Total Score
Equivalent Grade
*with patient
Final Grade
Signature of CI

Name of Student _______________________________________________________
EAR IRRIGATION
STEPS Return 1 2 PE
Demo
1. Explain procedure to patient.
2. Gather all equipment and bring to bedside.
3. Screen
4. Have patient sit up or lie with his head tilted toward
the side of the affected ear.
5. Place protective towel under affected area.
6. Have the patient support the basin under his ear to
receive the irrigation solution.
7. Clean pinna and auditory canal as necessary with
normal saline solution. Use cotton applicator to remove
any discharges.
8. Fill the bulb syringe with solution. Test temperature
of solution by allowing some to run on inner aspects of
the wrist. The temperature should be 35° c to 40.6 °c.
9. Straighten the auditory canal by pulling the pinna
upward and downward for an adult. For pediatric
patients, pull pinna downward then backward.
10. Direct a steady slow stream of solution against the
sides of the auditory canal, using only sufficient force
to remove secretions.
11. If an irrigation container is used, elevate not more
than 15 centimeters(6 inches)
12. Observe for sign of pain or dizziness.
13. If irrigation does not dislodge the wax, instill
several drops of glycerine or saturated solution of
sodium bicarbonate, 2-3 times daily for 2-3 days.
14. Tilt head to the affected side to drain the solution
and discharges.
15. Dry external ear with cotton pledgets.
16. Remove soiled towels, etc., and make the patient
comfortable
17. Soak all equipment in 5% Lysol solution for 30
minutes.
18. After 30 minutes, wash all equipmentwith soap and
water.
19. Chart: time of irrigation, kind and amount of
solution used, nature of return flow and effect of
treatment.

A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of the CI

Name of Student _________________________________________________________
ESSENTIAL INTRAPARTUM AND NEWBORN CARE
STEPS Return
Demo 1 2 PE
PREPARATION:
Prepare decontamination solution by mixing 1 part of 5% chlorine
each to 9 parts water to make 0.5% chorine solution. Change
chlorine solution at the beginning of each day or whenever solution
is very contaminated or cloudy.
PRIOR TO PATIENT’S TRANSFER TO THE DR
1. Ensure that mother is on her position of choice while in
labor.
2. Ask mother if she wishes to eat/drink or void.
3. Communicate with the mother-inform her of progress of
labor, give reassurance and encouragement.
PATIENT ALREADY IN THE DR
PREPARING FOR DELIVERY
1. Check temperature in DR area to be 25-28 C, check for
draft.
2. Ask patient if she is comfortable in the semi-upright
position which is the default position.
3. Ensure the patient’s privacy.
4. Remove all jewelry and give it to the watcher
5. Wash hands thoroughly observing the proper procedure.
(WHO 1-2-3-4-5)
6. Prepared clear, clean newborn resuscitation area. Check the
equipment if clean, functional and within easy reach.
7. Arrange materials/supplies in a linear fashion/sequence:
2 pairs of gloves, 2 dry linen, bonnet, oxytocin ampule
with 3cc syringe with needle, plastic clamp, instrument
clamp, 2 scissors, 2 kidney basins. In a separate sequence
for after the 1st breastfeed: Eye ointment, (stethoscope for
PE), vit. K, hepatitis B and BCG vaccines (plus cotton balls
and 3 tuberculin syringes with needles.
8. Clean the perineum with antiseptic solution.
9. Wash hands thoroughly observing the proper procedure.
(WHO 1-2-3-4-5)10.
10. Put on 2 pairs of sterile gloves aseptically. (if same worker
handles perineum and cord care)
AT THE TIME OF DELIVERY
11. Encourage patient to push as desired.
12. Drape the clean, dry linen over the mother’s abdomen or
arms in preparation for drying the baby.
13. Apply perineal support and do controlled delivery of the
head.
14. Call out time of birth and sex of baby.
15. Inform the mother of outcome.
FIRST 30 SECONDS
16. Place the baby on a clean, dry cloth/towel on the mother’s
abdomen.
17. Thoroughly dry baby for at least 30 seconds, starting from
the face and head, going down to the trunk and extremities
while performing a quick check for breathing.
1-3 MINUTES
18. Remove the wet cloth.
19. Place baby on skin-to-skin contact on the mother’s
abdomen or chest.
20. Cover the baby with a clean, dry cloth/towel.
21. Cover baby’s head with bonnet.
22. Exclude a 2nd baby by palpating the abdomen or perform
internal examination in preparation for giving oxytocin.
23. Administer oxytocin 10IU IM at 1minute after delivery of
the baby.
24. Inform the mother that an injection will be given at her
deltoid/thigh area.
25. Explain to the mother that this is to prevent bleeding.
26. Discard the sharps properly.
CLAMPS AND CUTS THE UMBILICAL CORD
27. Position the baby for clamping and cutting of the cord so
that the skin-to-skin contact with the mother is maintained.
28. Remove the first pair of gloves worn and place this in the
decontaminating solution.
29. Palpate the umbilical cord until pulsations stops or prepare
to clamp by 1-3minutes after birth.
30. Clamp using the sterile plastic cord clamp at 2cm. from the
base of the umbilicus near the baby’s abdomen.
31. Clamp the cord with instrument clamp at 5cm. from the
umbilical base.
32. Cut the cord close to the plastic clamp.
33. Place the instrument clamp with cut end of the umbilicus
top of the inguinal area of the mother.
34. Reposition the baby for skin-to-skin contact with the
mother.
35. Perform the remaining steps of the active management of
the third stage of labor (AMTSL).
36. Palpate for the mother’s uterus and feel for strong
contraction.
37. Place one hand above the symphysis pubis to await
contractions while keeping slight tension on the cord with
other hand.
38. Apply steady, controlled cord traction along the axis of the
vagina during a contraction while applying counter traction
abdominally.
39. Deliver the placenta.
40. Catch the placenta with both hands, then gently move it
upward to deliver the membranes completely.
41. Perform uterine massage until it is firm.
42. Check mother’s perineum, vagina, vulva for tears,
lacerations.
43. Check for completeness of the placenta.
44. Estimate degree of blood loss.
45. Clean the mother up, flush perineum and apply perineal
pad/napkin.
46. Dispose the placenta in a leak-proof container of plastic
bag.
47. Put all used instruments in decontaminating solution before
cleaning.
48. Rinse gloved hands in a basin of decontamination solution

to remove blood.
49. Grasp one glove near the cuff and pull off the glove
partway.
50. With the first glove still over the fingers, grasp the second
glove near the cuff.
51. Pull off the first glove, being careful to touch only inside
surface of the glove.
52. Dispose of the gloves in the infectious “yellow” trash bag.
53. Perform hand washing.
54. Monitor the condition of the mother and the baby’s vital
signs every 15 minutes. In the first hour every 30 minutes.
In the second hour and hourly for the first 6 hours.
55. Keep the mother and baby together, skin-to-skin contact
and observe for feeding cues expected by 20-60 minutes
after the birth like tonguing, mouthing, licking, rooting,
more active, eyes moving about, crawling, kicking.
56. Encourage breastfeeding.
57. Complete all records.
a.
b.
Total Score:
Equivalent Grade:
Signature of CI

Name of Student___________________________________________________________
ESTIMATING GESTATIONAL AGE
STEPS Return 1 2 P
Demo E
1. Explain the procedure and screen patient.
2. Gather equipment and bring to bedside.
3. Instruct client to empty bladder.
4. Place on supine position with knees slightly flexed and head and
shoulders slightly elevated.
5. Warm hands by rubbing your hands together.
6. Using fingerbreadth (FB): with your fingers, measure the anterior
abdominal wall where the fundus of uterus is palpable and compare your
findings with the following:
a. Uterus is palpable at the level of the symphysis pubis at 12 weeks
gestation.
b. 4FB above symphysis or midway between symphysis and
umbilicus is 16 weeks of gestation.
c. At the level of umbilicus – 20-22 weeks
d. 2FB above umbilicus – 24-26 weeks
e. 3-4 FB above umbilicus – 28 weeks
f. Just below xyphoid process – 40 weeks
g. 2 FB below xyphoid process – 40 weeks
7. If McDonald’s Rule is used.
a. With flexible tape measure, measure the height of fundus from
notch of symphysis pubis over the tip of the fundus without tipping
the corpus back.
b. Then calculate as follows: height of fundus (cm) x 2/7 (or 3.5) =
duration of pregnancy in lunar months.
Height of fundus (cm) x 8/7 = duration of pregnancy in weeks.
A.
B.
TOTAL SCORE
EQUIVALENT GRADE
 With patient
FINAL GRADE
SIGNATURE OF C.I.

Name of Student _____________________________________________________
EYE DROP INSTILLATION/ EYE OINTMENT APPLICATION

STEPS Return 1 2 PE
Demo
1. Check order and explain procedure.
2. Check order designating which eye require medication, bottle
or vial for correct medication and correct concentration.
4. Wash hands prior to instilling medication.
5. Position client comfortably. Clean eye gently of any
discharges using cotton ball starting from the inner canthus to
the outer canthus.
6. Draw desired amount of drug into the dropper. If using the
container with dropper, open ready the medication.
7. Using forefinger, pull down lower lid gently.
8. Instruct client to look upward.
9. With cotton ball held over inner angle of eye, allow drops to
fall in the center of averted lower lid.
10. Instruct client to close eyes slowly but do not squeeze and roll
the eyeball. Open eye.
11. Wipe off lid from overflow of drug or secretions.
12. Discard cotton ball into waste receptacle.
13. Make client comfortable.
14. Wash hands after instilling medication.
15. Return all equipment to its proper place.
16. Chart.
Eye Ointment Application
1 Follow steps 1-8 (in eye drop instillation)
2 Squeeze the ointment into the averted lower lid starting from
the inner to outer canthus.
3 Follow steps 10-16.
4 Ability to answer questions:
a.
b.
Total Score
Equivalent Grade
 With patient
Final Grade
Signature of CI

Name of Student _______________________________________________________
FBS AND INSULIN ADMINISTRATION

1 Check order and explain procedure to the patient.
2 Instruct patient to follow NPO post-midnight until blood for FBS is
drawn.
3 Offer breakfast after blood is drawn.
INSULIN ADMINISTRATION
1 Check order and explain procedure to the patient.
2 Get medication ticket, prepare equipment and medicine. Compute
for dosages PRN.
3 Roll bottle of insulin between palms of hand then wipe off top of
insulin vial with cotton ball with alcohol.
4 Attach withdrawal needle to tuberculin syringe.
5 Inject approximately the same volume of air into the insulin vial as
the volume of insulin to be withdrawn.
6 Withdrawn medication. Change withdrawal needle to injecting
needle then cover needle.
7 Insert medication ticket in-line with the syringe with prepared
medications.
8 Bring tray to bedside. Check medication card with patient’s name.
call name of patient.
9 Select areas of upper arms, thighs, flanks and upper buttocks for
injection.
10 Wipe the skin with cotton ball soaked in alcohol then form a skin
fold by picking up subcutaneous tissue between the thumb and
forefinger.
11 Get syringe from tray, remove cover and expel air.
12 Insert needle with quick thrust to the subcutaneous tissue at about
45-degree angle to skin surface.
13 Hold hub of needle with thumb and forefinger, pull the plunger to
test if needle did not hit a blood vessel.
14 Inject the insulin.
15 Hold alcohol sponge against the skin and gently withdraw the
needle. Wipe site with cotton ball with alcohol.
Do not rub or massage.
16 Turn medication ticket face down. Develop a systematic plan for
insulin administration (rotation of sites in a clockwise fashion).
Check site before leaving the patient.
17 Do aftercare and sign medication sheet indicating number of units
administered, time given, kind of insulin and site of administration.
18 Ability to answer questions:
a.
b.

Total Score
Equivalent Grade
*with patient
Final Grade
Signature of CI

Name of Student _____________________________________________________
GLASGOW COMA SCALE

STEPS Return 1 2 PE
Demo
2. Wash hands.
3. EYE opening:
3a. Call the patient by name: (no response, do step 3b)
3b. Pinch the patient on the anterior chest wall.
3c. Record patient’s score.
Spontaneously - 4
On command - 3
To pain -2
No response - 1
4. VERBAL response:
4a. Ask patient the time and place.
4b. Record patient’s score.
Alert & oriented -5
Confused -4
Inappropriate -3
Incomprehensible -2
No response -1
5. MOTOR response:
5a. Ask the patient to wiggle toes or move/raise arms (no
response, do step5b).
5b. Apply firm and gentle pressure on sternum (2nd above the
xiphoid process).
5c. Record the patient’s score
Follow directions -6
Localizes pain -5
Withdraws from pain -4
Decorticate posturing -3
Decerebrate posturing -2
No response -1
7. Report/ refer the score to the physician.
a.
b.
Total Score
Equivalent Grade
*with patient
Final Grade
Signature of CI

Name __________________________________________________________________
HOME VISIT
Step Retur 1 2 PE
n
Demo
1. Greet the patient and introduce

yourself
2. State the purpose of the visit
3. Observe the patient and determine

the health needs
4. Put the bag in a convenient place

then proceed to perform the bag
technique
5. Perform the nursing care needed and
give health teachings
6. Record all important data,

observation and care rendered
7. Make appointment for a return visit
Score
Equivalent
Signature of Clinical Instructor

Name of Student ___________________________________________________________
HOT WATER BAG APPLICATION
STEPS Return 1 2 PE
Demo
1. Wash hands before the procedure.
2. Assemble all the needed equipment within reached.
3. Check if the hot water bag is in good shape and without any leaks.
4. To check for leaks, pour the water into the bag, cover then turn it
upside-down. If there is no leak, discard the water.
5. Measure the temperature of the hot water using the bath thermometer.
6. Pour the hot water from the pitcher into the hot water bag until it is
about ½ to 2/3 full.
7. Expel the air from the bag by laying it on a flat surface and turn the
opening upwards then screw the cap tightly.
8. Wipe the bag with cotton flannel and re-check for leakage.
9. Wrap the hot H2O bag with warm cotton flannel in an envelope style.
10. Bring the hot water bag to the patient’s bedside.
12. Place it on the affected area as indicated. The opening of the bag
should face away from the patient’s body.
13. Apply the hot water bag for not more than 30 MINUTES. Check
after 5 minutes of application then re-check after 15 minutes and
observe for any untoward signs. Discontinue if any problem occurs.
14. When the use of the hot water bag is discontinued, remove the
cotton flannel and place it in the hamper.
15. Make the patient feel comfortable.
16. Empty the hot H2O bag. Wash it with soap and water. Rinse and
wipe it well.
17. Inflate it a little and screw the cap then return it to its proper place.
A.
B.
Total Score

Equivalent Grade
Final Grade
Signature of the CI
Name of Student: ________________________________________________________
ICE CAP / ICE BAG APPLICATION
Return
STEPS 1 2 PE
Demo
1. Wash hands before starting the procedure.
2. Assemble all the needed equipment within reach.
3 Check the ice cap / ice bag for leakage by pouring
water. Cover, turn it upside down then discard the
water.
4. Fill the bag with small pieces of ice about 2/3 full.
5. Expel the air from the bag by laying it on a flat
surface and screw the cap.
6. Wrap the ice cap with cotton flannel in an envelope
style, and then bring it to the bedside.
8. Apply it on the specified area for 20-30 minutes and
remove the ice cap. Wait for one hour before re-
applying it if necessary.
9. Examine the area and record client’s response.
11. Clean the ice cap / ice bag. Hang it to dry or place
on a tray turning it upside down without cover.
Return to its proper place.
A.
B.
Total Score:
Equivalent Grade:
Final Grade
Signature of CI:

Name of Student: _________________________________________________________
INTRADERMAL/INTRAMUSCULAR
Retur 1 2 3 PE
STEPS n
Demo
1. Check Doctor’s order. Explain the procedure to the
patient.
2. Obtain the medicine ticket- check with doctor’s order,
solve dosages PRN.
3. Secure ordered drugs. Wash hands.
4. Pick cotton balls with alcohol with forceps and place in
sterile tray.
5. Pick the syringe, injecting needle and withdrawal needle and
place them on the sterile tray.
6. Pick syringe with hand, and attach injecting needle (If
withdrawing medication from an ampule), test for
sharpness by passing through a dry sterile cotton ball
through the shaft of the needle; attach withdrawal needle to
syringe if withdrawing from a vial.
7. Prepare the drug for injection.
For Ampules
1. Disinfect file and neck of ampule with cotton
ball with alcohol.
2. Protect fingers with OS and file the neck of the
ampule.
3. Wipe the dust with cotton ball and break the top
portion.
4. Withdraw the solution into syringe. Recap
needle and place in sterile tray.
5. Insert medication ticket to hypo-towel in-line
with the syringe with prepared medication.
For Vial Liquid Form
1. Alcoholize file, break seal with file. Wipe top of
vial with cotton ball soaked with alcohol.
2. Pick withdrawal needle with forceps and attach
needle.
3. Inject air into vial with equal amount to be
withdrawn.
4. Withdraw desired amount. Change withdrawing
needle with injecting needle. Test for sharpness and
cover. Place syringe in sterile tray.
5. Insert medication ticket to hypo-towel in-line
with the syringe with prepared medication.
For Vial Powdered Form
1. Place syringe in sterile tray.
2. Alcoholize file, break seal with file, and wipe
rubber top with cotton ball soaked with alcohol.
3. Pick withdrawal needle with forceps and attach
needle to syringe.
4. Inject air to vial of distilled water equal to amount
to be withdrawn. Withdraw desired amount.
5. Disinfect vial with powder vial. Remove needle
into injecting needle and test for sharpness, the
cover.
6. Inject distilled water into powder vial. Remove
needle and syringe. Shake till completely
dissolved.
For Intramuscular Injection
1. Disinfect vial again.
2. Pick withdrawal needle and attach needle to syringe.
(When withdrawing the medication from a vial).
If withdrawing the medication from an ampule,
attach the injecting needle to the syringe.
3. Withdraw the desired amount of the medication.
4. Place syringe in tray.
5. Place enough cotton balls with alcohol on tray.
6. Bring tray to bedside
7. Check medication card with patient’s name. Call
name of patient.
8. Expose site and disinfect with cotton ball with
alcohol. Get syringe from tray. Remove cap and
place on tray. Expel air from syringe.
9. Grasp flesh firmly between thumb and first two
fingers of left hand (if right handed) and inject
needle quickly (For obese patients press firmly).
10. Hold the hub with thumb and forefinger of left
hand, then pull plunger to check if needle did not hit
a blood vessel.
11. Inject drug by pressing the plunger with thumb of
right hand.
12. Withdraw needle quickly then press site with cotton
ball soaked with alcohol. Massage unless
contraindicated.
13. Place use syringe on top of tray, turn medication
card facedown.
14. Readjusting patient’s clothing.
15. Check site before leaving patient.
16. After care of equipment, wash with soap and water
then sterilize.
17. Sign (medication sheet): time, drug, amount and site
of injection.
A.
B.
For Intradermal Injection
1. Disinfect vial again.

2. Pick withdrawal needle and attach needle to syringe.
(When withdrawing the medication from a vial).
If withdrawing the medication from an ampule,
attach
the injecting
3. Withdraw needle
first 0.9mltodistilled
the syringe.
water then 0.1ml of
the medication.
4. Change the withdrawal needle with the injecting
needle.
5. Place the syringe on the tray.
6. Place enough cotton balls with alcohol on the tray.
7. Bring the tray to the bedside.
8. Check the medication card with the patient’s name,
call the name of the patient.
9. Expose the site and disinfect using a cotton ball with
alcohol. Get the syringe from the tray. Expel the air
from the syringe.
10. Taut the inner aspect of the forearm.
11. The needle is inserted with the bevel upward at 10 –
15-degree angle. Do not aspirate.
12. Inject the drug by pressing the plunger slowly until
it produces a small wheal or bleb on the skin.
13. Withdraw the needle, do not press the site with
cotton ball soaked with alcohol.
14. Encircle the formed wheal or bleb using a blue or
black pen.
15. Test results are read 30 minutes after the
intradermal injection.
16. Ability to answer Questions.
A.
B.
Total Score
Equivalent Grade
*with Patient
Final Grade
Signature of C.I.

Name of Student __________________________________________________________
LEOPOLD’S MANEUVER
STEPS Return 1 2 PE
Demo

2. Let the patient empty her bladder.
3. Screen.
4. Place the patient in supine position with knees slightly
flexed.
5. Warm hands.
6. Do the first maneuver. While facing the mother, the
examiner palpates the fundus using the fingertips to
identify first the fetal part that occupies the fundus of the
uterus.
7. Second maneuver: Palpation of fetal back and small
parts. Still facing the mother, the examiner’s palmar
surface of one hand is placed on one side of the abdomen to
steady the uterus. While the other hand palpates the other
side in a slightly circular motion of fingers from top to
lower segments of the uterus to feel fetal outline.
8. The third maneuver: The maneuver should next
determine with the right hand (if right handed) which fetal
part presenting over the inlet. This is to confirm the first
maneuver. Still facing the mother, this is done by gently
grasping the lower pole of the uterus between the thumb
and fingers and pressing in slightly. If the presenting part is
not engaged, the next step is to determine the attitude of the
head.
9. Finally, the degree of descents is estimated. To do this,
the examiner faces the woman’s feet and uses both hands.
The side of the uterus just below umbilical level are
grasped snugly between the palms hands; the fingers held
close together pointing downward and inwards. If the hands
are placed correctly the first points at the little fingers will
be on level with the anterior iliac spine and the outstretched
thumbs will meet about the level of the umbilicus. When
the presenting part has descended deeply, only the small
portion of it maybe outlined. Palpation of the anterior
shoulder will aid in assessment of descent of the vertex.
10. Chart.
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of the CI
Name of Student
LUMBAR PUNCTURE
Demo
1. Explain the procedure to the patient and obtain consent.
2. Secure equipment from the CSR and bring to bedside.
3. Obtain baseline vital signs. Have patient empty bladder.
4. Screen. Assist patient to move nearer to side of bed.
5. Place patient in side lying position. Instruct to arch
lumbar segment of his back and draw up his knees to his
abdomen, clasping his knees with his hands and his chin
touching the chest.
Obese Patient: Have the patient straddle a straight
back chair (facing the back) and rest his head against
his arms which are folded on the back of the chair.
Pedia (Child): The child may be held across the front
of the nurse, legs secured with one arm and head and
arms secured with the other.
(Infant): The very young infant maybe placed in
sitting position with his head allowed to fall forward
thus arching his back. The nurse holds his hands and
feet and steadies his body with her hands.
6. Expose the lumbar area. Do skin preparation. Disinfect
area using cotton balls with Phisohex and sterile water
then dry.
7. Paint with betadine solution. Cover area with sterile
drape towel by using picking forceps, if doctor is not yet
ready.
8. Open tray aseptically and place within physician’s
reach.
9. Pour xylocaine to a medicine glass or alcoholize the
rubber cap of the Xylocaine vial and offer to the
physician.
10. Prepare gloves for the physician.
11. Provide stool. Assist the physician (throughout the
procedure) in maintaining patient’s position by supporting
behind knees and neck of the patient.
12. Assist physician as necessary.
a. Putting on gloves.
b. Anesthetizing the area.
c. Inserting of spinal needle which should be
introduced at L2 – L4 interspace. The needle is
advanced until the “give” of the ligamentum
flavum is felt and the needle enters the
subarachnoid space.
d. After the needle enters the subarachnoid space,
help the patient to slowly straighten his legs.
e. Instruct the patient to breath quietly (not to hold
his breath or strain) and not to talk.
f. The initial pressure reading is obtained by
measuring the level of the fluid column after it
comes to rest.
g. About 2-3 ml of spinal fluid is placed in each 3
test tubes for observation, comparison, and
laboratory analysis.
13. Receive bottles or specimen from the physician and
label.
14. Apply sterile dressing on punctured area when spinal
needle is removed.
15. Instruct patient to lie flat on bed for at least 4 – 6
hours.
16. Make patient comfortable and observe for untoward
reactions: take vital signs.
17. Send labeled specimen to laboratory with request form
as soon as possible.
18. Aftercare of the equipment.
19. Chart.
A.
B.
Total Score
Equivalent Grade
 With patient
Final Grade
Signature of C.I.

Name of Student____________________________________________________________
MAKING OF HOMEMADE SALT AND SUGAR SOLUTION
Steps RD 1 2 PE
1. Wash your hands thoroughly and prepare all equipment.
2. Measure 1 liter of pre-boiled drinking water into the container.
3. Scoop salt with a teaspoon.
4. Level the salt with a knife or a flat object.
5. Add and mix the salt into the 1 liter of water.
6. Taste the solution. It should not be very salty.
7. If it tastes saltier than the tears, discard the mixture and do the
same process.
8. Take 8-level teaspoonfuls of sugar.
9. Add these into the salt solution and mix well.
10. Label it properly
11. This will only be used in 24 hours
a)
b)
Total Score
Equivalent grade

Final Grade
Signature of CI
Name of Student ____________________________________________________________
MEASURING INTAKE AND OUTPUT
Return
STEPS Demo 1 2 PE
1. Assemble necessary equipment in the room or near

bedside.
a. I and O Sheet
b. Containers commonly used
c. Graduated metric container for measuring output
2. Explain to client and family why I and O
measurements are important.
3. Provide client with copy of hospital’s metric
conversion chart.
4. Measure and record all fluids taken by mouth.
a. Liquids with meals, feedings and ice chips etc.
b. Liquid taken with feedings.
c. Parenteral fluids: IV, blood components, total
parenteral fluids.
d. Enteral tube feedings.
5. Instruct client not to empty urinal, Foley drainage
bag, bedpan, or commode but ask nurse to empty and
record amount.
6. If using toilet, ask client to record each urination if
amount was small, moderate, and large.
7. Wash hands after measuring and recording output
fluids.
8. At the end of each nursing shift, calculate total intake
and output for each client.
9. Calculate and record total 24-hour intake and output
on 24-hour record sheet.
a.
b.
Total Score
Equivalent Grade
 With patient

Final Grade
Signature of CI
Name of Student ____________________________________________________________
MEDICAL HANDWASHING
STEPS Return 1 2 PE
Demo
1. Secure the necessary equipment.
2. Remove all jewelry and place them in the uniform pocket.
3. Roll sleeves if it is long enough.
4. Stand in front but away from the sink. Do not touch the outside
or inside portion of the sink.
5. Turn on the faucet and regulate the flow and adjust the
temperature of the water to warm one. (If there is a temperature
regulator)
6. Wet hands with running water.
7. Apply enough soap to cover all hand surfaces.
a) Rub hands palm to palm
b) Right palm over dorsum with interlaced fingers and vice
versa.
c) Palm to palm with fingers interlaced.
d) Back of fingers to opposing palms with fingers
interlocked.
e) Rotational rubbing, backwards and forwards with
clasped fingers of right hand in left palm and vice
versa.
f) Rotational rubbing of right arm towards the elbow and
vice versa.
8. Rinse hands with water. Keeping the hands lower than the
elbow.
9. Dry hands thoroughly with a single use towel.
10. Use towel to turn off faucet.
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of C.I.

Name of Student ____________________________________________________________
MORNING CARE
STEPS Return 1 2 PE
Demo
1. Assemble all necessary equipment. Wash and dry the
hands.
3. Screen the patient and close the door.
4. Don gloves. Put up the side rails on the opposite side from
where you stand. Help patient assume a high fowlers position,
with knee flexed and heels pressed against the bed. Pie fold
the top linen.
5. Assist the patient to lift his buttocks and placing the hand
under the back slid the bedpan to client’s buttocks. Place
rolled towel on the lumbar area.
6. Raise the side rail and leave signal device and toilet tissue.
Place a waste receptacle for tissue paper if stools are for
examination.
7. Remove the bedpan by turning the patient away from you,
while holding the bedpan firmly. Cover and place under the
foot part of the bed. Clean the perineal area. Remove gloves.
8. Line the edge of the bed with towel near the working area.
Place a paper lining over the towel, then the basin. Assist
patient in doing hand washing.
9. Place the towel under client’s chin. Put on gloves.
10. Inspect the mouth and teeth, buccal mucosa and gums.
11. Identify common oral problems.
12. Ask the patient to hold the kidney basin with his non-
dominant hand, fitting the small curve around the chin.
13. Hand the brush with toothpaste/ dentifrice to the patient
(or brush client’s teeth). Instruct patient to brush the teeth and
tongue properly.
14. Offer the water cup or mouth wash to rinse the mouth
vigorously.
15. Wipe the patient’s mouth with towel place over the chest
area.
16. For male patient assist in shaving.
17. Place the bath towel under the patient’s head. Adjust
towel under the chin.
18. Wash the region of the eyes with clear water from the
inner to the outer canthus using the different surfaces of the
wash cloth for each eye. Start from the farther eye.
19. Ask if patient prefer soap to his/her face. If not, use plain

water in cleaning the face, ears, and neck thoroughly using
gentle but firm upward stroke. Rinse well and dry.
20. Remove face towel and place it on a towel rack.
21. Comb patient’s hair if unable to do it by himself. Remove
the bath towel by rolling it from the farther side and
straighten the linens.
22. Place patient in comfortable position. Adjust the table in
preparation for patient’s meal and leave bell near the patient.
23. Do after care of the equipment. Return to its proper place.
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of the CI

Name of Student: __________________________________________________________
OCCUPIED BED
Retur 1 2 3 PE
STEPS n
Demo
1. Wash your hands and observe other appropriate infection
control measures.
2. Prepare the necessary linens. Fold them accordingly and
arrange in order of use.
3. Bring the linens to the bedside. Explain the procedure to
the patient.
4. Put on clean gloves. Loosen the foot part of the bed.
5. Change the top sheet with bath blanket, by placing the
bath blanket on the top of the chest, folded crosswise and
draw toward the foot part. Discard the top sheet into the
hamper.
6. Raise the bedside rail.
7. Assist client to turn on the side facing away from you.
Cover with bath blanket. Adjust pillow under the client’s
head.
8. Loosen the soiled linen moving from head to foot with
same side turned inward and rolled toward the center of the
bed under the patient’s buttocks, back and shoulder.
9. Wipe off any moisture on exposed mattress with
disinfectant and dry appropriately. Remove gloves.
10. Place the bottom sheet lengthwise starting from the foot
part towards the head part with the centerfold and center of
the bed.
11. Do the same process with the rubber sheet and cotton
draw sheet.
12. Put on clean gloves. Change the pillow case and place on
the clean side for client’s use with the opening facing away
the entrance of the door.
13. Assist client to rollover towards you onto the clean side
of the bed. Cover the patient and raise the bed side rail.
14. Move to the other side. Drop the bed side rail, loosen the
sides, roll and remove the soiled linen rolling them into a
bundle with soiled side turned in, discard into the lined bag
or hamper. If necessary wipe the mattress with antiseptic
solution and dry mattress surface. Remove gloves.
15. Pull bottom sheet from the center. Tuck and miter at the
head part.
16. Complete arrangement of the rubber sheet and cotton

draw sheet. Tuck excess under the mattress.
17. Reposition the client at the center of the bed. Adjust the
pillow.
18.Place the clean top linen, folded crosswise on top of the
patient’s chest (right side up) let patient hold on one edge
and bring the two edges down together towards the foot part.
Place the bath blanket into the hamper. Tuck and miter the
top sheet at the foot part.
19. Make necessary adjustment.
20. Make patient comfortable. Raise the side rail as
necessary.
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of C.I.

Name of Student: ___________________________________________________________
OFFERING AND REMOVING A BEDPAN AND URINAL
Retur 1 2 3 PE
STEPS n
Demo
1. Assemble all equipment and place them at bedside.
2. Explain the procedure.
3. Provide privacy, wash hands and apply gloves.
4. Place the bedpan or urinal at the foot part of the bed with
paper lining and cover.
5. FOR DISABLED PATIENTS: Elevate the head of the
bed to a high fowler position. Pie fold the top linen of the
patient. Be sure the height of the bed is within comfortable
working height. If elevation is contraindicated, support
client’s back with pillows as needed to prevent
hyperextension of the back.
6. Raise the side rail on the opposite side.
7. Warm bedpan under warm water if using a stainless
bedpan. If using a plastic bedpan wipe it with a tissue paper.
Powder the rim PRN.
8. If the patient needs assistance to move into the bedpan,
have him bend his knees and rest some of his weight on his
heels pressed against the bed.
9. Help the client as needed by placing hand over the lower
back, resting your elbow on the mattress and using your
forearm as lever.
10. Place regular bedpan to client’s buttocks on the smooth
rounded rim. Place a rolled towel under the patient’s back.
11. Check the placement of the bedpan, if patient is male,
urinal is then properly placed between slightly spread legs
with the bottom of the urinal resting on bed.
12. Fix top linen, leave a signal device and toilet paper
within patient’s reach. Leave the patient if it is safe to do so.
Raise the side rails.
13. When removing bedpan, don gloves. Hold the bedpan
and steady place patient on his side facing away from you
and wipe client’s perineal area with several layers of toilet
tissue. Clean from the urethra towards the anus.
14. Wash the perineal area of dependent client with soap and
water as indicated and thoroughly dry the area. Wash hands
by lining edge of bed with towel. Place over the towel a

paper lining, then the basin. Offer warm water, soap, rinse
and dry.
15. Remove the draw sheet if it is soiled, (with gloves on),
roll the sheet towards the opposite side of the bed.
16. Move to the opposite side of the bed and remove the
soiled sheet. Remove the gloves and replace new cotton
draw sheet.
17. Assist client to a comfortable position. Don gloves.
Empty and clean the bedpan and return it to the bedside.
18. Remove and discard the gloves and wash your hands.
19. For unconscious patient, after doing the perineal care,
place diaper.
20. Document and evaluate the color, odor, amount and
clarity of urine and presence of abnormalities of feces and
the condition of the perineal area.
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of C.I.

Name of Student _________________________________________________________
OPEN BED
STEPS Return 1 2 PE
Demo
1.Wash your hands.
2. Prepare the necessary linens. Fold them accordingly and
arrange in order of use.
3. Bring the linens to the bedside.
4. Straighten the mattress and turn if necessary.
5. Place the bottom sheet to the mattress, wrong side up and the
center fold of the sheet over the center mattress, the edge of the
bottom sheet should be in line with the edge of the foot part of
the bed.
6. Draw the top fold forward the head of bed, while facing the
foot part of the bed.
7. Lift the top most side of the sheet and fanfold towards the
center of the bed
8. Tuck the head end of the sheet well under the mattress, miter
the corner and tuck the sides smoothly towards the foot part.
9. Place the center fold of the rubber sheet which is folded
crosswise, wrong side up across the bed at least 2 feet from the
head part of the mattress. Lift the top most side of the sheet and
fanfold towards the center of the bed.
10. Place the center fold of cotton draw sheet which is folded
crosswise wrong side up on top of the rubber sheet. Lift the top
most side of the sheet and fanfold it towards the center, tuck them
together, starting from the center to the sides.
11. Place the top sheet folded right side up starting from the edge
of the head part of the bed.
12. Draw the top folds toward the foot of the bed while facing the
head part of the bed. Get the top most side and fanfold toward the
center of the bed.
13. Tuck the top sheet under the mattress at the foot part and
miter the corner leaving the side untucked.
14. Fold back the top sheet at about 18 inches from the edge of
the head part of the mattress.
15. Move to the other side of the bed and secure the bottom linen.
Tuck in the bottom sheet under the head part of the mattress, pull
the sheet firmly and miter the corner of the sheet. Complete the
same process for the rubber sheet and cotton draw sheet.
16. Straighten the top sheet.
17. Place the pillow case into the pillow by gathering up the sides
of the pillow case and grasp the closed end of the pillowcase at
the center with one hand and pull over the pillow. Place the
pillow appropriately at the head of the bed.
18. Inspect the bed and make necessary adjustments.
19. Pie fold the top sheet towards the center of the bed.
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of the CI

Name of Student: ____________________________________________________________
OPEN GLOVING
Return 1 2 3 PE
STEPS Demo
1. Secure the appropriate size and check the package including
the expiry date.
2. Wash and dry hands carefully.
3. Open the wrapper carefully and remove the inner package.
4. Place the sterile glove package on a clean and dry surface
above the waist.
5. Carefully open the inner package by grasping the flaps and
folded tabs.
6. Pick the glove for the dominant hand by its folded cuff edge.
Lift and step back.
7. Insert the dominant hand into the glove. Leave the cuff folded.
8. Insert gloved hand on the folded cuff into the other glove.
9. Adjust each glove and carefully pull the cuffs up.
10. After gloves are on, interlock hands.
11. To remove the gloves, grasp outside of one end of the cuff
with other gloved hand, avoid touching skin.
12. Pull glove off by turning it inside out.
13. Slide the 1st two fingers of the ungloved hand inside the
remaining glove. Grasp the glove inside and remove by turning
inside out from the hand and over the other glove.
14. Discard the gloves in an appropriate container and wash your
hands.
A.
B.
Total Score
Equivalent Grade

Final Grade
Signature of C.I.
Name of Student: ___________________________________________________________
PER OREM MEDICATION
Demo
1. Get medication card. Check with doctor’s order.
2. Arrange medication card on tray.
3. Place container with respective cards on tray.
4. Proceed with the preparation of medication.
5. Read medication card carefully.
6. Get medications one at a time from cubicle reading
label carefully and compare it with medicine ticket.
For liquid Medication
1. Read label before taking from the cubicle.
2. Read label before pouring.
3. Measure dosages accurately by pouring
medication at eye level and placing the
thumbnail on the medicine glass indicating
the prescribe dose.
4. Pour medication opposite the label of the
bottle.
5. Wipe mouth of the bottle with tissue paper.
6. Read label of the medication before putting it
back to cubicle.
For the tablets, capsules caplets and spansules medicines
1. Read label before taking from the cubicle.
2. Read label and stock before placing it in a
container.
3. Read label and stock before returning it back
to the medicine cubicle.
7. Place medicine in their proper container beside each

respective card.
8. Carry tray and medication to respective patients.
9. Ask patient’s name, verify with medication cards.
Prepare water if not contraindicated.
10. Place towel under chin as necessary.
11. Support back of neck of a bed patient in giving
medications. Give medications.
12. Follow with water if not contraindicated. Wipe
mouth with towel.
Note: if a number of medications are to be given liquid
medicine should be given last.
13. Turn each medicine card face down on corner of
tray after giving medication.
14. Leave patient comfortable.
15. Soak medicine glass in Lysol solution 5% for 30
minutes.
16. Wash with soap and water and scald.
17. Return to proper places.
18. Return medication cards after proper recording.
19. Chart medications whether given, refused, or
omitted.
20. Ability to answer question:
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of C.I.

Name of Student ____________________________________________
PHYSICAL ASSESSMENT
STEPS Return
Demo 1 2 3 PE
1. Prepare the necessary equipment and bring to the
area where the examination takes place.
2. Prepare the area where the examination takes place.
3. Wash your hands.
4. Explain the procedure to the client.
GENERAL SURVEY AND MENTAL STATUS
1. Observe body build, height and weight in relation to the
client’s age, lifestyle and health.
2. Observe the client’s posture and gait, standing, sitting
and walking.
3. Observe the client’s overall hygiene and grooming.
Relate this to the person’s activities prior to the
assessment.
4. Note body odor in relation to activity level.
5. Observe for the signs of distress in posture or facial
expression.
6. Note obvious signs of health or illness.
7. Assess the client’s attitude.
8. Note the client’s affect/mood; assess the
appropriateness of the client’s responses.
9. Listen for quantity, quality and organization of speech.
10. Listen for relevance and organization of thoughts.
11. Assess the client’s vital signs: temperature, pulse,
respirations, blood pressure and pain (as the 5th vital
sign)
12. Take the anthropometric measurements: height, weight,
waist and hip circumference and mid-arm
circumference, triceps skin fold thickness.
13. Calculate ideal body weight, body mass index, waist-
to-hip ratio, mid-arm muscle area and circumference.
14. Assess the client’s cognitive abilities (the Mini-Mental
Status Exam (MMSE) may be used):
 Orientation to person, time and place

 Concentration, ability to focus and follow directions
 Recent memory of happenings today
 Remote memory of the past
 Recall of unrelated information in 5, 10, and 30-
minute periods
 Abstract reasoning
 Judgment (what one would do in case of:)
 Visual perceptions and constructional ability (draw
a clock or shapes of square, etc…)
15. Ask the client to empty his bladder (give the client a
specimen cup, if sample is needed) and change into a
gown: ask client to sit on examination table.
SKIN
1. Inspect the skin color.
2. Inspect the uniformity of skin color.
3. Assess edema, if present.
4. Inspect, palpate, and describe skin lesions.
Apply gloves if lesions are open or draining (Describe
lesions according to location, distribution, color,
configuration, size, shape, type, or structure)
5. Observe and palpate skin moisture.
6. Palpate skin temperature (compare the two feet and two
hands using the back of your fingers)
7. Note skin turgor by lifting and pinching the skin on an
extremity.
SCALP AND HAIR
1. Inspect the scalp and hair for general color and
condition.
2. At 1(one) inch intervals, separate the hair from the
scalp and inspect and palpate the hair and scalp for
cleanliness, and dryness or oiliness.
3. Note presence of infections or infestations by parting
the hair in several areas and checking behind the ears
and along the hairline at the neck.
4. Inspect the amount and distribution of body hair.
NAILS
1. Inspect finger nail plate shape to determine its
curvature and angle.
2. Inspect finger nail and toenail texture.
3. Inspect finger nail and toenail bed color.
4. Inspect tissues surrounding nails.
5. Perform blanch test of capillary refill.
(Press two or more nails between your thumb and index
fingers; look for blanching and return of pink color to
nail bed.)
HEAD AND FACE
1. Inspect the skull for size, shape and symmetry.
2. Palpate the skull for nodules or masses and depressions.
(use a gentle rotating motion with the fingertips, begin
at the front and palpate down the midline, then palpate
each side of the head.)
3. Inspect the facial features.
4. Check function of CN VII (Facial) and note symmetry
of facial movement; have the client smile, frown, show
teeth, blow out cheeks, raise eyebrows, and tightly
close eyes.
5. Evaluate function of CN V (Trigeminal): Using the
sharp and dull sides of a paper clip, test sensations of
forehead, cheeks and chin.
6. Palpate temporal arteries for elasticity and tenderness.
7. As the client opens and closes mouth, palpate the
temporomandibular joint for tenderness, swelling and
crepitation.
EYES AND VISION
1. Inspect the eyebrow for hair distribution and alignment,
and for skin quality and movement.
2. Inspect the eyelashes for evenness of distribution and
direct of curl.
3. Inspect the eyelids for surface and characteristics,
position in relation to the cornea, ability to blink and
frequency of blinking. Inspect the lower eyelids while
the client’s eyes are closed.
4. Inspect the bulbar conjunctiva for color, texture and
presence of lesions.
5. Inspect the palpebral conjunctiva by everting the lids.
6. Evert the upper lids if a problem is suspected.
a. Ask the client to look down while keeping the
eyelids slightly open.
b. Gently grasp the client’s eyelashes with thumb and
forefinger. Pull lashes gently downward.
c. Place a cotton-tipped applicator stick about 1cm
above the lid margin, and push it gently downward
while holding the eyelashes.
d. Hold the margin of the everted lid or eyelashes
against the ridge of the upper bony orbit with the
applicator stick or your thumb.
e. Inspect the conjunctiva for color, texture, lesions
and foreign bodies.
7. Inspect and palpate the lacrimal gland.
a. Using the tip of your index finger, palpate the
lacrimal gland.
b. Observe the edema between the lower lid and the
nose.
8. Inspect and palpate the lacrimal sac and nasolacrimal
duct.
a. Observe for evidence of increased tearing.
b. Using the tip of your index finger, palpate inside
the lower orbital rim near the inner canthus.
9. Inspect the cornea for clarity and texture. Ask the client
to look straight ahead. Hold a penlight at an oblique
angle to the eye, and move the light slowly across the
corneal surface.
10. Perform the corneal sensitivity (reflex test to determine
the function of CN V (trigeminal): ask the client to
keep both eyes open and look straight ahead. Approach
from behind and beside the client, and lightly touch the
cornea with a corner of the gauze.
11. Inspect the anterior chamber for transparency and
depth. Use the same oblique lighting used when testing
the cornea.
12. Inspect the pupils for color, shape and symmetry of
size.

13. Assess each pupil’s direct and consensual reaction to
light.
a. Partially darken a room.
b. Ask the client to look straight ahead.
c. Using a penlight and approaching from the side,
shine a light on the pupil.
d. Observe the response. The pupil should also
constrict (direct response).
e. Shine the light on the pupil again and observe the
response of the other pupil. It should also constrict.
(consensual response)
14. Assess each pupil’s reaction to accommodation.
a. Hold an object about 10cm from the client’s nose.
b. Ask the client to look first at top of the object and
then at a distance object behind the penlight.
Alternate the gaze between the near and far objects.
c. Observe the pupil response. Pupils should constrict
when looking at near object and dilate when
looking at the far object.
d. Next, move the penlight or pencil toward the
client’s nose. The pupils should converge. To
record normal assessment of the pupils, use the
abbreviation PERRLA
15. Assess peripheral visual fields.
a. Have the client sit directly facing you at distance of
60-90cm.
b. Ask the client to cover right eye with the card and
look directly at your nose.
c. Cover or close your eye directly opposite the
client’s covered eye and look directly at the client’s
nose.
d. Hold an object in your fingers, extend your arm,
and move the object into the visual field from
various points in the periphery. The object should
be at an equal distance from the client and yourself.
Ask the client to tell you when the moving object is
first spotted.
e. To test the temporal field of the left eye, extend and
move your right arm in from the client’s right
periphery. Temporally, peripheral objects can be
seen at right angles to the central point of vision.
f. To test the upward field of the left eye, extend and
move the right arm down from the upward
periphery. The upward field of vision is normally
50 degrees because the orbital edge is in the way.
g. To test the downward field of the left eye, extend
and move the right arm up from the lower
periphery. The downward field of vision is
normally 70 degrees because the cheekbone is in
the way. (repeat the above steps for the right eye).
16. Assess six ocular movements to determine eye
alignment and coordination.
a. Stand directly in front of the client, and hold the
penlight at a comfortable distance such as 30cm in
front of the client’s eyes.
b. Ask client to hold the head in fixed position facing
you and follow the movements of the penlight with
the eyes only.
c. Move the penlight in a slow, orderly manner
through the six cardinal fields of gaze.
d. Stop the movement of the penlight periodically so
that nystagmus can be detected.
17. Assess for location of light reflex by shining a penlight
on the pupil in corneal surface (Hirschberg test)
18. Have the client fixate on a near or far object. Cover one
eye, and observe for movement in the uncovered eye
(cover test).
19. Assess near vision by providing adequate lighting and
asking the client to read from a magazine or newspaper.
20. Assess distance vision by asking the client to wear
corrective lenses unless they use for reading only.
a. Ask the client to sit or stand 6 meters (20ft) from
Snellen’s chart, cover the eye not being tested and
identify the letters or characters.
b. Take three readings: right eye, left eye, and both
eyes.)
c. Perform functional vision tests if the client is
unable to see the top line (20/200) of Snellen’s
chart.
21. Use the ophthalmoscope to inspect:
 Optic disc for shape, color, size, and physiologic
cup
 Retinal vessels for color and diameter and AV
crossings
 Retinal background for color and lesions
 Fovea central is (sharpest area of vision) and
macula
 Anterior chamber for clarity
EARS AND HEARING

1. Inspect the auricles for color, symmetry of size, and
position. To inspect position, note the level at which the
superior aspect of the auricle attaches to the head with
relation to the eye.
2. Palpate the auricles for texture, elasticity, and areas of
tenderness.
a. Gently pull the auricle upward, downward and
backward.
b. Fold the pinna forward. (it should recoil)
c. Push in on the tragus.
d. Apply pressure to the mastoid process.
3. Using an otoscope, inspect the external ear canal for
cerumen, skin lesions, pus and blood.
a. Attach a speculum to the otoscope.
b. Tip the clients head away from you and straighten
the ear canal.
c. Hold the otoscope either right side up, with your
fingers between the otoscope handle and the client’s
head, or upside down, with your fingers and the
ulnar surface of your hand against the client’s head.
d. Gently insert the tip of the otoscope into the ear
canal, avoiding pressure by the speculum against
either side of the ear canal.

4. Inspect the tympanic membrane for color, and gloss.
5. Assess the client’s response to normal voice tones. If
the client has difficulty hearing the normal voice,
proceed with the following tests.
a. Perform the watch tick test.
 Have the client occlude one ear. Out of the client’s
sight, place a ticking watch 2-3cm (1-2inches) from
the un-occluded ear.
 Ask what the client can hear. Repeat with the other
ear.
b. Tuning fork tests
Perform Weber test.
 Hold the tuning fork at its base. Activate it by
tapping the fork gently against the back of your
hand near the knuckles or by stroking the fork
between your thumb and index fingers.
 Place the base of the vibrating fork on top of the
client’s head, and ask whether the client hears the
noise.
Conduct Rinne Test.
 Ask the client to block the hearing in one ear
intermittently by moving a fingertip in and out of
the ear canal.
 Hold the handle of the activated tuning fork on the
mastoid process of one ear until the client states that
the vibration can no longer be heard.
 Immediately hold still the vibrating fork prongs in
front of the client’s ear canal. If necessary, push
aside the client’s hair. Ask whether the client now
hears the sound.
NOSE AND SINUSES
1. Inspect the external nose for any deviations in shape,
size, or color and flaring, or discharges from the nares.
2. Lightly palpate the external nose to determine any areas
of tenderness, masses, or displacements of bone and
cartilage.
3. Determine patency of both nasal cavities. Ask the client
to close the mouth, exert pressure on one nostril, and
breathe through the opposite nostril. Repeat the
procedure to assess patency of the opposite nostril.
4. Inspect the nasal cavities using a flashlight or a nasal
speculum.
a. Hold the speculum in your right hand and inspect
the client’s left nostril, and in your left hand to
inspect the client’s right nostril.
b. Tip the client’s head back.
c. Facing the client, insert the tip of the closed
speculum about 1cm or up to the point at which the
blade widens. Care must be taken to avoid pressure
on the sensitive nasal septum.
d. Stabilize the speculum with your index finger
against the side of the nose. Use the other hand to
position the head and then to hold the light.
e. Open the speculum as much as possible and inspect
the floor of the nose, the anterior portion of the
septum, the middle meatus, and the middle

turbinates. The posterior turbinate rarely is
visualized because of its position.
f. Inspect the lining of the nares and the integrity and
the position of the nasal septum.
5. Observe for presence of redness, swelling, growths and
discharge.
6. Inspect the nasal septum between the nasal chambers.
7. Palpate the maxillary and frontal sinuses for tenderness.
8. Percuss the sinuses, lightly tap over the frontal and
maxillary sinuses for tenderness.
9. If tenderness was detected trans-illuminate the sinuses.
MOUTH AND OROPHARYNX
1. Inspect the outer lips for symmetry of contour, color
and texture. Ask the client to purse the lips as if to
whistle.
2. Inspect and palpate the inner lips and buccal mucosa
for color, moisture, texture and the presence of lesions.
3. Inspect the teeth and gums while examining the inner
lips and buccal mucosa.
4. Inspect the dentures. Ask the client to remove complete
or partial dentures. Inspect their condition, noting in
particular broken or worn areas.
5. Inspect the surface of the tongue for position, color, and
texture. Ask the client to protrude the tongue and to
move it from side to side.
6. Inspect tongue movement. Ask the client to roll the
tongue upward and to move it from side to side.
7. Inspect the base of the tongue, the mouth floor and the
frenulum. Ask the client to place the tip of his/her
tongue against the roof of the mouth.
8. Palpate the tongue and floor of the mouth for any
nodules, lumps, or excoriated areas. Use a piece of
gauze to grasp the tip of the tongue and with the index
finger of your other hand, palpate the back of the
tongue, its borders, and its base.
9. Inspect salivary duct openings for any swelling or
redness.
10. Inspect the hard and soft palate for color, shape,
texture, and presence of bony prominences. Ask the
client to open mouth wide and tilt head backward.
Then, depress tongue with tongue blade as necessary,
and use a penlight for appropriate visualization.
11. Test CN IX and CN X: assess tongue strength by
asking client to press tongue against tongue blade.
12. Inspect the uvula for position and mobility while
examining the palates. To observe the uvula, ask the
client to say, “ahh” so that the soft palate rises.
13. Inspect the oropharynx for color and texture. Inspect
one side at time to avoid eliciting the gag reflex. To
expose one side of the oropharynx, press a tongue blade
against the tongue on the same side about halfway back
while the client tilts head back and opens mouth wide.
Use a penlight for illumination, if needed.
14. Inspect the tonsils for color, discharge, and size.
15. Test CN X: Elicit the gag reflex by pressing the
posterior tongue with a tongue blade.
16. Assess CN VII and CN IX: have the client close her
eyes. Check taste by placing salt, sugar, and lemon on
tongue.
NECK
1. Inspect the neck muscles, sternocleidomastoid and
trapezius for abnormal swelling or masses. Ask the
client to hold head erect.
2. Observe head movement. Ask the client to:
a. Move chin to the chest (determines function of the
sternocleidomastoid muscle).
b. Move head back so that the chin points upward
(determines function of the trapezius muscle).
c. Move head so that the ear is moved toward the
shoulder on each side (determines function of the
sternocleidomastoid muscle).
d. Turn head to the right and to the left (determines
the function of the sternocleidomastoid muscle.)
3. Assess muscle strength. Ask client to:
a. Turn head to one side against resistance of your
hand. Repeat with the other side.
b. Shrug shoulders against resistance of your hands.
4. Palpate the entire neck for enlarged lymph nodes.
5. Palpate the trachea for lateral deviation.
a. Place your fingertip or thumb on the trachea in the
suprasternal notch, then move your finger laterally
to the left and the right spaces bordered by the
clavicle, the anterior aspect of the
stemocleidomastoid muscle and the trachea.
6. Inspect the thyroid gland.
a. Stand in front of the client.
b. Observe the lower half of the neck overlying the
thyroid gland for symmetry and visible masses.
c. Ask the client to hyperextend head and swallow. If
necessary, offer a glass of water to make it easier
for the client to swallow.
7. Palpate the thyroid gland for smoothness. Note any
areas for enlargement, masses, or nodules.
8. If enlargement of the gland is suspected: Auscultate
over the thyroid area for a bruit. Use the bell-shaped
diaphragm of the stethoscope.
POSTERIOR AND LATERAL THORAX
1. Inspect the shape and symmetry of the thorax from
posterior and lateral views. Compare the anteroposterior
diameter to the transverse diameter.
2. Inspect the spinal alignment for deformities.
a. Have the client stand. From a lateral position,
observe the three normal curvatures: cervical
thoracic, and lumbar.
b. To assess for lateral deviation of the spine
(scoliosis), observe the standing client from the
rear. Have the client bend forward at the waist, and
observe from behind.
3. Palpate the posterior thorax.
a. For client who has no respiratory complaints, rapidly
assess the temperature and integrity of all chest skin.
b. For clients who do have respiratory complaints, palpate

all chest areas for bulges, tenderness or abnormal
movements.Avoid deep palpation for painful areas,
especially if a fractured rib is suspected.
4. Palpate the posterior chest for respiratory excursion.
a. Place the palms of both your hands over the lower
thorax with your thumbs adjacent to the spine and
your fingers stretched laterally. Ask the client to
take a deep breath while you observe the movement
of your hands and any lag in movement.
5. Palpate the chest for vocal (tactile) fremitus.
a. Place the palmar surfaces of your fingertips or the
ulnar aspect of your hand or closed fist on the
posterior chest, starting near the apex of the lungs.
b. Ask the client to repeat such words as “blue moon”
or “one, two, three”.
c. Repeat the two steps, moving your hands
sequentially to the base of the lungs.
d. Compare the fremitus on both lungs and between
the apex and base of each lung, either: using one
hand and moving it from one side of the client to
the corresponding area on the other side or using
two hands that are placed simultaneously on the
corresponding areas of each side of the chest.
6. Percuss the thorax.
7. Percuss the diaphragmatic excursion.
8. Auscultate the chest using the flat-disc diaphragm of the
stethoscope.
a. Use the systematic zigzag procedure used on
percussion.
b. Ask the client to take slow, deep breaths through
the mouth. Listen at each point to the breath sound,
adventitious sounds and voice sounds
(bronchophony, egophony and whispered
pectoreloquy) during a complete inspiration and
expiration.
c. Compare findings at each point with the
corresponding point on the opposite side of the
chest.
ANTERIOR THORAX
9. Inspect breathing patterns.
10. Inspect the coastal angle and the angle at which the ribs
enter the spine.
11. Palpate the anterior chest.
12. Palpate the anterior chest for respiratory excursion.
a. Place the palms of both your hands on the lower
thorax, with your fingers laterally along the lower
rib cage and your thumb along the coastal margins.
b. Ask the client to take a deep breath while you
observe the movement of your hands.
13. Palpate tactile fremitus in the same manner as for the
posterior chest, if the breasts are large and cannot be
retracted adequately for palpation, this part of the
examination usually is omitted.
14. Percuss the anterior chest systematically.
a. Begin at the clavicles in the supraclavicular space,
and proceed downward to the diaphragm.

b. Compare on side of the lung to the other.
c. Displace female breast for proper examination.
15. Auscultate the trachea.
16. Auscultate the anterior chest. Use the sequence used in
percussion, beginning over the bronchi between the
sternum and the clavicles.
HEART AND CENTRAL VESSELS
1. Simultaneously inspect and palpate the precordium for the
presence of abnormal pulsations, lifts, or heaves.
a. Inspect and palpate the aortic and pulmonic areas,
observing them at an angle and to the side to note
the presence or absence of pulsations.
b. Inspect and palpate the tricuspid area for pulsations
and heaves or lifts.
c. Inspect and palpate the apical areas for pulsation.
Note its specific location (it may be displaced
laterally or lower) and diameter, if displaced
laterally, record the distance between the apex and
the MCL in centimeters.
d. Inspect and palpate the epigastric area at the base of
the sternum for abdominal aortic pulsations.
2. Auscultate the heart in all four anatomic sites: aortic,
pulmonic, tricuspid, and apical (mitral).
3. Palpate the carotid artery. Use extreme caution.
4. Auscultate the carotid artery.
5. Inspect the jugular veins for distention. The client is placed
in a semi-Fowler’s position, 30-45 degrees elevated, with
the head supported on small pillow.
6. If jugular distention is present, assess the jugular venous
pressure (JVP).
a. Locate the highest visible point of distention of the
internal jugular vein.
b. Measure the vertical height of this point in centimeters
from sternal angle, the point at which the clavicles meet.
(repeat the steps above on the other side.)
PERIPHERAL VASCULAR SYSTEM

1. Palpate the peripheral pulses on both sides of the client’s
body individually, simultaneously (except the carotid
pulse), and systematically to determine the symmetry of
pulse volume.
2. Inspect the peripheral veins in the arms and legs for the
presence and/or appearance of superficial veins when limbs
are dependent and when limbs are elevated.
3. Assess the peripheral leg veins for sign of phlebitis.
a. Inspect calves for redness and swelling over vein sites.
b. Palpate the calves for firmness or tension of the muscle,
edema over the dorsum of the foot, and areas of
localized warmth.
c. Push the calves from side to side.
Firmly dorsiflex the client’s foot while supporting entire leg in
extension, or have the person stand or walk.
BREAST AND AXILLA
1. Inspect the breast for size, symmetry, and contour or shape
while the client is in a sitting position.
2. Inspect the skin of the breast for localized discoloration
or hyperpigmentation, retraction or dimpling, localized
hyper-vascular areas, swelling, or edema.
3. Emphasized any retraction by having the client:
 Raise the arms above the head;
 Push the hands together, with elbows flexed; and
 Press the hand down the hips.
4. Inspect the areola area for size, shape, symmetry, color,
surface characteristics, and any masses or lesions.
5. Inspect the nipples for size, shape, position, color,
discharges, and lesions.
6. Palpate the axillary, sub-clavicular, and supraclavicular
lymph nodes.
a. The client is seated with her arms abducted and
supported on the nurse’s forearm.
b. Use flat surface of all fingertips to palpate the four
areas of the axilla:
 The edge of the greater pectoral muscle along the
anterior axillary line
 The thoracic wall in the midaxillary area
 The upper part of the humerus
 The anterior edge of the latissimus dorsi muscle
along the posterior axillary line.
7. Palpate the breast for masses, tenderness, and any
discharge from the nipples.
8. Palpate the areola and the nipples for masses.
a. Compress each nipple to determine the presence of
any discharge. If discharge is present, milk the
breast along its radius to identify the discharge-
producing lobe.
b. Assess any discharge for amount, color,
consistency, and odor.
c. Note any tenderness on palpation.
9. Teach the client the technique for breast self-
examination.
ABDOMEN
1. Inspect the abdomen for skin integrity.
2. Inspect the abdomen for contour and symmetry.
a. Observe the abdominal contour while
standing at the client’s side when the
client is in supine.
b. Ask the client to take a deep breath and
to hold it.
c. Assess the symmetry contour while
standing at the foot of the bed.
d. If distention is present, measure the
abdominal girth by placing a tape
around the abdomen at the level of the
umbilicus.
3. Observe abdominal movements associated with
respiration, peristalsis, or aortic pulsations.
4. Observe the vascular pattern.
5. Auscultate the abdomen for bowel sounds, vascular
sound, and peritoneal friction rubs.
6. Percuss several areas in each of the four quadrants to
determine presence of tympany and dullness. Use
systematic pattern: Begin in the lower left quadrant,
then proceed to the lower right quadrant, the upper
right quadrant, and the upper left quadrant.
7. Percuss the liver to determine its size.
8. Perform light palpation first to detect areas of
tenderness and/or muscle guarding.Systematically
explore all four quadrants.
9. Perform deep palpation over four quadrants.
10. Palpate the liver to detect enlargement and tenderness.
11. Palpate the area above the pubic symphysis if the
client’s history indicates possible urinary retention.
MUSCULOSKELETAL SYSTEM
1. Inspect the muscle for size. Compare each muscle on
one side of the body to the same muscle on the other
side. For any apparent discrepancies, measure the
muscle with a tape.
2. Inspect the muscles and tendons for contractures.
3. Inspect the muscle for tremors. Inspect any tremors of
the hands and arms by having the client hold arms out
in front of the body.
4. Palpate muscles at rest to determine muscle tonicity.
5. Palpate muscles while the client is active and passive
for flaccidity, spasticity, and smoothness of movement.
6. Test muscle strength. Compare the right side with left
side.
7. Inspect the skeleton for normal structures and
deformities.
8. Palpate the bones to locate any areas of edema or
tenderness.
9. Inspect the joint for swelling. Palpate each joint for
tenderness, smoothness of movement, swelling,
crepitation, and presence of nodules.
10. Assess joint range of motion.Ask the client to move
selected body parts. If available, use a goniometer to
measure the angle of the joint in degrees.
NEUROLOGICAL SYSTEM
1. Test the cranial nerves:
Cranial Nerve I – Olfactory
 Ask client to close eyes and identify different mild
aromas such as coffee and vanilla.
Cranial Nerve II – Optic
 Ask client to read Snellen’s chart; check visual
fields by confrontation, and conduct an
opthalmoscopic examination.
Cranial Nerve III – Oculomotor
 Assess six ocular movements and pupil reaction.
Cranial Nerve IV – Trochlear
 Assess six ocular movements.
Cranial Nerve V – Trigeminal
 While client look upward, lightly touch the lateral
sclera of the eye to elicit the blink reflex. To test
the light sensation, have the client close eyes, and
wipe a wisp of cotton over client’s forehead and
paranasal sinuses. To test deep sensation, use
alternating blunt and sharp ends of safety pin over
the same areas.
Cranial Nerve VI – Abducens
 Assess direction of gaze.
Cranial Nerve VII – Facial
 Ask client to smile, raise eyebrows, frown, puff out
cheeks, and close eyes tightly. Ask the client to
identify various taste placed at the tips and sides of
tongue—sugar, salt—and to identify sense of taste
Cranial Nerve VIII – Auditory
 Assess client’s ability to hear the spoken word and
the vibrations of turning fork.
Cranial Nerve IX – Glossopharyngeal
 Apply tastes on posterior tongue for identification.
Ask the client to move tongue from side to side and
up and down.
Cranial Nerve X – Vagus
 Assessed with CN IX; assess the client’s speech for
hoarseness.
Cranial Nerve XI – Accessory
 As client to shrug shoulders against resistance for
your hands and to turn head to the side against
resistance from your hand. Repeat for other side.
Cranial Nerve XII – Hypoglossal
 Ask client to protrude tongue at midline, and then
move it side to side.
2. Test reflexes using percussion hammer, comparing one

side of the body with the other to evaluate the
symmetry of response.
Biceps Reflex:
The biceps reflex tests the spinal cord levels C-5, C-
6.
 Partially reflex the client’s arm at the elbow, and
rest the forearm over the thighs, placing palm of the
hand down.
 Place thumb on nondominant hand horizontally
over the biceps tendon.
 Deliver a blow (slight downward thrust) with
percussion hummer to the thumb
 Observe the normal slight flexion of the elbow, and
feel the bicep’s contraction through the thumb.
Triceps reflex:
The triceps reflex test the spinal cord levels C-7, C-8
 Flex the client’s arm at the elbow, and support it in
the palm of nondominant hand.
 Palpate the triceps tendon about 2-5cm (1-2 inches)
above the elbow.
 Deliver blow with a percussion hammer directly to
the tendon
 Observe the normal flexion and supination of the
forearm, the fingers of the hand might also extend
slightly.
Brachioradialis Reflex:
The brachioradialis reflex test the spinal cord levels
C-3, C-4.
 Rest the client’s arm in a relaxed position of the
forearm on the client’s own leg.
 Deliver a blow with the percussion hammer
directly on the radius 2-5 cm (1-2 inches) above the
wrist or the styloid process, the bony prominence
on the thumb side of the wrist.
 Observe the normal flexion and supination of the
forearm. The fingers of the hand might also extend
slightly.
Patellar Reflex
The patellar reflex text the spinal cord levels L-2, L-
3, L-4.
 Ask client to sit on the edge of the examining table
so that the legs hang freely.
 Locate the patellar tendon directly below the
patella.
 Deliver a blow with the percussion hammer
directly to the tendon.
 Observe the normal extension or kicking out of the leg as

the quadriceps muscle contracts.
 Of no response occur, and suspect the client’s is not
relaxed, ask the client to interlock fingers and pull.
Achilles Reflex:
The Achilles reflex tests the spinal cord levels S-1, S-2.
 With the client in the same position as for the patellar
reflex test, slightly dorsiflex the client’s angle by
supporting the foot lightly in the hand.
 Deliver blow with the percussion hammer directly to the
Achilles tendon just above the heel.
 Observe and feel the normal plantar flexion (downward
jerk) of the foot.
Plantar (Babinski’s) Reflex
The plantar or Babinski’s Reflex is superficial. It might be
absent in adults with pathology or overridden by voluntary
control.
 Use a moderately sharp object such as the handle of the
percussion hammer, a key, or the dull end of a pin or
applicator stick.
 Stroke the lateral border of the sole of the client’s foot,
starting at the heel, continuing to the ball of the foot, and
then proceeding across the ball of the foot toward the big
toe.
 Observe the response. Normally, all five toes bend
downward; this reaction is negative Babinski’s. In an
abnormal Babinski response, the toes spread outward and
the big toe moves upward.
3. Gross Motor and Balance Tests
Walking Gait
 Ask the client to walk across the room and back, and
assess the client’s gait.
Romberg’s Test
 Ask the client to stand with feet together and arms resting
at the sides first with eyes open, then closed.
Standing on One Foot with Eyes Closed
 Ask the client to close eyes and stand on one foot, then the
other. Stand close to the client during this test.
Heel-Toe Walking
 Ask the client to walk a straight line, placing the heel of
the one foot directly in front of the toes of the other foot.
Toe or Heel Walking
Ask the client to walk several steps on the toes and then on
the heels.
4. Fine Motor Tests for Upper Extremities
Finger-to-Nose Test
 Ask the client to abduct and extend arms at shoulder height
and rapidly touch nose alternately with one index finger
and then the other. Have the client repeat the test with eyes
close if the test is performed easily.
Alternating Supination and Pronation of Hands on Knees
 Ask the client to pat both knees with the palms of both
hands and then with the backs of hands, alternately, at an
ever-increasing rate.
Finger-to-Nose and to the Nurse’s Finger
 Ask the client to touch nose and then your index finger,
held at a distance of about 45 cm (18 inches), at a rapid
and increasing rate.
Fingers to Fingers
 Ask the client to spread arms broadly at shoulder height
and then bring fingers together at the midline, first with
eyes open and then closed, first slowly then rapidly.
Fingers to Thumb (Same Hand)
 Ask the client to touch each finger of one hand to the
thumb of the same hand as rapidly as possible.
5. Fine Motor Tests for Lower Extremities
Ask the client to lie supine and to perform these tests:
Heel Down Opposite Shin
 As the client to place the heel of one foot just below the
opposite knee and run the heel down the shin to the foot.
Repeat with the other foot. The client may also use a
sitting position for this test.
Toe or Ball of Foot to the Nurse’s Finger
 As the client to touch your finger with the large toe of each
foot.
6. Light Touch Sensation
 Compare the light touch sensation of symmetric areas of
the body.
 Ask the client to close eyes and to respond by saying “yes”
or “no” whenever the client feels the cotton wisp touching
the skin.
 With a wisp of cotton, lightly touch one specific spot and
then the same spot on the other side of the body.
 Test areas on the forehead, cheek, hand, lower arm,
abdomen, foot, and lower leg. Check the distal area of the
limb first.
 Ask the client to point to the spot where the touch was felt.
 If areas of sensory dysfunction are found, determine the
boundaries of sensation by testing responses
approximately every 2.5cm (1 inch) in the area. Make a
sketch of the sensory loss area for recording purposes.
7. Pain Sensation
Assess pain sensation as follows:
 Ask the client to close his/her eyes and say, “sharp,”
“dull,” or “don’t know” when the sharp or dull end of the
broken tongue depressor is felt.
 Alternatively, use the sharp and dull end of a sterile pin or
needle to lightly prick designated anatomic areas at
random. The face is not tested in this manner.
 Allow at least two seconds between each test.
8. Temperature Sensation
 Touch skin areas with test tubes filled with hot or cold
water.
 Have the client respond by saying “hot,” “cold,” or “don’t
know.”
9. Position or Kinesthetic Sensation
Commonly, the middle dingers and the large toes are tested for the
kinesthetic sensation.
 To test the fingers, support the client’s arm with one hand
and hold the client’s palm in the other. To test the toes,
place the client’s heels on the examining table.
 Ask the client to close his/her eyes.
 Grasp a middle finger or a big toe firmly between your
thumb and index finger and exert the same pressure on
both sides of the finger or toe while moving it.
 Move the finger or toe until it is up, down, or straight out
and ask the client to identify the position.
 Use a series of brisk up-and-down movements before
bringing the finger or toe suddenly to rest in one of the
three positions.
10. Tactile Discrimination
For all tests, the client’s eyes need to be closed:
One and Two-Point Discrimination
 Alternately stimulate the skin with two pins
simultaneously and then with one pin. Ask whether the
client feels one or two pinpricks.
Stereognosis
 Place familiar objects such as a key, paperclip, or coin in
the client’s hand and ask the client to identify them.
 If the client has a motor impairment of the hand and is
unable to manipulate an object, write a number or letter on
the client’s palm, using blunt instrument, and ask the client
to identify it.
Extinction Phenomenon
 Simultaneously stimulate two symmetric areas of the body
such as the thighs, cheeks, or hands.
FEMALE GENITALIA AND INGUINAL
1. Inspect the distribution, amount, and characteristics of the
pubic hair.
2. Inspect the skin of the pubic area for parasites,
inflammation, swelling, and lesions. To assess pubic skin
adequately, separate the labia majora and labia minora.
3. Inspect the clitoris, urethral orifice, and vaginal orifice
when separating the labia minora.
4. Palpate the inguinal lymph nodes.
MALE GENITALIA AND INGUINAL
1. Inspect the distribution, amount, and characteristics of the
pubic hair.
2. Inspect the penile shaft and glans penis for lesions,
nodules, swellings, and inflammation.
3. Inspect the urethral meatus for swelling, inflammation, and
discharge.
 Compress or ask the client to compress the glans
slightly to open the urethral meatus to inspect it for
discharge.
 If the client has reported discharge, instruct the
client to strip the penis from the base to the urethra.
4. Palpate the penis for tenderness, thickening, and nodules.
Use your thumb and first two fingers.
5. Inspect the scrotum for appearance, general size, and
symmetry.
a. To facilitate inspection of the scrotum during a
physical examination, ask the client to hold the
penis out of the way.
b. Inspect all skin surfaces by spreading the rugated
surface skin and lifting the scrotum as needed to
observe posterior surfaces.
6. Palpate the scrotum to assess the status of underlying
testes, epididymis, and spermatic cord. Palpate both testes
simultaneously for comparative purposes.
7. Inspect both inguinal areas for bulges while the client is
standing, if possible.
 First have the client remain at rest.
 Next, have the client hold his breath and strain or
bear down as though having a bowel movement.
8. Palpate hernias.
RECTUM AND ANUS
1. Inspect the anus and surrounding tissue for color, integrity,
and skin lesions.
o Then ask the client to bear down as though
defecating.
o Describe the location of all abnormal findings in
terms of a clock with the 12 o’clock position
toward the pubis symphysis.
2. Palpate the rectum for anal sphincter tonicity, nodules,
masses, and tenderness.
3. On withdrawing the finger from the rectum and anus,
observe it for feces. If ordered, perform a test for occult
blood on the stool.
A.
B.
Total Score
Equivalent
Signature of C.I.

Name of Student ___________________________________________________________
POSITIONING AND DRAPING THE PATIENT
Demo
DORSAL RECUMBENT POSITION
2. The patient lies close to the edge of the bed or
examining table.
3. While lying in his/her back, the legs are separated and
the knees are flexed, the soles of the feet are on the bed.
4. The pillow maybe placed under the head.
5. The drape is placed diagonally on the patient with
opposite corners protecting the legs and wrapped
around the feet.
6. The third corner of the drape covers the patient’s chest
and the fourth corner is placed between the legs.
LITHOTOMY POSITION
1. The patient’s buttocks are placed to the edge of the
table.
2. The knees are flexed and the feet are supported with
stirrups.
3. The pad maybe placed under the buttocks.
4. The draping is the same as in the dorsal recumbent
position.
SIM’S POSITION
1. The patient lies on his left side and rests his arm behind
his body.
2. The right arm is placed forward and the arm is resting
on a pillow placed under the patient’s head.
3. The patient’s body inclines slightly forward.
4. The knees are bent. The right knee is bent sharply in the
left Sim’s position and the placements of the extremities
are reversed.
ERECT POSITION
1. The normal anatomical standing position
PRONE POSITION
1. The patient lies on his abdomen.
DORSAL or SUPINE POSITION
1. The patient lies flat on his back with his legs together in
bed or examining table.
2. The patient’s head maybe supported with a pillow.
3. The patient’s legs are extended.
4. The patient’s feet must be supported with pillows.
FOWLER’S POSITION
1. The head and trunk are raised 45° - 60° angle.
2. The knees may or may not be flexed.
SEMI FOWLER’S POSITION
1. The head and trunk are raised 15° - 45°.
HIGH FOWLER’S POSITION
1. The head and trunk are raised 60° - 90°.
KNEE- CHEST or GENOPECTORAL POSITION
1. The patient in this position rests his knees and chest on
the surface of the bed with the body flexed.
2. The patient’s head turned to one side resting on a pillow

and small pillow maybe placed under the chest.
3. The arms are above the head or they maybe flexed at
the elbow and rest along the side of the patient’s head.
4. The lower legs are placed perpendicularly to the thighs.
HYPEREXTENSION POSITION
1. The patient’s cervical spine is hyper extended when
looking overhead toward the ceiling.
TRENDELENBURG POSITION
1. The patient lies flat on his back with the legs together
and the foot of the bed is elevated.
REVERSE TRENDELENBURG POSITION
1. The head of the bed is raised and the foot part is
lowered.
SHOCK POSITION
1. The head is supported with a pillow, the trunk is
horizontal and the legs are elevated at about 15° without
bending knees.
ORTHOPNIC POSITION
1. The client is either in bed or on the side of the bed with
an over bed table across the lap.
SITTING POSITION
1. A seated position, back unsupported and legs hanging
freely.
A.
B.
TOTAL SCORE
EQUIVALENT GRADE
 With patient
FINAL GRADE
SIGNATURE OF C.I.

Name of Student_____________________________________________________________
POST MASTECTOMY EXERCISES
STEPS Return 1 2 PE
Demo
1. Check doctor’s order and identify the patient.
3. Assume/place patient in standing/sitting position.
4. Ball squeezing. A rubber ball or a crumpled newspaper squeeze in
the hand of the involved side.
5. Wall climbing. The women sit or stand facing the wall, with toes
6-12 inches from wall. Bend elbows and place palms against wall at
shoulder level, and walk “the fingers up the wall by flexing the
fingers. Gradually move both hands up the wall parallel to each other
until incision pulling or pain occurs. (Mark that spot-on wall to
measure progress.) Work hands down to shoulder level. Move closer
to wall as height of reach improves. Do not expect to reach full
extension immediately but try to increase your range of motion each
time. Perform 5 repetitions. Always lead with the unaffected hand.
6. Pendulum or Arm swinging. Stand with feet 8 inches apart. Bend
forward from waist, allowing arms to hang toward floor. Swing both
arms up to side to reach shoulder level. Swing back to center, then
cross arms at center. Do not bend elbows, if possible, do this and
other exercise in front of mirror to ensure even posture and correct
motion.
7. Fitting clasped hands. The patient clasps her hands and lifts then
slowly over head, keeping the elbows straights.
8. Elbow spread. The hands are clasped behind the neck, and the
elbows are slowly raised to chin level while the head is held erect.
Gradually the elbows are spread apart to the point at which incision
pain or pulling is felt.
9. Pulley or rope pulling. The patient pulls the string down and
opposite arm is raised.
10. Rod or broomstick lifting. Grasps a rod with both hands, held
about 2 feet apart. Keeping the arms straight, raise the rod over the
head. Bend elbows to lower the rod behind the head. Reverse
maneuver, raising the rod above the head, then return to the starting
position.
11. Deep breathing. The patient is placed on sitting position, her
hand over the involve portion of her chest and takes a deep breath
through the nose, feeling her chest expand as the breath is inhaled, as
she exhaled, the chest and shoulder sags and reflex.
13. Chart procedure done, time and reaction of patient.
A.
B.
TOTAL SCORE
EQUIVALENT GRADE
 With patient
FINAL GRADE
SIGNATURE OF C.I.

Name of Student: ________________________________________________
POST MORTEM CARE
STEPS Return 1 2 3
Demo
1. As soon as the doctor has pronounced the patient dead, notify
supervisor.
2. Assemble all equipment needed and carry to bedside.
3. Remove jewelry, clothes, money and other valuables and give
them to the relatives and have them sign for the receipt of the
valuables. Wash hands.
4. Head nurse or supervisor takes relatives to business office.
5. Instruct relatives to get out of the room while procedure is to
be done.
6. Screen patient PRN.
7. Put on mask, and gown and gloves with technique (CD or
Non- CD).
8. Remove all covers except the top and bottom sheets. Remove
all rubber rings, ice caps, etc.
9. Place patient in dorsal recumbent position without pillow.
10. Put back false teeth if there is any and close mouth.
11. Apply tie around the anterior head to keep mouth closed.
12. Close eyes by bringing upper lids down by applying slight
pressure for 3-5 minutes.
13. Pack ears and nose with cotton balls.
14. Pack rectum with cotton balls with the use of forceps.
15. Pack vagina with cotton balls with the use of forceps.
16. Remove soiled dressings and drains and replace with clean
ones with the use of the dressing forceps.
17. Bath body with 2% Lysol solution. Follow CBB technique (use
plain water for the face).
18. Trim fingernails and toenails PRN.
19. Tie leg in place. Hands across the chest.
20. Put on patient’s clothing.

21. Comb hair, braid if long.
22. Place one identification card on chest.
23. Wrap patient with sheet and pin securely.
24. Pin another ID card outside on chest area.
25. Call male attendant to secure stretcher to carry the body to the
morgue.
26. Wrap soiled dressings in newspaper in incinerator for CD cases
and in waste box for Non-CD cases.
27. Remove gloves, mask then gown.
28. Clean forceps and soak in disinfectant.
29. Clean unit and its furnishings after discharge of patient.
30. Chart: time and date patient expired, time the patient was
pronounced dead, the doctor’s name who made the
pronouncement, and relatives/kin who received patient’s
possessions.
A.
B.
Total Score
Equivalent Grade
*with patient
Final Grade
Signature of CI

Name of Student _______________________________________________________
POSTPARTUM EXERCISE
STEPS Return 1 2 PE
Demo
1. Explain the exercise to the patient and demonstrate the
following:
2. Day 1. Raise abdomen while inhaling deeply. Slowly exhale
through pursed lips while contracting abdominal muscle forcibly.
3. Day 2. Lie flat on back with legs parted slightly. With
abducted arms, raise arms to midline then return arms slowly to
original position.
4. Day 3. Lie flat on back with arms at sides. Raise buttocks,
arching back then lower buttocks slowly.
5. Day 4. Lie flat on back with one leg and both arms touching
the floor and one knee raised. Reach towards raised knee with
opposite hand. Relax and repeat with other knee and hand.
6. Day 5. Lie flat on back with one leg and both arms touching
the floor and one knee raised. Reach towards raised knee with
opposite hand. Relax and repeat with the other knee.
7. Day 6. Lie flat on back with arms and legs straight. Flex one
leg at knee and thigh until foot reaches buttocks. Straighten up
and lower legs slowly.
8. Day 7. While lying flat on back with legs extended, point toes
and raise one leg as high as possible, then, lower slowly. Use
abdominal muscles with hands at sides.
9. Day 8. Do pelvic rocking or lifting.
10. Day 9. Lie flat on back with arms on sides, raise and lower
both legs slowly simultaneously.
11. Day 10 from supine position, with hands behind head,
contract abdominal muscles and sit up.
A.
B.
Total Score
Equivalent Grade
*with patient
Final Grade
Signature of the CI
Name of Student __________________________________________________________
PREPARATION OF AKAPULKO OINTMENT
Steps RD 1 2 PE
Date
13. Wash hands and prepare all equipment.
14. Wash the fresh young akapulko leaves.
15. Chop the washed akapulko leaves.
16. Prepare 1 glass of esperma or thinly scraped pieces of white

candle
17. Prepare 1 glass of cooking oil.
18. Pre-heat the clay pot over medium heat.
19. Pour 1glass of cooking oil into the pre-heated clay pot then
pour the akapulko leaves.
20. Mix and stir the leaves using a wooden spoon or ladle until the
leaves become crispy golden brown.
21. After cooking, strain and pour the boiling mixture into the
container with 1 glass of esperma or thinly scraped candle.
22. Let it cool.
23. Record the results and other observable characteristics

correctly.
a.
b.
Total Score
Equivalent grade

Final Grade
Signature of CI
Name of Student: __________________________________
SUPPOSITORY INSERTION ANAL/VAGINAL
Retur 1 2 3 PE
STEPS n
Demo
3. Have vaginal/ anal suppository ready and check with
medication ticket. (Suppositories should be soaked in ice to
keep it firm).
4. Prepare gloves, rubber sheet and draw sheet.
5. Carry equipment to bedside.
6. Screen the patient. Place rubber and draw sheets.
7. Position patient on her side with upper knee flexed.
8. Drape patient appropriately.
9. Open suppository ready for application.
10. Wear sterile gloves.
11. Pick suppository with gloved hand.
12. Instruct patient to breathe through the mouth then
introduce suppository gently to the anus or vagina. The
pointed tip should be introduced first.
13. Press the buttocks together for 1-2 minutes.
14. Reposition and leave patient comfortably.
15. Offer bedpan if there is a feeling of defecation (e.g. if
laxative are given).
16. Wash hands then remove screen.
17. Wash equipment and return to CSR.
18. Sign medication sheet.
19. Chart time of insertion, care done to patient and reaction
of patient.
A.
B.
Total Score

Equivalent Grade
Final Grade
Signature of C.I.
Name of Student: __________________________________________________________
SPECIAL MOUTH CARE
Retur 1 2 3 PE
STEPS n
Demo
2. Inspect the condition of the mouth.
3. Prepare the mouthwash solution. Assemble the articles
needed on the tray and carry it to the bedside.
4. Turn the patient’s face towards you and place the towel
across the chest close to the patient’s chin. Place the kidney
basin near the patient’s mouth.
5. Brush the patient’s teeth if they are not contraindicated. If
the patient has no toothbrush, wrap the tongue depressor
with gauze and use it as a toothbrush.
6. Pour the solution to the tongue depressor with gauze or to
the toothbrush. Clean the mouth, gums, teeth, tongue, inside
part of the cheeks and the roof of the mouth.
7. Rinse the patient’s mouth with prescribed mouthwash.
Use the suction PRN.
8. Place the kidney basin close to the patient’s cheek to
allow water to flow from the corner of the mouth.
9. Wipe the patient’s mouth with towel.
10. Apply the lubricant to the lips if needed.
11. Leave the patient dry and comfortable.
12. Discard the soiled tongue depressor, toothpicks and
empty swabs into the garbage can.
13. Empty the kidney basin into the comfort room.
14. Treat kidney basin with 2% Lysol solution, rinse in
running water and return to proper place.
15. Chart: Time, solution used, condition of mouth and
patient’s reaction.
A.
B.

Total Score
Equivalent Grade
Final Grade
Signature of C.I.
Name of Student ___________________________________________________________
SELF-BREAST EXAMINATION
STEPS Return 1 2 PE
Demo
1. Explain the procedure to the client, what you are going to do, why
it is necessary and how the client will cooperate.
2. Wash hands and observe appropriate infection control procedures.
3. Provide client privacy.
4.Inspection before a mirror
 Palpate the areola and nipple for masses. Compress each
nipple to determine the presence of any discharge. If
discharge is present, milk the break along its radius to
identify milk producing lobe. Note the amount, color,
consistency and odor and any tenderness on palpation.
 Stand before a mirror
 Inspect both breasts for anything unusual.
 Look for any change in size or shape; lumps or thickening;
any rashes or skin irritation; dimpled or puckered skin; any
discharges or change in the nipples (position or asymmetry)
 Stand and face the mirror with your arm relaxed at your sides
or hands resting on the hips, then turn to the right and left for
a side view (look for any flattening in the side view).
 Bend forward from the waist with arm raised over the head
 Stand straight with the arms raised over the head and move
the arms slowly up and down at sides. (Look for free
movement of breast over the chest wall)
 Press your hands firmly together at chin level while the
elbows are raised to shoulder level
 Inspect the areola area for size, shape, position, color,
discharge, and lesion
5. Palpation: Lying Position
 Place a pillow under your right shoulder and place the right
hand behind your head. This position distributes breast tissue

more evenly on the chest
 Use the finger pads (tips) of the three middle fingers (held
together) on your left hand to feel for lumps
 Press the breast tissue against the chest wall firmly enough to
know how your breast feels. A ridge of firm tissue in the
lower cure of each breast is normal
 Choose one of the three patterns of palpation:
a) Hands-of-the-clock or spokes –on-a-wheel
b) Concentric circles
c) Vertical strips pattern
 Set at one point for palpation and move systematically to the
endpoint to ensure all breast surface area assessed.
 Pay particular attention to upper outer quadrant area and tall
of Spence
 Use small circular motions along one following your chosen
pattern, then move your fingers about 2cm and feel along the
next arrow. Repeat this action as many times as necessary
until the entire breast is covered.
 Bring your arm down to your side and feel under your
armpit, where breast tissue is also located
 Repeat the exam on your left breast, using the finger pads of
your right hand
6. Palpation: Standing or sitting position
 Repeat examination of both breasts while upright with one arm
behind your head. This position makes it easier to check the area
where a large percentage of breast cancers are found, the upper
outer part of the breast and toward the armpit.
 Optional: Do the upright BSE in the shower. Soapy hands glide
more easily over the wet skin.
7. Document findings:
TOTAL
GRADE
CI Name and Signature/Date

Name of Student: _________________________________________________________
SHAMPOO ON BED
Return
STEPS 1 2 PE
Demo
2. Prepare the equipment and carry it to the
bedside.
3. Remove the pillow from the patient’s
head.
4. Place a folded blanket near the edge of
the bed (head part).
5. Place the bath towel over the folded
blanket.
6. Make an improvised Kelly Pad using a
rubber sheet and place it over the bath
towel. Place a pail under the rubber-
improvised Kelly pad, lined with
newspaper and adjust in place.
7. Have the patient lie over the rubber
sheet or improvised Kelly Pad.
8. Comb the patient’s hair. Place a cotton
ball in both ears.
9. Place a folded face towel on both eyes.
10. Wet the hair with warm water. Apply
the diluted shampoo, and massage the
scalp using the finger pads.
11. Rinse the hair thoroughly using warm
water and do the final rinsing with cold
water. Squeeze out the excess water
from the hair and remove the earplugs
and eye cover.
12. Roll the rubber sheet and place it inside
the pail.

13. Pat the hair dry and wrap the head with
towel and comb the hair.
14. Do the ‘after care’ of the equipment.
15. Chart: Condition of scalp, any unusual
observation, and the reaction of the
patient.
A.
B.
Total Score:
Equivalent Grade:
Final Grade
Signature of CI:
Name of Student ___________________________________________________________
TAKING ELECTROCARDIOGRAM

2. Assemble equipment:
a. ECG machine
b. Electrode paste
3. Close room door or bedside swab
4. Place client in supine or semi Fowler’s position
5. Remove clothing chest to waist line
6. Instruct to lie still without talking
7. Standardize ECG machine
8. Cleanse and prepare skin: wipe site with alcohol
9. Attach leads
Limb leads: Right arm - Red
Left arm - Yellow
Right leg - Black
Left leg - Green
Precordial or chest leads:
V1 – Rt 4th intercostals space sternal boarder – Red
V2 – Lt 4th intercostals space sternal boarder – Yellow
V3 – Midway between V1 and V4, left – Green
th
V4 – 5 ICS, midclavicular left – Brown
V5 – 5th ICS, anterior axillary left – Black
V6 – 5th ICS, midaxillary left – Lavender
For 15 Lead ECG in addition to 12 – Lead
V3R – Rt ICS at Level of V3
V4R – Rt ICS mid clavicular
V7 – 5th ICS posterior left
10. Start run the ECG machine 12-lead and long Lead-II
Bipolar limb lead – L1, L2, L3
Unipolar limb lead – AVR, AVL, AVF
Chest lead - V1, V2, V3, V4, V5, V6
11. Disconnect electrodes and leads and wipe electrode paste if any
12. On ECG strip check the tracing, write the name of the patient, age, date and time
taken
13. Mount to the ECG sheet
14. Refer to the Doctor
15. Return the ECG machine properly
Name of Student ___________________________________________________________
TEPID SPONGE BATH
STEPS Return 1 2 PE
Demo
1. Obtain physician’s order if client has heart disease or
cardiac problems. Assess client’s body temperature.
2. Explain the procedure to client.
3. Wash hands before doing the procedure
4. Prepare the equipment and bring them to bedside.
5. Close windows and screen patient.
6. Offer the bedpan or urinal if the patient wants to void
or defecate before the procedure.
7. Replace the top sheet with bath blanket.
8. Remove all clothing and place on a chair.
9. Place ice cap on the head and hot water bag under the
feet. Place wet washcloth under each axilla and over both
groins. Place towel across the chest and under the head.
10. Sponge the face three times and the body parts in the
following order: arms and hands, back, buttocks, thighs
and legs. Spread towel in each body parts to be sponged.
Sponge for 30 minutes only.
11. Dry extremities and body parts thoroughly. Cover
client with light blanket or sheet.
12. Remove the hot water bag, ice cap, and washcloth
under axilla and over groin and put on patient’s gown.
13. Replace the bath blanket with top sheet.
14. Remove the screen and open windows.
15. Give cold drinks (not very cold, or not iced drink
unless indicated)
17. Wash the basin and put it in proper place. Place all
used and soiled linens to the hamper.
18. Reassess the vital signs at 15 minutes and after
completing the bath.
19. Record the time procedure was started and
terminated, vital signs changes and client’s response.
A.
B.
TOTAL SCORE
EQUIVALENT GRADE
FINAL GRADE
SIGNATURE OF C.I.
Name of Student: ________________________________________________
TESTICULAR EXAMINATION
STEPS Return 1 2 3
Demo
1. Check doctor’s order.
2. Explain the procedure to the patient, if nurse conducts the
examination.
3. Wash hands and don clean gloves.
4. Have the patient hold his penis away from the scrotum.
5. Spread the surface of the scrotum and examine the skin for swelling,
nodules, redness, ulceration and distended veins.
6. Feel the test through the scrotal tissue with both hands.
7. Locate the epididymis, this is the irregular cordlike structure on the
top and at the back of the testicle that stores and transports sperm.
8. Feel each testis between the thumb and first two fingers of each
hand. Palpate each testis for size, consistency, shape, smoothness and
presence of masses.
9. Note size, shape, abnormal tenderness. An abnormality may be felt
as a firm area on the front side of the testicle. It is normal to find
onetestis larger than the other and the left one is usually lower than the
right because the left spermatic cord is longer.
10. If swelling, irregularities or nodules are detected, attempt to trans-
illuminate the lesion by shining a flashlight behind the scrotum in a
darkened room.
11. Replace the patient’s underwear and pants.
12. Remove the gloves and wash hands.
13. Return the flashlight to the station and disinfect.
14. Document symmetry, size, shape and color. For children also note
for the degree of descent.
Ability to answer questions.
A.
B.

TOTAL
GRADE
NAME OF C.I. AND SIGNATURE
Name of Student_________________________________________________________
TRACHEOSTOMY CARE
STEPS Return 1 2 PE
Demo
1. Explain the procedure to the client, what you are going to do,
and how the client can cooperate. Provide for means of
communication, such as blinking or raising a finger, to indicate
pain or distress.
2. Wash hands and observe appropriate infection control
procedures.
3. Provide privacy.
4. Prepare the client and the equipment.
 Assist the client to semi-Fowler’s position to promote
lung expansion
 Open the tracheostomy kit or sterile basins. Pour
hydrogen peroxide and sterile normal saline into separate
containers.
 Establish a sterile field.
 Open other sterile supplies as needed including sterile
applicators, suction kit, and tracheostomy dressing.
5. Suction the tracheostomy tube.
 Put a clean glove on your non-dominant hand and sterile
glove on your dominant hand (or put on a pair of sterile
gloves)
 Suction the full length of the tracheostomy tube to
remove the secretions and ensure the patent airway.
 Rinse the suction catheter and wrap the catheter around
your hand and peel the glove off so that it turns inside
out over the catheter.
 Using the gloved hand unlock the inner cannula (if
present) and remove it by gently pulling it toward you in
line with its curvature. Place the inner cannula in the
hydrogen peroxide solution. This moistens and loosens

dried secretions.
 Remove the soiled tracheostomy dressing. Place the
soiled dressing in your gloved hand and peel the gloved
off so that it turns inside out over the dressing. Discard
the glove and the dressing.
 Put on the sterile gloves. Keep your dominant hand
sterile during the techniques.
6. Clean the inner cannula.
 Remove the inner cannula from the soaking solution
 Clean the lumen and the entire cannula thoroughly using
the brush or pipe cleaners moistened with sterile normal
saline. Inspect the cannula for cleanliness by holding it at
eye level and looking into the light.
 Rinse the inner cannula thoroughly in sterile normal
saline. Thorough rinsing is important to remove
hydrogen peroxide from inner cannula.
 After rinsing, gently tap the cannula against the inside
edge of the sterile saline container. Use a pipe cleaner
folded in half to dry only the inside of the cannula. Do
not dry the outside. This removes excess liquid from
cannula and prevents possible aspiration by the client,
while leaving a film of moisture on the outer surface to
lubricate the cannula for reinsertion.
 Using sterile technique, suction the outer cannula.
Suctioning removes secretions from the outer cannula.
7. Replace the inner cannula, securing it in place.
8. Clean the incision site.
9. Apply a sterile dressing.
10. Change the tracheostomy ties.
11. Tape and pad the tie knot.
12. Check the tightness of the ties.
13. Document the relevant information.
A.
B.
TOTAL
GRADE
NAME OF C.I. AND SIGNATURE

Name of Student: _________________________________________________________
USING PULSE OXIMETER
Retur 1 2 3 PE
Steps n
Demo
2. Perform hand hygiene.
3 Select an adequate site for application of sensor.
Use patient’s index, middle, or ring finger.
Check proximal pulse and capillary refill at pulse closest to
site.
If circulation at site is adequate, and earlobe or bridge of
nose may be considered.
Use toe only if lower extremity circulation is not
compromised.
4. Use the proper equipment.
If one finger is too large for the probe, use a small one. A
pediatric probe may be used for a small adult.
Use probes appropriate for the patient’s age and size.
Check if the patient is allergic to adhesive. A non-adhesive
finger clip if reluctance sensor is available.
5. Prepare the monitoring site.
Cleanse the selected area and allow it to dry.
Remove nail polish and artificial nails after checking
manufacturer’s instructions.
6. Apply the probe securely to skin. Make sure light-emitting
sensors are aligned opposite each other (not necessary to
check if placed on forehead or bridge of nose).
7. Connect sensor probe to pulse oximeter. And check
operation of equipment (presence of audible beep fluctuation
of bar of light or waveform on the face of the oximeter).
8. Set alarms on pulse oximeter. Check manufacture’s
limits for high and low rate settings.
9. Check oxygen saturation at regular intervals as ordered by
the physician and necessitated by alarms. Monitor patient’s
hemoglobin.
10. Remove sensor on a regular basis and check for skin
irritation or signs or pressure (every 2 hours for spring-
tension sensor or every 4 hours for adhesive finger or toe
sensor).
11. Evaluate any malfunctions or problems with equipment.
For absent or weak signal, check vital signs and patient
condition. If satisfactory check connections and circulation
to site.
For inaccurate reading, check prescribed medication and
history of circulatory disorders. Try device on a healthy
person to see if problems are equipment-related or patient
related.
If bright light(sunlight or fluorescent light) is suspected of
causing equipment malfunctions, cover probe with a dry
wash cloth.
12. Document and report SaO2 appropriately.
A.
B.
Total Score
Equivalent Grade
Final Grade
Signature of C.I.

NAME OF STUDENT ______________________________________________________
USER AUTONOMY CHECKLIST FOR THE MUCUS METHOD
Demo
1. Was the client able to clarify her fertility intentions with
her partner?
2. Was the client able to state how long her cycle was
based on her chart?
3. Was the client able to describe the length of her cycle
(short, average, or long) based on her chart?
4. Was the client able to identify the start of her fertile
days based on her chart?
5. Was the client able to identify the end of her fertile days
based on her chart?
6. Was the client able to describe her mucus pattern based
on her chart?
7. Was the client able to apply the Day Rule base on her
chart?
8. Was the client able to explain the benefits or advantages
of the mucus method of natural family planning?
9. Was the client able to explain the benefits or advantages
of the mucus method of natural planning?
10. Was the client able to describe the strategy that she and
her partner used to handle waiting period during the fertile
time?
A.
B.
Total Score
Equivalent Grade
*with patient
Final Grade
Signature of CI
Name of Student: ________________________________________________
URINALYSIS
STEPS Return 1 2 3
Demo
A. Test for Albumin using heat and the Acid Test using the Acetic
Acid.
1. Arrange the paper and the equipment in a straight line on the table.
2. The 5cc urine specimen should be collected early in the morning
before breakfast.
3. Heat, but do not bring to boil the upper portion of the test tube with
urine without shaking to be able to compare the results with the
bottom part of the test tube.
4. If there is no change in the heated portion, the result is negative. No
need to add acetic acid.
5. If cloudiness appears at the heated portion, add 2-4 drops of acetic
acid. Heat again to rule out the presence of phosphates. If
cloudiness disappears, results are still negative, but if it persists
despite of the addition of acetic acid, or even deepens, the result is
positive.
B. Test for the Presence of Sugar- use of Benedict Solution
2. Explain the procedure.
3. Give the sterile bottle to the patient and instruct her on how to
collect urine.
4. Prepare the equipment.
5. Place all the needed equipment on the table with newspaper lining.
6. Light the burner, then pour the 5 cc of Benedict’s solution into test
tube and heat over the flame.
7. Drop 3-5 drops of urine and boil.

8. Let the test tube stand in the test tube rack and wait until the
precipitate settles down before reading. The degree of positivity will
depend on the change of color from the yellow green to brick red.
.
Test for Sugar: Results

Negative………………….Blue
+………………….Greenish blue
++………………….Yellow green
+++………………….Orange
++++………………….Red
C. Ability to answer questions:
A.
B.
Total Score
Equivalent Grade
*with patient
Final Grade
Signature of CI
Name of Student: ________________________________________________
WOUND DRESSING
STEPS Return 1 2 3
Demo
2. Secure equipment and bring to bedside.
3. Wash hands.
4. Undo materials securing the dressing. Lift dressing off by touching
the outside portions only. If soiled, use forceps.
5. If dressing adheres to wound, moisten with sterile water or NSS or
hydrogen peroxide. Remove dressing using dressing forceps when
completely loose.
6. Drop soiled dressing into waste receptacle/kidney basin for later
burning. If hands were used for removing soiled dressings, wash hands.
7. Clean wound aseptically using dressing forceps from the center to the
outer portion using cotton balls with:
a. phisohex or betadine cleanser
b. sterile water or NSS
c. betadine solution
8. Cover wound with sterile dressing and secure with adhesives.
9. Make patient comfortable and tidy the unit.
10. Wash hands
11. After care of equipment. Soak dressing forceps in 5% Lysol
solution for 30 minutes, then, wash with soap and water, rinse then dry.
Send to CSR for sterilization.
12. Chart. Site of wound, character of wound/discharges, treatment
given if any (e.g. ointment used) and reaction of the patient.
A.

B.
Total Score
Equivalent Grade
*with patient
Final Grade
Signature of CI
Name: ___________________________________________________
Donning Sterile Gown and Closed Gloving

STEPS Return 1 2 PE
Demo
Assessment:
1. Select the proper size and type of sterile gloves

2. Select proper size and type of sterile surgical gowns.
Implementation:
3. Open sterile gown and gloves package on clean dry flat

surface
4. After drying hands pick up gown (folded inside out)
from the
Sterile package, holding the inside surface of the gown
at the
collar
5. Locate neckband; with both hands grasp the inside

front of gown just below the neckline
6. Allow gown to open, keeping at the arm’s length away
from the body. Do not touch the outside of the gown or
allow touching the floor
7. Slip both hands into armholes simultaneously (Do not
allow hand to through the cuff opening) keeping hands
at the shoulder level. Have circulating nurse pull on the
gown by reach inside arm seams. Gown is pulled on,
leaving sleeves covering hands

8. Have circulating nurse tie gown at neck and waist. If
wraparound gown, sterile flap is not touch until sterile
gown have been applied.
9. Apply gloves using closed gloves method.
a. With hands covered with gown cuffs and sleeves,

open inner sterile glove package.
b. Grasp folded cuff of glove of dominant hand with
dominant hand.
c. Extend dominant forearm forward with palm of
glove
Against palm of dominant hand. Glove fingers
point toward
Elbow.
d. Grasp cuff edges with thumb and forefingers of

dominant hand. Grasp back of glove cuff with
nondominant hand. Extend fingers into glove and
pull glove over cuff
e. Grasp top of the glove and underlying gown sleeve
with covered dominant hand. Extend fingers into
glove, being sure glove’s cuff covers gown cuff.
f. Glove non-dominant hand in same manner with
glove
With dominant hand. Keep hand inside sleeve. Be
sure fingers are fully extended into both gloves.
10. For wraparound gown:
g. Grasp sterile waist tie with gloves hands and untie.
h. Pass tie to another sterile team member, who stands

still, or wrap tie in sterile towel and pass to
circulating nurse. Keep gown tie in left hand.
i. Allowing margin of safety, turn to the left one-half
turn, covering back with extended gown flap.
Retrieve tie only from team member and secure
both ties in place.
TOTAL SCORE
EQUIVALENT

 With patient
Name and signature of Clinical Instructor
Name and signature of student
Name of Student _____________________________________________
Surgical Hand Antisepsis

STEPS Return 1 2 PE
Demo
Assessment:
1. Determine type and length of time for hand wash or

scrub
2. Remove bracelets, rings, and watches
3. Inspect finger nails, which must be short, clean and

healthy. Remove artificial nails / nail polish
4. Inspect skin and cuticles of hand and arms for
abrasions, cuts or open lesion
Implementation
5. Put on surgical shoe covers, cap, or hood, face mask,

and Protective eye wear.
6. Turn water on using foot or knee control and adjust to
comfortable temperature.
7. Wet hands and arms, keeping arms flexed with hands

pointed Upward, allowing water to flow off at the elbow
8. Rinse hands at arms, keeping arms flexed with hands
pointed upward allowing water to flow off at the elbow
9. Clean under nails of both with the file under running
water and then discard the file.
10. Surgical Hand Scrub (with brush)
a. Wet brush and apply antimicrobial agent Scrub the
nails of one hand with 15 strokes, scrub the palm,
each side of the thumb, fingers and posterior side of
the hand with 10 strokes each.
b. Mentally divides the arms into thirds and scrub each
third 10 times. Rinse brush and repeat sequence on
the other hand
c. Discard brush flex arms and rinse from the finger tips
to elbow in one continuous motion, allowing water to
run at the elbow
d. Turn off water with foot or knee control and back
into the room with hands elevated in from and away
from the body
e. Go to sterile set up and grasp the sterile towel taking
care not to drip water on the sterile field
f. Bending slightly at the waist, use a sterile towel
To dry one hand thoroughly moving from fingers to
elbow in rotating motions
g. Transfer sterile towel to opposite end and repeat steps

(e) for another hand
h. Drop towel into linen hamper or into circulating
nurse’s hands
II. OPTION
Antiseptic anatomic scrub (brushless)
a. Dispense 2 ml of antimicrobial agent into the palm of

the hand. Dip finger tips of opposite hand into prep
and work under nails. Spread
Remaining hand prep and up to just above the elbow.
b. Using another 2 ml of hand prep, repeat procedure

with other hand
c. Dispense 2ml of hand prep into either hand and
reapply to all aspect of both hands up to the wrist.
Allow to dry before applying gloves.
11. Ability to answer question.
TOTAL SCORE
EQUIVALENT
 With patient
Final Grade
Signature of CI

Signature student
Name of Student____________________________________________________________
SPUTUM COLLECTION AND SMEARING
Steps RD 1 2 PE
Date
COLLECTION
1. Prepare the sputum cup.
2. As soon as you wake up in the morning (before you eat or drink

anything), brush your teeth and rinse your mouth with water.
Do not use mouthwash.
3. If possible, go outside or open a window before collecting the
sputum sample
4. Take a very deep breath and hold the air for 5 seconds. Slowly
breathe out. Take another deep breath and cough hard until
some sputum comes up into your mouth.
5. Spit the sputum into the plastic cup
6. Keep doing this until the sputum reaches the 5 ml line (or
more) on the plastic cup. This is about 1 teaspoon of sputum.
7. Screw the cap on the cup tightly so it doesn’t leak.
8. Wash and dry the outside of the cup.
9. Write on the cup the date you collected the sputum.
10. Put the cup into the box or bag the nurse gave you
11. Give the cup to your clinic or nurse. You can store the cup in
the refrigerator overnight if necessary. Do not put it in the
freezer or leave it at room temperature.
SMEARING

12. Get a clean microscopic slide and label the right end of the
slide with the number corresponding to the patient’s code.
13. Select the muco-purulent portion of the sputum and using a
cotton applicator, spread it thinly at the center of the
microscopic slide (about the size of the eyepiece of the
microscope).
14. Let it dry, arrange in a corrugated container, pack, write the
name of the sending health center and send to the laboratory.
A.
B.
Total Score
Equivalent grade
Final Grade
Signature of CI

Reference: FUNDAMENTALS OF NURSING, Concepts, Process and Practice by Kozier
&Erb, Eight Edition, Volume 1

College of Nursing - Clinical Nursing Skills Checklist

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College of Nursing | Clinical Nursing Skills Checklist 1

College of Nursing | Clinical Nursing Skills Checklist 2

Criteria: (One point each)

1. States the step correctly. Able to express oneself confidently.

3. States the rationale correctly with scientific basis.

4. Basic nursing considerations are observed.

5. Displays confidence and compassion when performing the step.

5 Excellent All criteria are met.

ANTEPARTAL EXERCISE 5 ASSESSING PERIPHERAL PULSE 11

ASSESSMENT OF APICAL PULSE 7 ASSESSING BLOOD PRESSURE 12

ASSISTING IV INFUSION 8 ASSESSING BODY TEMPERATURE 14

ASSESSING RESPIRATIONS 10 APPLICATION OF ABDOMINAL

College of Nursing | Clinical Nursing Skills Checklist 3

ASSISTING ENDOTRACHEAL MAKING OF HOMEMADE SALT

ADMINISTERING OXYGEN 19 MEASURING INTAKE AND OUTPUT 69

ASSISTING PHYSICIAN IN NGT MEDICAL HANDWASHING 70

BASIC CLEANING PROCEDURE 26 OPEN BED 77

BAG TECHNIQUE 29 OPEN GLOVING 79

BLOOD TRANSFUSION 30 PER OREM MEDICATION 80

BANDAGING 31 PHYSICAL ASSESSMENT 82

CARDIO PULMONARY RESUSCITATION 33 POSITIONING AND DRAPING

CATHETERIZATION 37 POST MORTEM CARE 103

CENTRAL VENOUS PRESSURE READING 39 POSTPARTUM EXERCISE 105

CHECKING BLOOD GLUCOSE 40 PREPARATION OF AKAPULKO

SUPPOSITORY INSERTION ANAL

CRUTCH WALKING 47 SELF-BREAST EXAMINATION 109

EAR IRRIGATION 49 SHAMPOO ON BED 111

ESSENTIAL INTRAPARTUM AND TAKING ELECTROCARGIOGRAM 112

HOME VISIT 59 URINALYSIS 120

HOT WATER BAG APPLICATION 60 WOUND DRESSING 121

ICE CAP / ICE BAG APPLICATION 61 SPUTUM COLLECTION\ANDSMEARING 126

SURGICAL HAND ANTISEPSIS 124

Name of Student: _________________________________________________________

College of Nursing | Clinical Nursing Skills Checklist 4

College of Nursing | Clinical Nursing Skills Checklist 5

College of Nursing | Clinical Nursing Skills Checklist 6

ASSESSMENT OF APICAL PULSE

College of Nursing | Clinical Nursing Skills Checklist 7

College of Nursing | Clinical Nursing Skills Checklist 9

College of Nursing | Clinical Nursing Skills Checklist 10

ASSESSING PERIPHERAL PULSE

College of Nursing | Clinical Nursing Skills Checklist 11

ASSESSING BLOOD PRESSURE

 Deflate the cuff rapidly and completely.

9. If this is the client’s initial examination repeat the procedure on

College of Nursing | Clinical Nursing Skills Checklist 12

College of Nursing | Clinical Nursing Skills Checklist 13

ASSESSING BODY TEMPERATURE

College of Nursing | Clinical Nursing Skills Checklist 14

College of Nursing | Clinical Nursing Skills Checklist 15

APPLICATION OF ABDOMINAL BINDER

College of Nursing | Clinical Nursing Skills Checklist 16

ASSISTING ENDOTRACHEAL TUBE INSERTION

College of Nursing | Clinical Nursing Skills Checklist 17

College of Nursing | Clinical Nursing Skills Checklist 18

College of Nursing | Clinical Nursing Skills Checklist 19

Name of Student _________________________________________________________

ASSISTING PHYSICIAN IN NGT INSERTION/GAVAGE

College of Nursing | Clinical Nursing Skills Checklist 20

20. If client begins to cough, gag, or choke, withdraw

Name of Student: __________________________________________________________

College of Nursing | Clinical Nursing Skills Checklist 22