Checklst 202

UPHSL/DJGTMU-ACAD -RDC-10B
06-02-2014-00
UNIVERSITY OF PERPETUAL HELP SYSTEM LAGUNA

UNIVERSITY OF PERPETUAL HELP-DR. JOSE G. TAMAYO MEDICAL UNIVERSITY
COLLEGE OF NURSING
Student's Name: _____________________________

Rating
Section/Group No. ___________________
PERFORMANCE CHECKLIST IN BEDMAKING
Legend:
4 Competent. (Performs consistently in an effective and efficient manner).
3 Progress Acceptable (Performance is usually effective and efficient but not always).
Needs Improvement (Progress in performance is too slow to judge satisfactorily. Task is not done properly
2
to majority of the time).
Progress unacceptable ( No progress in performance has been demonstrated, and/or performance is
1 consistently ineffective and inefficient).
Station 2: Post Op or Surgical Bed 4 3 2 1 Comments

I. Important Points to Consider in Bedmaking
A. Infection Control:
1 Washes hands before .
2 Handles linen carefully.
Holds both soiled and cleans linen away from your
3
uniform.
B. Body Mechanics:
4 In position like bodning - bend the knees and not

the patient's back.
Avoid twisting by facing patient's body in direction
5
of movement.
6 Organize work.
II. Procedure for Bedmaking
A. Assessment
7 Assess patient for incontinence risk or body

discharge.
8 Check for condition of linen.
9 Assess for other special needs of patients.
B. Planning
10 Washes hands and dons clean gloves.
11 Obtains laundry hamper or bag.
12 Gathers linen to be used.
13 Obtains other needed items or equipment.
C. Implementation
Raises bed to appropriate working height. Be
14
certain wheels are locked.
15 Removes cases from pillow.
06-02-2014-00

COLLEGE OF NURSING
Student's Name: _____________________________

Rating
Section/Group No. ___________________
Legend:
2

16 Loosens top and bottom linen from mattress.
Removes items to be re-used, folds and places
17
across back of chair.
18 Removes remaining linen and place in hamper.
19 Turns mattress if necessary.
20 Moves mattress to head of bed.
If gloves were worn, removes and washes hands
21
before touching clean items.
22 Places bottom sheet on bed.
23 Miters top corner of bottom sheet.
24 Tucks remainder of sheet under.
25 Places rubber sheet on bed.
Places cloth draw sheet over rubbed sheet. Tucks
26
near edge.
Goes to the other side. Tucks bottom sheet under
27 head of bed, and miters corner. Tucks remainder
of sheet.
28 Tucks under sheet and draws sheet snugly.
Places top sheet on bed, using centerfold as
29
guide.
Folds top sheet away from foot and head of bed to
30
form a cuff.
31 Fan folds far linen to near side of the bed.
32 Places hot water bags in between fanfolds.
Places pillow against headboard and puts bed on
33
raised position.
Puts IV stand, kidney basin, tissue and other
34
needed items on bedside.
TOTAL / 72 =
STUDENT'S SIGNATURE: _________________________________
CLINICAL INSTRUCTOR'S SIGNATURE: ______________________
06-02-2014-00

COLLEGE OF NURSING
Student's Name: _____________________________

Rating
Section/Group No. ___________________
Legend:
2
4/10/2020
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COLLEGE OF NURSING
Student's Name: _____________________________

Section/Group No. ___________________
RETURN DEMO CHECKLIST LEVEL 2

BLOOD PRESSURE
Legend:
Needs Improvement (Progress in performance is too slow to judge satisfactorily.
2
Task is not done properly to majority of the time).
Progress unacceptable ( No progress in performance has been demonstrated, and/or
1
performance is consistently ineffective and inefficient).
STATION THREE 4 3 2 1 Comments

1 Washes hands before starting the procedure.
2 Identifies the patient.
3 Places the patient in a sitting/supine position.
4 Explains the procedure.
Asks the patient's previous activity , waits for another 30 minutes
5 before doing the actual assessment as indicated.
6 Inquires about patient's blood pressure reading (or checks patient's

record)
7 Prepares sphygmomanometer, stethoscope, pen, paper and other

equipment necessary for the procedures.
ASSESSMENT OF BLOOD PRESSURE
8 Obtains sphygmomanometer and stethoscope.
9 Cleans earpieces and diaphragm of stethoscope.
10
Instructs or assists patient to place his/her arm on a table or armrest.
Rolls or pushes patient's sleeve and applies cuff 1-2 inches above the
11 antecubital fossa.
12 Palpates for the brachial pulse.
Positions earpieces and place diaphragm of stethoscope over the
13
pulse site.
14 Inflates cuff to 170 or 20-30 mmHg above previous reading.
15 Opens control valve to release pressure slowly.
Deflates cuff completely (if repeat measurement is necessary, waits 1
16
minute before inflating again) and takes it off patient's arm.
17 Repositions patient's sleeve.
18 Folds cuff capacity and clean stethoscope.
19 Records blood pressure reading.
20 Washes hands.
TOTAL

CLINICAL INSTRUCTOR'S SIGNATURE: ______________________ 4/10/2020
06-02-2014-00
COLLEGE OF NURSING
Student's Name: _____________________________ Rating

Section/Group No. ___________________

IV - PERINEAL CARE
Legend:
2
1
4 3 2 1 Comments
Assessment
1 Assesses genitalia for inflammation, skin beakdown or infection.
2 Determines if the client is incontinent of urine or stool.
3 Assesses whether the client has recently had perineal /genital surgery.
Planning
4 Prepares equipment.
Implementation
5 Explains to client the purpose and nature of procedure.
6 Provides
Positions privacy.
client in Uses bath blanket
comfortable to position.
working keep client covered.
Puts towel (lenghtwise)
7 along side of patient.
Removes any fecal matter using of fold of underpad/toilet tissue.

9 Cleanses client's buttocks and anus, washes, beginning from front to
back. Dries area thoroughly.
10 Changes gloves if become soiled.

A - Female Perineal Care
11 Assists client to assume a dorsal recumbent position.
12 Drapes the client properly.
13 Places the rubber protector and bedpan under the buttocks.
14 Using one hand flushes the perineal area with warm water.
Proceeds and cleans the area with gentle downward stroke using "figure
15 of seven" starting from labia majora to vaginal orifice on one side then to
the opposite side.
Pours warm water over the perineum. Dries thoroughly using front-to-
16
back method. Uses one cotton ball per stroke.
17 Removes bedpan and underpad. Places client in a comfortable position.
TOTAL ____/68=

4/10/2020
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COLLEGE OF NURSING

Section/Group No. ___________________
B - Male Perineal Care 4 3 2 1

Assessment
1 Assesses genitalia for inflammation, skin beakdown or infection.
2 Determines if the client is incontinent of urine or stool.
Assesses whether the client has recently had perineal perineal/genital
3
surgery.
Planning
4 Prepares equipment.
Implementation
5 Explains to client the purpose and nature of procedure.

6 Provides privacy. Uses bath blanket to keep client covered.
Positions client in comfortable working position. Puts towel (lenghtwise)
7
along side of patient.
Removes any fecal matter using of fold of underpad/toilet tissue.
9 Cleanses client's buttocks and anus, washes, beginning from front to
back. Dries area thoroughly.
10 Changes gloves if becomes soiled.
11 Assists client in supine position.
Raises client's penis gently and puts bath towel. Grasps penis shaft
12
gently. Retracts foreskin for uncircumcised client.
Begins washing from the tip of client's penis at the erethral meatus. Uses
13
a circular motion, cleansing the meatus outward. Rinses and dries.
Uses gentle but firm downward strokes in washing the shaft of the penis.
14
Rinses and dries.
Cleanses the scrotum gently, lifting carefully and washing underlying
15
skin folds. Rinses and dries thoroughly.
16 Assists client to establish a comfortable position and cover with a sheet.
Disposes all used equipment and soiled linen. Removes and disposes
17
gloves properly.
TOTAL___ /68 =

4/10/2020
06-02-2014-00
COLLEGE OF NURSING
Student's Name: _____________________________

Rating
Section/Group No. ___________________

REMOVAL OF THE INDWELLING CATHETER
Legend:
2
1
4 3 2 1 Comments
1 Equipment and supplies
a. Syringe (10 cc)
b. Tissue paper / paper towel
c. Kidney basin
d. Clean gloves
e. Flushing tray
f. Catheter clamp
PROCEDURE
2 Checks physician's order.
3 Washes hands and gathes equipment.
4 Explains procedure to the client.
5 Provides privacy
6 Positions the patient.
7 Wears gloves before clamping the catheter.
8 Deflates the balloon by aspirating the distilled water.
Pulls the cathter slowly using the dominant hand. If there's no
9 resistance slowly withdraws the catheter allowing it to fall into the paper
towel.
10 Disconnects catheter bag from bed frame and puts aside.
11 Performs perineal care.
12 Places the patient in comfortable position.
Discards all used equipment in appropriate receptcle and washes
13 hands.
14 Proper documentation
a. Time when the catheter is removed.
b. Amount color of urine.
c. Patient's reaction
d. Indicate time when to void.
TOTAL /56 =
GRADE DATE CLINICAL INSTRUCTOR

ASSESSMENT
FEMALE CATHETERIZATION
MALE CATHETERIZATION
REMOVAL OF INDWELLING CATHETER
4/10/2020
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COLLEGE OF NURSING

Section/Group No. ___________________
PERFORMANCE CHECKLIST IN HANDWASHING
Legend:
2
1
PERFORMANCE POINTS 4 3 2 1 Comments

ASSESSMENT
Inspects hands for breaks / cuts in the skin or cuticles.
1 Report and covers affected part, if possible.
care.
2 Inspects hands for heavy soiling / dirt, and nails for length.
PLANNING
Prepares the following :
a. soap and soap dish d. tissue paper
3
b. orange stick e. lotion (optional)
c. towel
Rolls uniform sleeves above elbow. Wristwatch andIMPLEMENTATIONrings should be
4 removed
Stands inprior
frontto
ofhandwashing.
sink, keeping hands and uniform away from sink
5 surface.
Turns on water by turning faucet on or using knee/foot control to
6 regulate water flow and temperature.
7 Be careful not to splash water into uniform.
8 Wets hands and elbow thoroughly under running water.
9 Hands and forearms
Builds lather and uses should
plentybeof lowered during
friction for washing.
minimum of 10-15 secs.
10 Applies afingers.
Interlace small amount of antiseptic.
Rubs palms and dorsumLather thoroughly.
back of hands using
11 circular motion at least 5x for each hand.
12 Keeps fingerlips
Uses both handsdown.
to clean fingernails using additional soap and
13 orange hands
Rinses stick. and wrists thoroughly, keeping elbows up and hands
14 down.
15 Makes a lather starting from the elbow, apply soap in rotating motion.
16 Rinses
Uses thoroughly,
paper keeping
towel, single usehands
towellower thandryer
or warm elbows.
to dry hands. Dry
17 hands thoroughly from fingers to wrists and forearms.
18 Discards soiled paper towel properly.
19 Turnsclean,
Uses off water
dry flow
paperusing
towelfoot
to or
turnknee pedals.
off hand faucet. Avoid touching it
20 with bare hand.
21 Applies a small amount of lotion or barrier cream if hands are dry or
22 chapped.
After care of equipment/environment
88/_____ AVE:

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COLLEGE OF NURSING
Student's Name: _____________________________

Rating
Section/Group No. ___________________
Legend:
2
1
Catheterization
4 3 2 1 Comments
Assessment
1 Assesses the client's overall condition.
2 If the client is able to cooperate and hold still during the procedure.
3 If the client can be positioned in supine with head relatively flat.
4 When client last voided or was last catheterized.
5 Percusses the bladder to check for fullness or distention.
Planning
6 a. Prepares equipment and supplies
Catheterization set
* Cotton balls
* Forceps (straight or curved)
* Specimen bottle (2)
* Kidney basin
* Eye sheet
7 b. Prepares other needed equipment.
* Pair of sterile gloves
* Lubricating jelly
* Sterile 10 cc syringe
* Distilled water & Betadine solution
* Urine bag
* Besheet for drape
* Goose lamp
* Padding sheet
Implementation - MALE
8 Opens the pack, if pack is not available, arranges all equipment first
before wearing gloves.
9 Opens and pours cleansing solution over swabs.
10 Opens and prepares the lubricating jelly on the side of sterile kidney
basin.
11 Opens or sets aside specimen bottle (optional)
Prepares urine bag and distilled water. Opens the sterile syringe and
12
catheter.
13 Wears gloves .
14 Applies eye sheet over the perineum.
15 Inserts the syringe to the indwelling catheter inflation hub and test the
balloon.
16 Fills the syringe with distilled water.
06-02-2014-00

COLLEGE OF NURSING
Student's Name: _____________________________

Rating
Section/Group No. ___________________
17 Grasps firmly the penis just below the glans with non dominant hand in
upright position with slight tension.
06-02-2014-00

COLLEGE OF NURSING
Student's Name: _____________________________

Rating
Section/Group No. ___________________
Continuation Male Catheterization 4 3 2 1 Comments

Using a forceps with dominant hand cleanses the meatus from the
18 center in circular motion. Do it three times.
19 Discards each cotton ball after use in area where it will not
contaminate other equipment.
20 Grasps and lubricates the catheter sparingly.
Inserts the catheter 5-7 inches, do not touch any area with the
21 catheter except the meatus itself until urine flows, then inserts 1-2
inches further.
Without releasing the catheter holds the inflation hub between two
22 fingers with non dominant hand while attaching the syringe and
infaltes the catheter with dominant hand.
23 Pulls catheter gently until resistance is felt to ensure that the balloon is
in place.
24 Collects urine specimen if needed.
25 Removes the eye sheet and connects catheter to the urine bag.
26 Secures the catheter tubing to upper thigh or abdomen.
27 Wipes the perineal area of any remaining antiseptic or lubricant.

Returns the patient to a comfortable position.
28 Discards all used equipments in approriate receptable and washes

hands.
29 Records the procedure.
a. Type and size of the catheter used.
b. Time of procedure.
c. Amount & description of urine obtained.
d. Patient's response.
e. Disposition of the specimen if taken.
TOTAL /87 =
4/10/2020
06-02-2014-00
COLLEGE OF NURSING
Student's Name: _____________________________

Rating
Section/Group No. ___________________
Legend:
2
1
BAG TECHNIQUE
4 3 2 1 Comments
Assessment
Assesses the environment. Selects appropriate place where to place
1
the bag.
Planning
2 Prepares the equipment and contents of the bag.
* paper lining
* extra paper for making waste bag
* apron
* hand towel
* soap and soap dish
* thermometer
* bandage scissors
* forceps
* cotton balls
* cord clamp
* micropore plaster
* tape measure
* sphygmomanometer
* stethoscope
* alcohol
Implementation
Upon arrival at the patients home, places the bag on the table line with
3 a clean paper. The clean side must be out and the folded part touching
the table.
4 Asks for a basin of water or a glass of drinking water if tap water is not
available.
5 Opens the bag and take out the towel and soap.
6 Washes hands using soap and water. Wipes to dry.
7 Takes out the apron from the bag and puts it on with the right side out.
8 Puts out all the necessary articles needed for the specific care.
9 Closes the bag and puts it in one corner of the working area.
10 Proceeds in performing the necessary nursing care and treatment.
After giving the treatment cleans all things that were used. Washes
11
hands.
Opens the bag and returns all things that were used in their proper
12
places after cleaning them.
13 Removes apron, folding it away from the person, the soiled side in and
the cleans side out. Place it in the bag.
14 Folds the lining, place it inside the bag and closes the bag.
Evaluation
Documents all the necessary data that were gathered, observations,
15 nursing care and treatment rendered. Gives health teachings
accordingly or as appropriate.
Makes appointment for the next visit (either home or clinic) taking note
16
of the date and time.
TOTAL /48 =
4/10/2020
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COLLEGE OF NURSING
Student's Name: _____________________________

Rating
Section/Group No. ___________________
Legend:
2
1
III. CLOSED GLOVING
4 3 2 1 Comments
1 With hands still inside the gown sleeves, opens the inner wrapper of
the sterile gloves.
With nondominant sleeves hand, places the palm of the dominant-
2
hand glove against the sleeves palm of the dominant hand.
s the glove cuff with dominant hand. Turns the cuff over the end of
3
dominant hand and gown's cuff.
4 While holding the glove and gown cuffs securely, slowly extends the
fingers into the glove.
5 With the gloved dominant hand, places the palm of the non-dominant-
hand glove against the sleeved palm of the non-dominant hand.
Grasps the glove cuff with non-dominant hand, turns the cuff over the
6 end of non-dominant hand and gown's cuff. Slowly extends the fingers
into the glove.
Interlocks gloved fingers and secures inside the front pocket of the
7
gown.
IV. OPEN GLOVING
Applies powder on both hands, discards the envelope into the
8
wastebasket/pail.
9 With the non-dominant hand soap grasps the cuff of the dominant
glove on the fold. Picks up the glove and steps back from the table.
Inserts the dominant hand into the glove and draws it on leaving the
10
cuff turned well down over the hand.
11 Slips the fingers of the dominant hand under the turned back cuff of
the non-dominant glove, picks it up and steps back.
Inserts the non-dominant hand into the non-dominant glove and pulls it
12
on; leaving the cuff turned well down over the hand.
With the fingers of the dominant hand, pulls the cuff of the non-
13 dominant glove over the cuff of the sleeves. Avoid touching the gloved
fingers to the bare wrist.
14 Repeats for the dominant cuff.
TOTAL /42 =

4/10/2020
06-02-2014-00
COLLEGE OF NURSING
Student's Name: _____________________________

Rating
Section/Group No. ___________________
Legend:
2
1
II. APPLYING SURGICAL GOWN

4 3 2 1 Comments
Assessment
1 Assesses the surrounding environment.
2 Assesses the condition of your hands.
Planning
3
Dons a sterile gown without compromising the sterility of the gown.
Implementation
4 Grasps the sterile towel on the edge, allowing it to fall open.
Dries each hand and arm separately with rotating motion up to the
5
elbow.
6 Throughly dries the skin.
7 Discards the towel into the linen hamper.
Reaches down into the sterile pack and lifts the gown directly upward
8
avoiding the edge of the wrapper.
9 Steps away from the non-sterile objects. Give a wide range of safety.
10 Grasps the gown near armhole with both hands.
Slips the hands into the armholes, holding the arms upward on the
11
level with the shoulders.
12 Keeps hands inside the sleeves of the gown.
Bends slightly and swing into the direction that will bring the ties away
13 from the sterile gown. Secures the ties at the neck and waistThe
circulating nurse will secure the ties at the neck and waist.
TOTAL /39 =

4/10/2020
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COLLEGE OF NURSING
Student's Name: _____________________________

Rating
Section/Group No. ___________________
Legend:
2
1
I. SURGICAL HANDWASHING
4 3 2 1 Comments
Assessment
1 Assesses the environment for equipment and cleanliness.
2 Assesses oneself for preparedness/capabilities
Planning
3 Hands and forearms will be adequately cleansed before wearing

sterile gloves and gown.
Implementation
Preparation
4 Removes jewelry and chipped nail polish.
5 Have two surgical scrub brushes and nail file available.
6 Applies mask and cap approprately.
7 Applies surgical shoe-cover.
Surgical Handwashing
8 At the sink, wets forearms and hands under warm flowing water.
9 Applies soap and rub hands and arms 2 inches above elbows.
10 Cleans underneath each nail of both hands and drop file onto the
sink.
11 Scrubs nails and all areas of nondominant hand and arm with
soap,scrub brush in dominant hand using circular motion.
12 Rinses brush thoroughly, reapplies soap.
13 Continues with scrub of nondimant arm. Drops brush into the

sink.
14 With second scrub brush, does the same with the dominant hand
and arm. (repeat step 11-13)
15 Rinses fingers, hands and arms thoroughly.
16 Keeps arms flexed and proceed to the sterile field.

TOTAL /48 =

4/10/2020
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COLLEGE OF NURSING

Section/Group No. ___________________
PERFORMANCE CHECKLIST IN HANDWASHING
Legend:
2
1
PERFORMANCE POINTS 4 3 2 1 Comments

ASSESSMENT
Inspects hands for breaks / cuts in the skin or cuticles.
1 Report and covers affected part, if possible.
care.
2 Inspects hands for heavy soiling / dirt, and nails for length.
PLANNING
Prepares the following :
a. soap and soap dish d. tissue paper
3
b. orange stick e. lotion (optional)
c. towel
IMPLEMENTATION
4 Rolls uniform sleeves above elbow. Wristwatch and rings should be

removed prior to handwashing.
Stands in front of sink, keeping hands and uniform away from sink
5
surface.
6 Turns on water by turning faucet on or using knee/foot control to

regulate water flow and temperature.
7 Be careful not to splash water into uniform.
8 Wets hands and elbow thoroughly under running water.
9 Hands and forearms should be lowered during washing.
10 Applies a small amount of antiseptic. Lather thoroughly.
Builds lather and uses plenty of friction for minimum of 10-15 secs.
11 Interlace fingers. Rubs palms and dorsum back of hands using
circular motion at least 5x for each hand.
12 Keeps fingerlips down.
13 Uses both hands to clean fingernails using additional soap and

orange stick.
14 Rinses hands and wrists thoroughly, keeping elbows up and hands

down.
Makes a lather starting from the elbow, apply soap in rotating
15
motion.
16 Rinses thoroughly, keeping hands lower than elbows.
17 Uses paper towel, single use towel or warm dryer to dry hands. Dry
hands thoroughly from fingers to wrists and forearms.
18 Discards soiled paper towel properly.
19 Turns off water flow using foot or knee pedals.
20 Uses clean, dry paper towel to turn off hand faucet. Avoid touching it
with bare hand.
Applies a small amount of lotion or barrier cream if hands are dry or
21 chapped.
22 After care of equipment/environment

88/_____ AVE:

4/10/2020
06-02-2014-00
COLLEGE OF NURSING
Student's Name: _____________________________ Rating :

Section/Group No. ___________________

Catheterization
Legend:
2
1
4 3 2 1 Comments
Assessment
1 Assesses the client's overall condition.
If the client is able to cooperate and hold still during the
2
procedure.
3 If the client can be positioned in supine with head

relatively flat.
4 When client last voided or was last catheterized.
5 Percusses the bladder to check for fullness or

distention.
Planning
6 a. Prepares equipment and supplies
Catheterization set
* Cotton balls
* Forceps (straight or curved)
* Specimen bottle (2)
* Kidney basin
* Eye sheet
7 b. Prepares other needed equipment.
* Pair of sterile gloves
* Lubricating jelly
* Sterile 10 cc syringe
* Distilled water & Betadine solution
* Urine bag
* Besheet for drape
* Goose lamp
* Padding sheet
Implementation - FEMALE
8 Opens the pack, if pack is not available, arranges all

equipment first before wearing gloves.
9 Opens and pours cleansing solution over swabs.
10 Opens and prepares the lubricating jelly on the side of

sterile kidney basin.
11 Opens or sets aside specimen bottle (optional)
Prepares urine bag and distilled water. Opens the
12
sterile syringe and catheter.
06-02-2014-00
COLLEGE OF NURSING

Section/Group No. ___________________

13 Wears gloves .
06-02-2014-00
COLLEGE OF NURSING

Section/Group No. ___________________

Female Catheterization 4 3 2 1 Comments
14 Applies eye sheet over the perineum.
15 Inserts the syringe to the indwelling catheter inflation

hub and test the balloon.
16 Fills the syringe with distilled water.
Exposes the meatus establishes a firm, but gentle
17
position using the non-dominant hand.
Using forceps with dominant hand, picks up a cleansing

18
ball and wipes in an anterior to posterior direction.
Cleans first both sides of the labia minora then uses the
last cotton ball to cleanse the meatus directly.
Discards each cotton ball after use in area where it will
19 not contaminate other equipment. Keeps the labia apart
at his point in time.
20 Grasps and lubricates the catheter sparingly.
Inserts the catheter 2-3 inches, do not touch any area

21 with the catheter except the meatus itself until urine
flows, then inserts 1-2 inches further.
Without releasing the catheter, holds the inflation valve

22 between two fingers with non-dominant hand while
attaching syringe and inflates the balloon with dominant
hand.
23 Pulls catheter gently until resistance is felt to ensure

that the balloon is in place.
24 Collects urine specimen if needed.
25 Removes the eye sheet and connects catheter to the

urine bag.
26 Secures the catheter tubing to inner thigh.
27 Wipes the perineal area of any remaining antiseptic or

lubricant. Places the patient to a comfortable position.
28 Discards all used equipments in approriate receptable

and wash hands.
29 Records the procedure.
a. Type and size of the catheter used.
b. Time of procedure.
c. Amount & description of urine obtained.
d. Patient's response.
e. Disposition of the specimen if taken.
TOTAL -116 /____=
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COLLEGE OF NURSING
Student's Name: _____________________________

Rating
Section/Group No. ___________________
Legend:
2
1

I. Important Points to Consider in Bedmaking
A. Infection Control:
1 Handles linen carefully.
Holds both soiled and cleans linen away from your
2
uniform.
3 Washes hands before and after the procedure.
B. Body Mechanics:
4 When she must bend, bend her knees and not her
back.
Faces her entire body in the direction in which she
5
is moving and avoids twisting.
6 Organizes her work and conserves steps.
II. Procedure for Bedmaking
A. Assessment
7 Assesses potential for patient being incontinent or

having excess discharge on bed.
8 Checks condition of linen on bed.
9 Checks for special needs of the patient.
B. Planning
11 Obtains laundry hamper or bag.
12 Gathers linen to be used.
13 Obtains other needed items or equipment.
C. Implementation
Raises bed to appropriate working height. Be
14
certain wheels are locked.
15 Removes cases from pillow.
06-02-2014-00

COLLEGE OF NURSING
Student's Name: _____________________________

Rating
Section/Group No. ___________________
Legend:
2
1

16 Loosens top and bottom linen from mattress.
Removes items to be re-used, folds and places
17
across back of chair.
18 Removes remaining linen and place in hamper.
19 Turns mattress if necessary.
20 Moves mattress to head of bed.
If gloves were worn, removes and washes hands
21
before touching clean items.
22 Places bottom sheet on bed.
23 Miters top corner of bottom sheet.
24 Tucks remainder of sheet under.
25 Places rubber sheet on bed.
Places cloth draw sheet over rubbed sheet. Tucks
26
near edge.
Goes to the other side. Tucks bottom sheet under
27 head of bed, and miters corner. Tucks remainder
of sheet.
28 Tucks under sheet and draws sheet snugly.
Places top sheet on bed, using centerfold as
29
guide.
Folds top sheet away from foot and head of bed to
30
form a cuff.
31 Fan folds far linen to near side of the bed.
32 Places hot water bags in between fanfolds.
Places pillow against headboard and puts bed on
33
raised position.
Puts IV stand, kidney basin, tissue and other
34
needed items on bedside.
TOTAL / 72 =
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4/10/2020

Checklst 202

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UPHSL/DJGTMU-ACAD -RDC-10B

UNIVERSITY OF PERPETUAL HELP SYSTEM LAGUNA

Student's Name: _____________________________

PERFORMANCE CHECKLIST IN BEDMAKING

Station 2: Post Op or Surgical Bed 4 3 2 1 Comments

4 In position like bodning - bend the knees and not

7 Assess patient for incontinence risk or body

UNIVERSITY OF PERPETUAL HELP SYSTEM LAGUNA

Student's Name: _____________________________

PERFORMANCE CHECKLIST IN BEDMAKING

Station 2: Post Op or Surgical Bed 4 3 2 1 Comments

UNIVERSITY OF PERPETUAL HELP SYSTEM LAGUNA

Student's Name: _____________________________

PERFORMANCE CHECKLIST IN BEDMAKING

Station 2: Post Op or Surgical Bed 4 3 2 1 Comments

UNIVERSITY OF PERPETUAL HELP SYSTEM LAGUNA

Student's Name: _____________________________

RETURN DEMO CHECKLIST LEVEL 2

STATION THREE 4 3 2 1 Comments

6 Inquires about patient's blood pressure reading (or checks patient's

7 Prepares sphygmomanometer, stethoscope, pen, paper and other

STUDENT'S SIGNATURE: _________________________________

Student's Name: _____________________________ Rating

RETURN DEMO CHECKLIST LEVEL 2

Removes any fecal matter using of fold of underpad/toilet tissue.

10 Changes gloves if become soiled.

17 Removes bedpan and underpad. Places client in a comfortable position.

STUDENT'S SIGNATURE: _________________________________

Student's Name: _____________________________ Rating

RETURN DEMO CHECKLIST LEVEL 2

B - Male Perineal Care 4 3 2 1

5 Explains to client the purpose and nature of procedure.

16 Assists client to establish a comfortable position and cover with a sheet.

STUDENT'S SIGNATURE: _________________________________

Student's Name: _____________________________

RETURN DEMO CHECKLIST LEVEL 2

STUDENT'S SIGNATURE: _________________________________

CLINICAL INSTRUCTOR'S SIGNATURE: ______________________

GRADE DATE CLINICAL INSTRUCTOR

UNIVERSITY OF PERPETUAL HELP SYSTEM LAGUNA

Student's Name: _____________________________ Rating

PERFORMANCE CHECKLIST IN HANDWASHING

PERFORMANCE POINTS 4 3 2 1 Comments

STUDENT'S SIGNATURE: _________________________________

UNIVERSITY OF PERPETUAL HELP SYSTEM LAGUNA

Student's Name: _____________________________

RETURN DEMO CHECKLIST LEVEL 2

UNIVERSITY OF PERPETUAL HELP SYSTEM LAGUNA

Student's Name: _____________________________

RETURN DEMO CHECKLIST LEVEL 2

UNIVERSITY OF PERPETUAL HELP SYSTEM LAGUNA

Student's Name: _____________________________

RETURN DEMO CHECKLIST LEVEL 2

Continuation Male Catheterization 4 3 2 1 Comments

27 Wipes the perineal area of any remaining antiseptic or lubricant.

28 Discards all used equipments in approriate receptable and washes

STUDENT'S SIGNATURE: _________________________________