UNIVERSITY OF MAKATI

COLLEGE OF ALLIED HEALTH STUDIES

CENTER OF NURSING
BACHELOR OF SCIENCE IN NURSING

LEVEL 2:
NURSING SKILLS
A.Y. -

NAME OF STUDENT:

YEAR AND SECTION:

Compiled by: Esmeraldo C. De Las Armas IV MAN, RN, EMT-B

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 NAME OF STUDENT:

YEAR/SECTION:

LEVEL 2 NURSING SKILLS

TABLE OF CONTENT PAGE

NUMBER

NP 4 – Community Health Nursing 1 5

1. Bag Technique 6
A.Y. 2021-2022
1st SEMESTER,

2. Cleaning a Wound and Applying Sterile Dressings 8

3. First Aid 12
4. Intradermal Injection 14
5. Intramuscular Injection 16
6. Subcutaneous Injections 18
7. Breast Examination 20
8. Leopold’s Maneuver 22
Summary of Grades 24

NP 7 – Care of Mother, Child, Adolescent (Well Client) 25

9. Oral, Buccal, and Sublingual Medication Administration 26
10. Administering Eye and Ear Medications 29
11. Administering Vaginal and Rectal Suppositories 31
12. Oxygen Administration 33
13. EINC 34
14. Enema Administration 36
15. Surgical Handwashing 38
16. Gowning and Gloving (closed method) 40
17. Skin Preparation for Surgery 42
18. Urinary Catheterization (Male & Female) 44
19. Obtaining a urine specimen from a closed-drainage system 49
20. Removing Indwelling Catheter 51
Summary of Grades 53

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 TABLE OF CONTENT PAGE
NUMBER

NP 9 – Care of Mother, Child at Risk or with Problems

54
(Acute and Chronic)
21. Setting up Intravenous Infusion 55
22. Setting the flow rate (IV infusion) 58
23. Administering of drugs through IV push and Heplock 60
24. Drug Incorporation into IV Solution 63
A.Y. 2021-2022

25. Administering medication via Piggy Back 65

1st SEMESTER,

26. Changing Intravenous Site Dressing 67

27. Blood Transfusion 69
28. BLS for Pediatric Patient 71
29. BLS for Infant with AED 73
30. Nebulization Administration 76
Summary of Grades 78

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 UNIVERSITY OF MAKATI

VISION
We envision the University of Makati as the primary instrument where
University education and Industry training programs interface to mold Makati
youth into productive citizens and IT-enabled professionals who are exposed to
the cutting edge of technology in their areas of specialization. The University
shall be the final stage of Makati City's integrated primary level to university
educational system that allows its less privileged citizens to compete for high
paying job opportunities in its business and industries.
A.Y. 2021-2022

MISSION
1st SEMESTER,

To achieve our vision, University of Makati shall mold highly competent

professionals and skilled workers from the children of poor Makati residents
while inculcating in them good moral values and desirable personality
development by offering baccalaureate degree, graduate degree, and non-
degree programs with parallel on campus social, cultural, sports and other co-
curricular activities.

COLLEGE OF ALLIED HEALTH STUDIES

VISION
The College of Allied Health Studies is dedicated to becoming the top of the
mind innovative provider of relevant and needs based-health care education.

MISSION
Development of health care industry workforce that is resilient to its dynamics;
and who are competent, creative and socially responsible.

CORE VALUES
• Resiliency
• Competence
• Creativity
• Social Responsibility

CENTER OF NURSING

VISION-MISSION
The Center supports the College’s vision in becoming the top of mind
innovative provider of relevant and needs-based education by producing
graduate nurses who are fully competent in delivering standard and quality
nursing care, as well as expanded nursing career roles, integrating theory,
practice, and values.

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A.Y. 2021-2022

NP 4 - Community
1st SEMESTER,

Health Nursing 1

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 NAME OF STUDENT:

YEAR/SECTION: DATE: GRADE: (%) CLINICAL

INSTRUCTOR:

Correctly Needs
Not Done
SKILL: BAG TECHNIQUE RATIONALE Done Improvement
(0)
(2) (1)

ASSESSMENT
1. Assess the family health record.
2. Assess the health needs of the client and
family.
3. Assess the articles, supplies which may be
used to answer emergency needs.
4. Assess for the arrangements of the contents
of the bag.
A.Y. 2021-2022

5. Assess the environment and look for a flat

surface.
1st SEMESTER,

PLANNING / EXPECTED OUTCOMES:

6. To minimize or eradicate the spread of
infection.
7. To render effective nursing care.
MATERIALS:
8. CHN/ PHN Bag
9. Paper or plastic lining
10. Plastic (waste receptacle)
11. Apron
12. Hand towel in plastic bag
13. Liquid soap or soap with soap dish
14. Thermometer
15. 2 scissors (surgical and bandage)
16. 2 forceps (curved and straight)
17. Syringes (5mL, 3mL, 1mL)
18. Hypodermic needles (g. 18, 20, 22, 23 and
25)
19. Sterile dressing
20. Sterile cord clamp
21. Sterile gloves (5 pairs)
22. Clean gloves (5 pairs)
23. Tape measure
24. Baby’s scale
25. Adhesive tape (micropore)
26. 2 test tubes
27. Test tube holder
28. Specimen bottle
MATERIALS:
29. Povidone iodine – antiseptic solution for
clean wounds
30. 70% isopropyl or ethyl alcohol
31. Alcohol lamp
32. Ophthalmic ointment
33. Zephiran solution – disinfection of materials
(forceps, scissors)
34. Hydrogen peroxide – antiseptic solution for
dirty wounds
35. Spirit of ammonia
36. Acetic acid – to test for protein in urine
37. Benedict’s solution - to test for glucose in
urine
IMPLEMENTATION:
38. Assess for presence of dogs in the area.
Knock or ring doorbell.
39. Introduce yourself and explain the purpose
of your visit.
40. Upon entering the client’s home, ask
permission to use a flat surface
41. Place your bag on the flat surface, lined with
paper lining with clean side out (folded part

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 touching the table). Tuck the strap beneath
the bag
42. Ask for a basin of water, if faucet is not
available. Place it outside the working area
43. Open the bag, take the plastic linen and
spread over the work field area (folded part
out of the paper lining)
44. Take out the hand towel, soap & apron,
leaving the plastic wrappers of the towel and
soap dish inside the bag. Place the towel,
soap dish and apron at the corner with the
confines of the linen.
45. Perform hand washing, pat dry with towel.
46. Put on the apron right side out and wrong
side with crease touching the body.
47. Put out the things most needed for the
specific case.
48. Place the waste bag outside the work area.
49. Close the bag
50. Proceed to the specific nursing care or
treatment
51. After completing nursing care, clean with
A.Y. 2021-2022

alcohol to cleanse materials used

AFTER CARE:
1st SEMESTER,

52. Perform hand washing again

53. Open the bag and put back all the articles in
their proper places
54. Remove apron folding away the body with
soiled side folded inwards and the clean side
out and place it in the bag.
55. Carry the bag from the table and fold the
paper and plastic lining clean side out. If it is
heavily soiled, discard. If still clean, place
between the flaps and cover the bag
DOCUMENTATION:
56. Record all relevant findings about the client
and members of the family
57. Take note of the environmental factors which
affects the client
58. Include quality of nurse-patient relationship
EVALUATION:
59. Infection and spread of microorganisms have
been minimized.
60. Nursing care has been rendered effectively.
TOTAL
/ 120

Computation: Raw Score / Total Score X 100 = FINAL GRADE

Clinical Instructor: %
REMARKS:

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 NAME OF STUDENT:

YEAR/SECTION: DATE: GRADE: (%) CLINICAL

INSTRUCTOR:

Correctly Needs
SKILL: CLEANING A WOUND AND Not Done
RATIONALE Done Improvement
(0)
APPLYING STERILE DRESSING (2) (1)

ASSESSMENT
1. Verify the physician’s order
2. Assess the situation to determine the need
for wound cleaning and a dressing change.
3. Assess the patient’s level of comfort and the
need for analgesics before wound care.
4. Assess if the patient experienced any pain
related to prior dressing changes and the
effectiveness of interventions employed to
minimize the patient’s pain.
A.Y. 2021-2022

5. Assess the current dressing to determine if it

1st SEMESTER,

is intact.
6. Assess for excess drainage, bleeding, or
saturation of the dressing.
7. Inspect the wound and the surrounding
tissue.
8. Assess the appearance of the wound for the
approximation of wound edges, the color of
the wound and surrounding area, and signs
of dehiscence.
9. Assess for the presence of sutures, staples,
or adhesive closure strips.
10. Note the stage of the healing process and
characteristics of any drainage.
11. Assess the surrounding skin for color,
temperature, and edema, ecchymosis, or
maceration.
PLANNING / EXPECTED OUTCOMES:
12. The expected outcome to achieve when
cleaning a wound and applying a dry, sterile
dressing is that the wound is cleaned and
protected with a dressing without
contaminating the wound area, without
causing trauma to the wound, and without
causing the patient to experience pain or
discomfort.
13. Other outcomes that are appropriate include:
the wound continues to show signs of
progression of healing, and the patient
demonstrates understanding of the need for
wound care and dressing change.
MATERIALS:
14. Sterile gloves
15. Clean disposable gloves
16. Additional PPE, as indicated
17. Sterile gauze dressing
18. Surgical or abdominal pads
19. Sterile dressing set or suture set (for the
sterile scissors and forceps)
20. Sterile cleaning solution (0.9% normal saline
solution)
21. Sterile basin (optional)
22. Sterile drape (optional)
23. Plastic bag or other appropriate waste
container for soiled dressings
24. Waterproof pad and bath blanket
25. Adhesive tape or Ties
26. Other linen for draping patient
27. Additional dressings and supplies, as
needed or physician’s order
IMPLEMENTATION:

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 28. Review the medical orders for wound care or
the nursing plan of care related to wound
care.
29. Gather the necessary supplies and bring to
the bedside stand or overbed table.
30. Perform hand hygiene and put on PPE, if
indicated.
31. Identify the patient.
32. Close curtains around bed and close door to
room if possible. Explain what you are going
to do and why you are going to do it to the
patient.
33. Assess the patient for possible need for
nonpharmacologic pain reducing
interventions or analgesic medication before
A.Y. 2021-2022
wound care dressing change. Administer
1st SEMESTER,
appropriate prescribed analgesic. Allow
enough time for analgesic to achieve its
effectiveness.
34. Place a waste receptacle or bag at a
convenient location for use during the
procedure.
35. Adjust bed to comfortable working height,
usually elbow height of the caregiver.
36. Assist the patient to a comfortable position
that provides easy access to the wound
area. Use the bath blanket to cover any
exposed area other than the wound. Place a
waterproof pad under the wound site.
37. Check the position of drains, tubes, or other
adjuncts before removing the dressing. Put
on clean, disposable gloves and loosen tape
on the old dressings. If necessary, use an
adhesive remover to help get the tape off.
38. Carefully remove the soiled dressings. If
there is resistance, use a silicone-based
adhesive remover to help remove the tape. If
any part of the dressing sticks to the
underlying skin, use small amounts of sterile
saline to help loosen and remove.
39. After removing the dressing, note the
presence, amount, type, color, and odor of
any drainage on the dressings. Place soiled
dressings in the appropriate waste
receptacle. Remove your gloves and dispose
of them in an appropriate waste receptacle.
40. Inspect the wound site for size, appearance,
and drainage. Assess if any pain is present.
Check the status of sutures, adhesive
closure strips, staples, and drains or tubes, if
present. Note any problems to include in
your documentation.
41. Using sterile technique, prepare a sterile
work area and open the needed supplies
42. Open the sterile cleaning solution.
Depending on the amount of cleaning
needed, the solution might be poured directly
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Reviewing the order and plan of
care validates the correct patient
and correct procedure.
Preparation promotes efficient time
management and organized
approach to the task. Bringing
everything to the bedside
conserves time and energy.
Hand hygiene and PPE prevent
the spread of microorganisms.
PPE is required based on
transmission precautions.
Identifying the patient ensures the
right patient receives the
intervention and helps prevent
errors.
This ensures the patient’s privacy.
Explanation relieves anxiety and
facilitates cooperation.
Pain is a subjective experience
influenced by past experience.
Wound care and dressing changes
may cause pain for some patients.
Having a waste container handy
means the soiled dressing may be
discarded easily, without the
spread of microorganisms.
Having the bed at the proper
height prevents back and muscle
strain.
Patient positioning and use of a
bath blanket provide for comfort
and warmth. Waterproof pad
protects underlying surfaces.
Checking ensures that a drain is
not removed accidentally if one is
present. Gloves protect the nurse
from contaminated dressings and
prevent the spread of
microorganisms. Adhesive-tape
remover helps reduce patient
discomfort during removal of
dressing.
Cautious removal of the dressing is
more comfortable for the patient
and ensures that any drain present
is not removed. A silicone-based
adhesive remover allows for the
easy, rapid, and painless removal
without the associated problems of
skin stripping. Sterile saline
moistens the dressing for easier
removal and minimizes damage
and pain.
The presence of drainage should
be documented. Proper disposal of
soiled dressings and used gloves
prevents spread of
microorganisms.
Wound healing or the presence of
irritation or infection should be
documented.
Supplies are within easy reach and
sterility is maintained.
Sterility of dressings and solution is
maintained.
Page 9
 over gauze sponges over a container for
small cleaning jobs, or into a basin for more
complex or larger cleaning.
43. Put on sterile gloves
44. Clean the wound. Clean the wound from top
to bottom and from the center to the outside.
Following this pattern, use new gauze for
each wipe, placing the used gauze in the
waste receptacle. Alternately, spray the
wound from top to bottom with a
commercially prepared wound cleanser.
45. Once the wound is cleaned, dry the area
using a gauze sponge in the same manner.
Apply ointment or perform other treatments,
as ordered.
46. If a drain is in use at the wound location,
A.Y. 2021-2022
clean around the drain. (Refer to care for
1st SEMESTER,
Penrose drain, T-tube drain, Jackson-Pratt
drain and Hemovac drain).
47. Apply a layer of dry, sterile dressing over the
wound. Forceps may be used to apply the
dressing.
48. Place a second layer of gauze over the
wound site.
49. Apply a surgical or abdominal pad (ABD)
over the gauze at the site as the outermost
layer of the dressing.
50. Remove and discard gloves. Apply adhesive
tape or roller gauze to secure the dressings.
Alternately, many commercial wound
products are self-adhesive and do not
require additional tape.
51. After securing the dressing, label dressing
with date and time. Remove all remaining
equipment; place the patient in a comfortable
position, with side rails up and bed in the
lowest position.
52. Remove PPE, if used. Perform hand
hygiene.
53. Check all wound dressings every shift. More
frequent checks may be needed if the wound
is more complex or dressings become
saturated quickly.
DOCUMENTATION:
54. Document the location of the wound and that
the dressing was removed.
55. Record your assessment of the wound
including approximation of wound edges,
presence of sutures, staples or adhesive
closure strips, and the condition of the
surrounding skin.
56. Note if redness, edema, or drainage is
observed.
57. Document cleansing of the incision with
normal saline and any application of
antibiotic ointment as ordered.
58. Record the type of dressing that was
reapplied.
59. Note pertinent patient and family education
and any patient reaction to this procedure,
including patient’s pain level and
effectiveness of nonpharmacologic
interventions or analgesia if administered.
EVALUATION:
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Use of sterile gloves maintains
surgical asepsis and sterile
technique and reduces the risk for
spreading microorganisms.
Cleaning from top to bottom and
center to outside ensures that
cleaning occurs from the least to
most contaminated area and a
previously cleaned area is not
contaminated again. Using a single
gauze for each wipe ensures that
the previously cleaned area is not
contaminated again.
Moisture provides a medium for
growth of microorganisms. The
growth of microorganisms may be
inhibited and the healing process
improved with the use of ordered
ointments or other applications.
Cleaning the insertion site helps
prevent infection.
Primary dressing serves as a wick
for drainage. Use of forceps helps
ensure that sterile technique is
maintained.
A second layer provides for
increased absorption of drainage.
The dressing acts as additional
protection for the wound against
microorganisms in the
environment.
Proper disposal of gloves prevents
the spread of microorganisms.
Tape or other securing products
are easier to apply after gloves
have been removed.
Recording date and time provides
communication and demonstrates
adherence to plan of care. Proper
patient and bed positioning
promote safety and comfort.
Removing PPE properly reduces
the risk for infection transmission
and contamination of other items.
Hand hygiene prevents the spread
of microorganisms.
Checking dressings ensures the
assessment of changes in patient
condition and timely intervention to
prevent complications.
Page 10
 60. The expected outcome is met when the
patient exhibits a clean, intact wound with a
clean dressing in place.
61. The wound is free of contamination and
trauma.
62. Patient reports little to no pain or discomfort
during care.
63. Patient demonstrates signs and symptoms of
progressive wound healing.

TOTAL
/ 126

Computation: Raw Score / Total Score X 100 = FINAL GRADE

Clinical Instructor: %
REMARKS:
A.Y. 2021-2022
1st SEMESTER,

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 NAME OF STUDENT:

YEAR/SECTION: DATE: GRADE: (%) CLINICAL

INSTRUCTOR:

Correctly Needs
Not Done
SKILL: FIRST AID RATIONALE Done Improvement
(0)
(2) (1)

ASSESSMENT
1. Assess if the scene is safe
2. Assess the client's condition to be sure the The condition of the client may
order of the health care provider is have changed.
appropriate.
3. Assess the client's age. As pediatric/geriatric clients may
have special needs.
4. Assess the client’s understanding of the
purpose of the intervention
PLANNING / EXPECTED OUTCOMES:
5. To prevent further complications
A.Y. 2021-2022

6. The client will be able to discuss the purpose

of the intervention
1st SEMESTER,

7. The client will encounter minimum

discomfort.
8. The client will receive the maximum benefit
from the intervention
9. The client will show the desired response to
the intervention such as pain relief, and
stable
MATERIALS:
10. Clean gloves
11. Ice compress
12. 0.9% normal saline
13. Sterile gauze
14. Splints
IMPLEMENTATION:
15. Put on the necessary PPE
16. Explain the procedure to patient
17. Remove watches, rings and bracelet on the To prevent any further injury cause
affected limb. And put to a properly labelled by possible swelling.
container.
BLEEDING
18. Cover the wound with a gauze or a cloth Applying a tourniquet may do more
damage to the limb than good. The
2010 American Heart Association
guidelines also discount the value
of elevation and using pressure
19. Apply direct pressure to stop the blood flow points.
20. If gauze is already soak, don't remove the Upon removal of soaked gauze,
gauze. Add more layers of gauze if needed. possibility of removing of clotted
parts in the injury. Clots help stop
the flow.
21. Remove PPE and dispose to the proper
receptacle
22. Advise patient to seek medical evaluation or
call EMS, if necessary
FRACTURES
23. Put on necessary PPE
24. Expose and examine injury
25. Don’t try to straighten it.
26. Assess the distal pulse, motor and sensory
function of the affected extremity
27. Measure splint appropriately
28. Stabilize the limb using a splint and padding
to keep it immobilized. Apply splint above
and below injury.
29. Secure splint in place
30. Reassess circulation, motor and sensory
function
31. Loosen splint and/or bandages if necessary
32. Put a cold pack on the injury, avoid placing
ice directly on the skin.

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 33. Elevate the extremity or the splinted part, if
possible
34. Remove PPE and dispose to the proper
receptacle
35. Advise patient to seek medical evaluation or
call EMS, if necessary
BURN
36. Remove watches, rings and bracelet on the To prevent any further injury cause
affected limb. And put to a properly labelled by possible swelling.
container.
37. Flush the burned area with cool running
water for several minutes. Do not use ice.
38. Apply a light gauze bandage. Do not break Do not apply ointments, butter, or
any blisters that may have formed. oily remedies to the burn.
39. Classify the degree and depth of a burn. Use The extent of burn, clinically
rule of nines to determine the measurement referred to as the total surface area
or extent of burn. (Lund and Browder Chart burned, is defined as the
is used for children younger than 10 years). proportion of the body burned.
40. Call EMS for serious burns The severity of burn is based on
depth and size.
NOSEBLEED
41. Ask the patient to lean forward Do not ask the patient to lean back
A.Y. 2021-2022

42. Pinch the nose just below the bridge Do not pinch the nostril closed by
pinching lower.
1st SEMESTER,

43. Check after five minutes to see if bleeding If not, continue pinching and check
has stopped. after another 10 minutes.
44. Apply cold pack to the bridge of the nose
while pinching.
45. Call EMS or bring to nearest medical center
to be assessed
EVALUATION:
46. Client was able to discuss the purpose of the
procedure
47. Bleeding was controlled, with minimal blood
loss
48. No untoward incident; fracture was
immobilized
49. For burns. Client was removed from the
source and given the appropriate treatment
50. Appropriate intervention was provided to the
client
TOTAL
/ 100

Computation: Raw Score / Total Score X 100 = FINAL GRADE

Clinical Instructor: %
REMARKS:

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 NAME OF STUDENT:

YEAR/SECTION: DATE: GRADE: (%) CLINICAL

INSTRUCTOR:

Correctly Needs
SKILL: INTRADERMAL Not Done
RATIONALE Done Improvement
(0)
INJECTION (2) (1)

ASSESSMENT
1. Assess the 10 Rights of Medication
Administration
2. Verify the physician’s order
3. Assess the client’s allergies to medication
4. Check the specific drug action, side effects,
interactions and adverse effects.
5. Check the appearance of injection site.
(redness, hair distribution, skin condition)
6. Assess client’s knowledge about the
A.Y. 2021-2022

procedure.
1st SEMESTER,

PLANNING / EXPECTED OUTCOMES:

7. The client will experience minimal discomfort
at the injection site.
8. Medication will be administered properly.
9. The client will verbalize understanding of the
procedure.
MATERIALS:
10. 1 cc syringe or tuberculin syringe with
needle
11. Cotton balls (1 wet cotton ball, 1 dry cotton
ball)
12. Pen (black or blue)
13. Micropore
14. Sterile water or PNSS for injection
15. Medication for testing
16. Clean gloves
17. Medication Administration Record (MAR)
IMPLEMENTATION:
PREPARATION
18. Check the doctor’s order and MAR Ensures safety of the client and
19. Perform three checks for administering prevent medication error. Check
medications. Read the label on the the label on the medication
medication: carefully against the MAR.
1. When it is taken from the medication cart
2. Before withdrawing the medication
3. After withdrawing the medication.
PERFORMANCE
20. Perform hand hygiene. Don gloves.
21. Prepare the medication to be administered.
22. Prepare the client. Identify the correct patient
using two identifiers.
23. Explain the procedure to the client. Information can facilitate
• Explain that the medication will produce a acceptance of and compliance with
small wheal or bleb. (A wheal/ bleb is a the therapy.
small raised area like a blister.
• Explain that the client will feel a slight prick
as the needle enters the skin.
• Explain that once the medication is
administered, the client should not touch the
area and that it will be interpreted at a
particular time. (Medication test: after 30
minutes; Mantoux test: 24-48 hours)
24. Provide for privacy.
25. Assist/ place the client in a comfortable
position.
SKIN PREPARATION
26. Select an appropriate site.
27. Cleanse the skin at the site using a firm
circular motion starting at the center and
widening the circle outward. Allow the area to
dry thoroughly.

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 SYRINGE PREPARATION
28. Remove the needle cap while waiting for the
antiseptic to dry.
29. Expel any air bubbles from the syringe.
*Small bubbles that adhere to the plunger
are of no consequences.
30. Grasp the syringe in your dominant hand,
close to the hub, holding it between the
thumb and forefinger.
31. Hold the needle almost parallel to the skin
surface, with the bevel of the needle up.
INJECTION PREPARATION
32. Assist the client to a comfortable position
33. Discard the uncapped needle and syringe in
a sharps container
34. With the nondominant hand, pull the skin at Taut skin allows for easier entry of
the site until it is taut. the needle hence less discomfort
for the client.
35. Insert the tip of the needle far enough to
place the bevel through the epidermis into the
dermis. The outline of the needle should be
visible under the skin.
A.Y. 2021-2022

36. Stabilize the syringe and needle. Slowly inject

the medication producing the wheal/ bleb.
1st SEMESTER,

37. Withdraw the needle, gently wipe the Massage can disperse the
injection site with clean dry cotton. Do not medication into the tissue or out
massage the site. through the needle insertion site.
38. Dispose the syringe and needle into the Prevent needle stick injury.
sharp’s container.
DO NOT RECAP THE NEEDLE.
39. Remove and discard gloves.
40. Perform hand hygiene.
41. Encircle the wheal, note the time of injection,
name of medication and initials of the nurse.
DOCUMENTATION:
42. Document the relevant information:
medication, time, site, route and nursing
assessment.
EVALUATION:
43. Evaluate the client’s response to the
procedure. The client verbalized
understanding of the procedure.
44. Evaluate the site after 30 mins depending on
the test. Measure the area of redness and
induration.
45. The client experienced minimal discomfort
during the procedure.
TOTAL
/ 90

Computation: Raw Score / Total Score X 100 = FINAL GRADE

Clinical Instructor: %
REMARKS:

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 NAME OF STUDENT:

YEAR/SECTION: DATE: GRADE: (%) CLINICAL

INSTRUCTOR:

SKILL: INTRAMUSCULAR Correctly Needs

Not Done
RATIONALE Done Improvement
(0)
INJECTION (2) (1)

ASSESSMENT
1. Assess the 10 rights of giving medication
2. Review the physician’s orders
3. Review information regarding the drug
ordered such as action, purpose, time, of
onset and peak action, normal dosage,
common side effects, and nursing
implications
4. Assess the client for factors that may
influence any injection, such as circulatory
shock, reduced local tissue perfusion, or
muscle atrophy
A.Y. 2021-2022

5. Assess for previous intramuscular injections

1st SEMESTER,

6. Assess for the indications for intramuscular

injections
7. Assess the client’s age
8. Assess the client’s knowledge regarding the
medication to be received
9. Assess the client’s response to discussion
about an injection
10. Assess the client’s size and muscle
development
PLANNING / EXPECTED OUTCOMES:
11. The client will experience only minimal pain
or burning at the injection site
12. The client will experience no allergic reaction
or other side effects from the injection
13. The client will be able to know and
understand the reason for taking medication
and side effects of the drugs
MATERIALS:
14. 3 cc syringe with needle (g. 23, 25)
15. Cotton balls (1 wet cotton ball, 1 dry cotton
ball)
16. Pen (black or blue)
17. Micropore
18. Sterile water or PNSS for injection
19. Medication
20. Clean gloves
21. Medication Administration Record (MAR)
IMPLEMENTATION:
PREPARATION
22. Check the doctor’s order and MAR Ensures safety of the client and
23. Perform three checks for administering prevent medication error. Check
medications. Read the label on the the label on the medication
medication: carefully against the MAR.
1. When it is taken from the medication cart
2. Before withdrawing the medication
3. After withdrawing the medication.
PERFORMANCE
24. Perform hand hygiene. Don gloves.
25. Prepare the medication to be administered.
26. Prepare the client. Identify the correct patient
using two identifiers.
27. Explain the procedure to the client. Information can facilitate
acceptance of and compliance with
the therapy.
28. Provide for privacy.
29. Assist/ place the client in a comfortable
position.
SELECT, LOCATE AND CLEAN SITE
30. Select an appropriate site. If the injections changing sites can reduce the
are to be frequent, alternate the sites. discomfort of intramuscular
injections.

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 31. Don clean gloves.
32. Cleanse the skin at the site using a firm
circular motion starting at the center and
widening the circle outward (about 5cm).
Allow the area to dry thoroughly.
SYRINGE PREPARATION
33. Remove the needle cap while waiting for the
antiseptic to dry.
34. *IF USING A PRE-FILLED UNIT-DOSE Medication left on the needle can
MEDICATION: cause pain when it is tracked
Take caution to avoid dripping medication on through the subcutaneous tissue.
the needle prior to injection. If this occurs,
wipe the medication off the needle with a
sterile gauze or replace the needle.
INJECTION PROCEDURE
35. While holding the swab/ cotton ball between Pulling the skin and subcutaneous
the fingers of the nondominant hand, use the tissue or pinching the muscle make
ulnar side to pull the skin approximately it firmer and facilitates needle
2.5cm into the side, or pinch the muscle for insertion.
emaciated infant or child.
36. Hold the syringe between thumb and
forefinger using the dominant hand like a
pen/ dart.
A.Y. 2021-2022

37. Inject the needle quickly and smoothly at a using a quick motion lessens the
1st SEMESTER,

90-degree angle. client’s discomfort.

38. Hold the barrel of the syringe steady with
your nondominant hand.
39. The dominant hand will aspirate by pulling if the needle is in a small blood
back on the plunger. Aspirate for 5 – 10 vessel, it takes time for blood to
seconds. appear. If blood appears, withdraw
the needle and discard the syringe
and prepare a new set.
40. Inject the medication steadily and slowly injecting medication slowly
(approx. 10 seconds per mL) while holding promotes comfort and allows time
the syringe steadily. for tissue to expand and begin
absorption of the medication.
Holding of the syringe steadily will
minimize the discomfort.
41. Withdraw the needle quickly at the same
angle of insertion
42. With the nondominant hand, apply pressure massaging the site may cause the
on the site. Do not massage the area. leakage of the medication from the
site of injection.
43. Assist the client to comfortable position.
44. Discard the uncapped needle and syringe
into the sharp container.
45. Remove gloves and perform hand hygiene.
DOCUMENTATION:
46. Document the relevant information:
medication, time, site, route and nursing
assessment.
EVALUATION:
47. Evaluate the client’s response to the
procedure. The client verbalized
understanding of the procedure.
48. Evaluate the effectiveness of the medication
at the time it is expected to act.
49. The client experienced minimal discomfort
during the procedure.
TOTAL
/ 98
Computation: Raw Score / Total Score X 100 = FINAL GRADE

Clinical Instructor:
%
REMARKS:

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do not wish them to appear on the workbook, please contact us and they will be promptly removed.
 NAME OF STUDENT:

YEAR/SECTION: DATE: GRADE: (%) CLINICAL

INSTRUCTOR:

Correctly Needs
SKILL: SUBCUTANEOUS Not Done
RATIONALE Done Improvement
(0)
INJECTION (2) (1)

ASSESSMENT
1. Assess the 10 Rights of Medication
Administration
2. Verify the physician’s order
3. Assess the client’s allergies to medication
4. Check the specific drug action, side effects,
interactions and adverse effects.
5. Check the appearance of injection site and
tissue integrity. (redness, hair distribution,
skin condition)
6. Assess client’s knowledge about the
A.Y. 2021-2022

procedure and willingness to participate.

7. Previous injection sites
1st SEMESTER,

PLANNING / EXPECTED OUTCOMES:

8. The client will experience minimal discomfort
at the injection site.
9. Medication will be administered properly.
10. The client will verbalize understanding of the
procedure.
MATERIALS:
11. 3 cc syringe with needle (g. 23, 25)
12. Cotton balls (1 wet cotton ball, 1 dry cotton
ball)
13. Pen (black or blue)
14. Micropore
15. Sterile water or PNSS for injection
16. Medication
17. Clean gloves
18. Medication Administration Record (MAR)
IMPLEMENTATION:
PREPARATION
19. Check the doctor’s order and MAR Ensures safety of the client and
20. Perform three checks for administering prevent medication error. Check
medications. Read the label on the the label on the medication
medication: carefully against the MAR.
1. When it is taken from the medication cart
2. Before withdrawing the medication
3. After withdrawing the medication.
PERFORMANCE
21. Perform hand hygiene. Don gloves.
22. Prepare the medication to be administered.
23. Prepare the client. Identify the correct patient
using two identifiers.
24. Explain the procedure to the client. Information can facilitate
acceptance of and compliance with
the therapy.
25. Provide for privacy.
26. Assist/ place the client in a comfortable
position.
SELECT, LOCATE AND CLEAN THE SITE
27. Select an appropriate site. If the injections Changing sites can reduce the
are to be frequent, alternate the sites. discomfort of intramuscular
injections.
28. Don clean gloves.
29. Cleanse the skin at the site using a firm
circular motion starting at the center and
widening the circle outward (about 5cm).
Allow the area to dry thoroughly.
SYRINGE PREPARATION
30. Remove the needle cap while waiting for the
antiseptic to dry.

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 31. *IF USING A PRE-FILLED UNIT-DOSE Medication left on the needle can
MEDICATION: cause pain when it is tracked
Take caution to avoid dripping medication on through the subcutaneous tissue.
the needle prior to injection. If this occurs,
wipe the medication off the needle with a
sterile gauze or replace the needle.
INJECTION PROCEDURE
32. Grasp the syringe in your dominant hand by
holding it between your thumb and fingers.
33. With the nondominant hand, pinch or spread
the skin at the site.
34. With palm facing to the side or upward for a
45-degree angle insertion, prepare to inject.
35. Insert the needle using the dominant hand
and a firm steady push.
36. Hold the barrel of the syringe steady with
your nondominant hand.
37. The dominant hand will aspirate by pulling
back on the plunger.
38. Inject the medication steadily and slowly Injecting medication slowly
(approx. 10 seconds per mL) while holding promotes comfort and allows time
the syringe steadily. for tissue to expand and begin
A.Y. 2021-2022

absorption of the medication.

Holding of the syringe steadily will
1st SEMESTER,

minimize the discomfort.

39. Remove the needle smoothly, pulling along Depressing the skin places counter
the line of the insertion while depressing the traction on it, minimizing the
skin with your nondominant hand. client’s discomfort when the needle
is withdrawn.
40. Apply pressure on the site with the cotton
swab.
41. Assist the client to comfortable position.
42. Discard the uncapped needle and syringe
into the sharps container.
43. Remove gloves and perform hand hygiene.
DOCUMENTATION:
44. Document the relevant information:
medication, time, site, route and nursing
assessment.
EVALUATION:
45. Evaluate the client’s response to the
procedure. The client verbalized
understanding of the procedure.
46. Evaluate the effectiveness of the medication
at the time it is expected to act.
47. The client experienced minimal discomfort
during the procedure.
TOTAL
/ 94

Computation: Raw Score / Total Score X 100 = FINAL GRADE

Clinical Instructor: %
REMARKS:

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do not wish them to appear on the workbook, please contact us and they will be promptly removed.
 NAME OF STUDENT:

YEAR/SECTION: DATE: GRADE: (%) CLINICAL

INSTRUCTOR:

Correctly Needs
Not Done
SKILL: BREAST EXAMINATION RATIONALE Done Improvement
(0)
(2) (1)

ASSESSMENT
1. Ask the client’s age, menstrual period,
number of pregnancies and lactation
2. Assess the client’s breast for obvious lumps,
nodules, or lesions
3. Assess the client’s previous breast surgeries
4. Assess the amount and color of breast
discharges
5. Assess for anxiety, restlessness and fear of
the procedure
A.Y. 2021-2022

6. Assess the client’s understanding of the of

1st SEMESTER,

the procedure
PLANNING / EXPECTED OUTCOMES:
7. Procedure will be performed without trauma
to the client
8. Client’s anxiety will be minimal during
procedure
9. Client’s breast will be free of redness and
excoriation
MATERIALS:
10. Antimicrobial soap
11. water
12. Clean gloves
13. Drape sheet or blanket
14. screen
IMPLEMENTATION:
15. Identify the client, introduce yourself and
explain the procedure
16. Ask the client’s menstrual period
17. Provide privacy. Expose only the area to be
examined
18. For male examiner, ask someone to be with
while performing the procedure
19. Wash and warm hands. Don clean gloves if
necessary
20. Ask the patient to sit and raise arm over her
head (one arm at a time)
21. With the patient’s arm raised, inspect the
axilla for any rash, infection or unusual
pigmentation
22. Palpate the tail of the breast tissue and any
lymph or nodules on the axilla
23. Ask the patient to press her hands against
her hips and assess for asymmetry.
24. Lower the head of the bed and position
patient in supine
25. Place a small pillow under the patient’s
shoulder on the side you are examining
26. Ask her to raise her arms above her head
27. Begin with the lateral portion of the breast
28. Palpate one breast at a time, starting from
the tail using parallel line technique
29. Palpate in circular motion, soft to medium.
30. Use a systematic pattern to palpate the
entire breast
31. Try to identify any nodule or mass that is
larger or different from the rest of the breast
tissue
32. To examine the median portion of the
breast, position patient in supine
33. Palpate in straight line with one hand above
the shoulder between nipple and bra line

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 then up to the clavicle using the same
systematic pattern
34. Palpate the nipple, note for the elasticity and
check for discharges
35. Drape the breast and proceed to the other
using the same technique
MALE:
36. Inspect for symmetry and size
37. Inspect each nipple and areola for nodules
38. Check for axillary’s lymph nodes in the
same technique you used for female clients
39. Make sure male patients arm remains on
the side
40. If the breast appears to be large at the
areola, try to distinguish some fats from the
firm disc of tissue
41. Wash hands
42. Document necessary findings such as color,
contour, symmetry description of nodules
EVALUATION:
43. Presence of lymph, nodules, lesions, color,
and discharges was noted
A.Y. 2021-2022

44. Client’s anxiety was minimal during the

procedure
1st SEMESTER,

45. Procedure was performed without trauma to

the patient
TOTAL
/ 90

Computation: Raw Score / Total Score X 100 = FINAL GRADE

Clinical Instructor: %
REMARKS:

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do not wish them to appear on the workbook, please contact us and they will be promptly removed.
 NAME OF STUDENT:

YEAR/SECTION: DATE: GRADE: (%) CLINICAL

INSTRUCTOR:

Correctly Needs
Not Done
SKILL: LEOPOLD’S MANUEVER RATIONALE Done Improvement
(0)
(2) (1)

ASSESSMENT
51. Assessment of the maternal pelvis’ shape
52. Assess the need for cesarean section
53. Assess the presenting part into the maternal
pelvis, extent of flexion of the fetal head,
estimated fetal weight and size,
54. Determine if complication will occur during
delivery
55. Determine the fetal position in the maternal Accuracy is greatest after 36
abdomen. weeks of gestation
56. Identify the upper and lower fetal poles
A.Y. 2021-2022

namely, the proximal and distal fetal parts.

PLANNING / EXPECTED OUTCOMES:
1st SEMESTER,

57. Patient verbalizes decrease discomfort

58. Patient understands the reason for the
procedure performed
59. Patient remains free from injury
60. Patient exhibits no untoward incident
MATERIALS:
61. Clean gloves
62. Soap or Alcohol
IMPLEMENTATION:
63. Verify the physician’s order
64. Perform hand hygiene and put on PPE, if Hand hygiene and PPE prevent
indicated. the spread of microorganisms.
PPE is required based on
transmission precautions.
65. Identify the patient Identifying the patient ensures the
right patient receives the
intervention and helps prevent
errors.
66. Instruct the patient to empty her bladder Patient will be comfortable and the
before the procedure. contour of the fetus is not
obscured.
67. Close curtains around bed and the door to This ensures the patient’s privacy.
room, if possible.
68. Position the patient. Back slightly elevated. Relieve the stress on the patient.
Put her in a comfortable position with her
knees flexed. Make sure the table is slightly
elevated.
69. Drape the patient and place pillow under her
head.
70. Explain the purpose of the procedure and Explanation relieves anxiety and
what you are going to do. Answer any facilitates cooperation.
questions.
71. Rub hands together vigorously. Make sure To prevent uterine contractions
that hands are warm before coming in and use the palm of the hand
contact with the patient’s abdomen. instead of the fingers.
FIRST MANEUVER (UPPER FETAL POLE)
72. Stand at the woman’s side, facing her head.
73. Palpate the uppermost part of gravid uterusThe fetal buttocks are usually at
gently, with the fingertips together, to the upper fetal pole; they feel firm
determine what fetal part is located at thebut irregular, and less globular
fundus, which is the “upper fetal pole”. than the head. The fetal head feels
firm, round, and smooth.
Occasionally, neither part is easily
palpated at the fundus, as when
the fetus is in a transverse lie.
SECOND MANEUVER (SIDES OF THE MATERNAL ABDOMEN)
74. Place one hand on each side of the woman’s By 32 weeks’ gestation, the fetal
abdomen, capturing the fetal body between back has a smooth, firm surface as
them. long or longer than the examiner’s
hand.

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 75. Steady the uterus with one hand and palpate
the fetus with the other, looking for the back irregular bumps. The fetus may
on one side and extremities on the other.
THIRD MANEUVER (LOWER FETAL POLE AND DESCENT INTO
PELVIS)
76. Face the woman’s feet.
77. Place the flat palmar surfaces of the
fingertips on the fetal pole just above the
pubic symphysis.
78. Palpate the presenting fetal part for texture
and firmness to distinguish the head from the
buttock.
79. Judge the descent, or engagement, of the
presenting part into the maternal pelvis.
80. Alternatively, use the Pawlik grip by grasping
the lower fetal pole with the thumb and
fingers of one hand to assess the presenting
part and descent into pelvis; however, this
technique tends to be uncomfortable to the
gravid patient.
A.Y. 2021-2022
The fetal arms and legs feel like
kick if awake and active.
Again, the fetal head feels very
firm and globular; the buttocks feel
firm but irregular, and less globular
than the head.
In a vertex or cephalic
presentation, the fetal head is the
presenting part.
If the most distal part of the lower
fetal pole cannot be palpated, it is
usually engaged in the pelvis.
If you can depress the tissues over
the maternal bladder without
touching the fetus, the presenting
part is proximal to your fingers.

FOURTH MANEUVER (FLEXION OF THE FETAL HEAD)

1st SEMESTER,

81. This maneuver assesses the flexion or If the cephalic prominence juts out
extension of the fetal head, presuming that along the line of the fetal back, the
the fetal head is the presenting part in the head is extended.
pelvis.
82. Still facing the woman’s feet, with your hands If the cephalic prominence juts out
positioned on either side of the gravid uterus, along the line of the fetal anterior
identify the fetal front and back sides. side, the head is flexed.
83. Using one hand at a time, slide your fingers
down each side of the fetal body until you
reach the “cephalic prominence,” that is,
where the fetal brow or occiput juts out.
EVALUATION:
84. Patient verbalizes knowledge regarding the
procedure
85. No untoward incident for both patient
86. Patient remains free from injury
87. Patient tolerate the procedure
TOTAL
/ 74

Computation: Raw Score / Total Score X 100 = FINAL GRADE

Clinical Instructor: %
REMARKS:

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do not wish them to appear on the workbook, please contact us and they will be promptly removed.
 NAME OF STUDENT:

YEAR/SECTION: COMMUNITY HEALTH NURSING 1

CHECKLISTS
SUMMARY OF GRADES

RAW TOTAL PASSED/ CI’s STUDENT’s

ACTIVITY NAME SCORE SCORE %
FAILED SIGNATURE Signature

Bag Technique

Cleaning a Wound and

Applying Sterile
Dressings
A.Y. 2021-2022

First Aid
1st SEMESTER,

Intradermal Injection

Intramuscular Injection

Subcutaneous
Injections

Breast Examination

Leopold’s Maneuver

TOTAL

STUDENT’S NAME AND SIGNATURE

YEAR/GROUP/SECTION:

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