Republic of the Philippines

Isabela State University

Echague, Isabela

PERFORMANCE EVALUATION CHECKLIST

Name: Rating: _____________

Year/Group: __________________________

SKILL: Skin Preparation

Preparation 0 1 2 Comments
1. Assess client’s knowledge of
Caesarean section, reinforce
information.
2. Verified the correct patient
using two identifiers
3. Verify that operative permit is
signed on chart.
Assemble Equipment:

 Shave and preparation kit(razor,

soap, sponge, tray for water)
 Procedure gown
 Fingernail polish remover
 Preoperative medications and
administration equipment
 Gloves
 Surgical scrub solution

1. Provide patient privacy by

withdrawing the curtain closing the
doors
2. Mix an appropriate amount of
antiseptic scrub solution with an
appropriate amount of warm sterile
water in a basin. This allows for sudsing
action of the antiseptic scrub solution
3.Expose the site to be prepped, make
sure that the blanket will not become
contaminated
4. Place protective pads around the
patient to collect excess prepping
solution.
Tuck drip towels under patient as
necessary to prevent pooling of solution
5. Don sterile gloves

6. Wet sponge with antiseptic solution

and squeeze out excess.
You must use sufficient pressure and
friction to remove dirt and
microorganisms from skin and pores.
7. Scrub the skin in a circular motion.
Always prep from “clean to dirty” areas
taking care not to transfer
microorganisms from the periphery
back to the proposed incision site.
Do not double dip. “Double dipping”
into the antiseptic solution with a
contaminated sponge may lead to
microorganisms being brought back to
the proposed incision site.
8. After contact with peripheral or
contaminated areas of the prep site,
discard the sponge/applicator, and use
another sterile sponge/applicator for
any additional product applications.
9. Scrub for a minimum of five minutes
or according to hospital policy.
10. Dry the area with a sterile towel by
placing the towel and then patting the
area, using the cuff to lift the towel off
the skin when completed.

11. The soiled sponges are discarded

into the kick bucket.
12. Documentation of the skin
condition, hair removal technique if
applicable, prep solutions, person
performing the prep.

TOTAL
ISUE-CON-PEC-096

Note: You are rated using the criteria below:

0 - Missed/Failed to do the procedure
1 - Performed procedure but failed to explain the rationale for doing the procedure
2 - Performed procedure with confidence and explained the reason for doing said procedure.