Checklists

University of Cebu – Banilad
College of Nursing
Cebu City
SKILLS LABORATORY PERFORMANCE CHECKLIST
MEDICAL HANDWASHING
Name: _Trisha Faye Y. Pasay_____ Year & Section: _BSN 1-I___ Grade: __________
DEFINITION:
It is the rubbing together of all surfaces and crevices of the hands using a soap or chemical and
water.
PURPOSE:
Prevent and control transmission of infectious agents.
EQUIPMENT NEEDED: LEGEND:
Soap 1 - Excellent
Sink 2 – Very Satisfactory
Paper or cloth towels 3 – Satisfactory
Running water 4 –Needs Improvement
5 – Poor
E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
1. Prepare materials. To promote efficient time

management
2. Remove jewelry. Push sleeves of uniform To facilitate proper cleaning of

or shirt up above the wrist at mid forearm the hands and arms
level.
3. Assess hands for hangnails, cuts, or breaks To reduce risk for transmission of
in the skin, and areas that are heavily infectious organisms due to the
soiled. chance of acquiring or passing on
an infection
4. Turn on the water. Adjust the flow and Warm water removes less of the
temperature. protective oil of the skin and
removes microorganisms more
effectively.
5. Wet hands and lower forearms thoroughly The water should flow from the
by holding under running water. Keep least contaminated to the most
hands and forearms in the down position contaminated area; the hands are
with elbows straight. Avoid splashing water generally considered more
and touching the sides of the sink. contaminated than the lower arms.
Running water rinses organisms
and dirt into the sink.
6. Apply about 5ml of liquid soap, or place The required amount of soap
bar soap on hand and rub vigorously. helps in easy lathering that helps
Lather thoroughly. in breaking up the oily dirt.
7. Thoroughly rub hands together for about The circular action creates friction
10 to 15 seconds. Interlace fingers and that helps remove dirt and
thumbs and move back and forth to wash microorganisms mechanically.
between digits. Rub palms and back of Interlacing the fingers and thumbs
hands with circular motion. Special cleans the interdigital spaces.
attention should be provided to areas such
as knuckles and fingernails, which are
known to harbour organisms.
8. Rinse with hands in the down position, To allow water to run from the
elbows straight. Rinse in the direction of area that has the fewest
forearm to wrist to fingers. microorganisms to area with a
relatively greater number.
9. Blot hands and forearms to dry thoroughly. To prevent chapping and skin
Dry in the direction of fingers to wrist and
forearms. Discard paper towels in the irritation
proper receptacle.
10. Turn off the water faucet with a clean, dry To prevent the transfer of
paper towel. microbes and to avoid picking up
organisms from the faucet handles
POST-PROCEDURE ACTIVITY:
11. After Care To prepare the hand washing area

for next usage
ATTITUDE OF THE STUDENT:
12. Accepts constructive suggestion and Attaining such attitude leaves

criticisms. room for improvement and better
care in the future
13. Assumes accountability. To cultivate a positive attitude of

willingness to accept
responsibility
Source:
Daniel, Ricks. Nursing Fundamentals: Caring and Clinical Decision Making. Thomson Asian Edition.
United States: Delmar, 2004, pp. 518-519.
Smith-Temple, Jean. Nurses’ Guide to Clinical Procedures. 5th edition. Philadelphia: Lippincott William and
Wilkins, 2006, pp. 12-13.
SCORING: 1 x _____ = _______

2 x _____ = _______
3 x _____ = _______
4 x _____ = _______
5 x _____ = _______
Total divided by no. of items = _______
COMMENTS:
______________________________________________________________________________________
______________________________________________________________________________________
_______________________ ________________________
Student’s Name and signature Clinical Instructor’s Signature
_________________________
DATE
College of Nursing
Cebu City
INSTITUTIONAL HOUSEKEEPING
Name: _Trisha Faye Y. Pasay_______ Year & Section: _BSN 1-I___ Grade: __________
DEFINITION:
Refers to housekeeping maintenance in a commercial lodging establishment like hotels, resorts,
inns, dormitory, hospitals and apartels. Domestic housekeeping refers to house maintenance in a house.
Institutional housekeeping applies to establishment.
PURPOSE:
To ensure that everything is in order and that all occupants are made comfortable, safe and
protected from disease causing bacteria.
Bucket/pail Polishing cloth Hand Brush 1 - Excellent
Plastic Trash Bag Scrubbing PadsMop 2 – Very Satisfactory
Broom Floor Wax Dustpan 3 – Satisfactory
Floor Polisher (optional) Water All-purpose cleaner 4 –Needs Improvement
5 – Poor
E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
PREPARATION OF STUDENTS
1. Wash hands. To prevent the spread of infection
2. Prepare Equipment To promote efficient time

management
CEILING, WALLS AND DOORS
3. Mix ½ bucket of water with ½ cup of all- For effective killing of bacteria
purpose cleaner.
4. Remove cobwebs from ceiling and walls To remove all dust, dirt and
using broom. Wipe walls if dirty from top to breeding places of
bottom. microorganisms with least
disturbance to the client
5. Clean the door including jambs, hinges and To leave a clean polished surface
doorknobs. Clean the front and back portion of where possible, so that dirt may
the door. not be accumulated
WINDOWS CLEANING
6. Change solution. To keep it diluted for effective

killing of bacteria
7. Wash window frames and windows using To easily remove dirt and dust
new cleaning solution.
8. Clean from top to bottom, then inside and To avoid missing spots or sections
outside.
9. Wipe dry from top to bottom, inside and To remove dust sticking into the
outside. window
10. Polish Glass. To keep it smooth and for neat

appearance
FURNITURE’S AND FIXTURES

killing of bacteria
12. Start by cleaning mirrors and picture To start with the area easiest to
frames. clean with less dirt and dust
13. Dust and polish all furniture and fixture, To keep the area clean and fresh
from main door to the next corner. Move from
one corner to the next corner, wiping every
furniture and fixture soon.
14. Empty waste baskets To avoid waste from

accumulating
FLOORS

killing of bacteria
16. Dry-clean the floor with broom To remove all dust, dirt and waste
17. Damp the floor To prepare for applying of floor

wax
18. Apply wax to the area To keep it smooth and protect

floor from scratches and stains
19. Polish the floor For clean and spotless appearance
20. Sweep again the area To completely remove dirt and

dust
21. Return furniture to position To avoid damage and for

organization
22. After Care For sanitation purpose and to

promote cleanliness
23. Wash Hands To prevent the spread of infection
SCORING: 1 x _____ = _______

2 x _____ = _______
3 x _____ = _______
4 x _____ = _______
5 x _____ = _______
COMMENTS:
______________________________________________________________________________________
______________________________________________________________________________________
_______________________ ________________________
_________________________
DATE
College of Nursing
Cebu City
TEMPERATURE ASSESSMENT
Name: _Trisha Faye Y. Pasay______ Year & Section: _BSN 1-I___ Grade: __________
DEFINITION:
It is the measurement of the body’s physiological function of heat regulation.
PURPOSE:
Provides clinical data regarding the thermoregulation of the patient.
Digital Thermometer - Oral or rectal at client’s bedside. 1 - Excellent
Lubricant for route 2 – Very Satisfactory
Two pairs of non – sterile gloves (as needed) 3 – Satisfactory
Tissue paper 4 –Needs Improvement
5 – Poor
E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
1. Review patient’s medical record for baseline To avoid misreading of the

data and factors that influence vital signs. client’s vital signs and find any
changes in his/her vital signs from
the usual
2. Explain to the client that vital signs will be Providing information fosters
assessed. Encourage client to remain still and cooperation and understanding
refrain from drinking, eating, and smoking.
3. Assess client’s toileting needs. To be able to prioritize the nursing

needs
4. Wash hands before preparing materials. To prevent the spread of infection
5. Gather equipment. To promote efficient time

management
6. Provide for privacy. To maintain client’s privacy
7. Wash hands again apply gloves if needed. To prevent the spread of infection
8. Position the client in a sitting or lying To promote client’s comfort and

position with the head of the bed elevated 40 to safety
60 degrees for measurement of all vital signs
except those designated otherwise.
ORAL TEMPERATURE
9. Remove thermometer from storage container To refresh the thermometer from

and cleanse probe under cool water. its current temperature and to
limit spread of infection
10. Use a tissue paper to dry thermometer from To remove moisture and to reduce
probe to end. transmission of microorganisms
11. Turn on thermometer To prepare thermometer for

temperature taking
12. Place tip of the thermometer under the To ensure an accurate reading
client’s tongue and along the gum line to the
posterior sublingual pocket lateral to center of
lower jaw. Instruct client to hold lips closed.
13. Leave in place. Thermometer will signal To inform the patient or nurse that
(beep) when a constant temperature registers. the constant temperature has been
classified
PREPARATION
14. Remove thermometer and wipe with a To prevent the spread of infection
tissue away from fingers toward the
thermometer.
15. Read the temperature. Read measurement To ensure an accurate reading

on digital display of thermometer.
16. Inform client temperature reading. To share his/her data and provide
care needed immediately
17. Remove and dispense of gloves in a To prevent the spread of infection

receptacle and wash hands.
18. Record reading according to institution’s Documentation provides ongoing

policies. data collection
AXILLARY TEMPERAURE
Do STEPS 1 – 8 first To assess and facilitate proper

procedure
19. Remove gown’s arm and shoulder on one To provide easy access to axilla
sleeve. Avoiding exposing chest.
To expose axilla for correct
thermometer bulb placement
20. Make sure axillary skin is dry. If necessary, Moisture will alter the reading.
pat dry. Under the condition moistening,
temperature is generally measured
lower than the real.
21. Prepare thermometer. Cleanse with To prevent the spread of infection

alcoholised cotton from probe to tip.
22. Turn on and place thermometer or probe To maintain proper position of

into center to axilla. Fold client’s upper arm bulb against blood vessels in
straight down and place arm across client’s axilla and to ensure a more
chest accurate temperature registration
23. Wait until thermometer will signal (beep) To ensure an accurate reading
when a constant temperature registers.
24. Remove and read thermometer. To ensure an accurate reading
25. Inform client temperature reading. To share his/her data and provide
26. Cleanse thermometer from tip to probe, To prevent the spread of infection
turn off and return to storage container.
27. Assist client temperature reading. To give the prescribed medication

immediately
28. Record reading according to institution’s A careful record is important for

policies. planning and individualizing the
client’s care.
RECTAL TEMPERAURE
Do STEPS 1 – 8 first To assess and facilitate proper

procedure
29. Place client in Sim’s position with upper To maintain standard position for
knee flexed. Adjust sheet to expose only anal monitoring the core body
area. temperature
30. Place tissues in ease reach. For easy access on tissues
31. Prepare the thermometer. To check the core body

temperature
32. Lubricate tip of rectal thermometer. To easily slide the rectal

thermometer into the anus
33. With dominant hand, grasp thermometer. To easily insert the rectal
With other hand, separate buttocks to expose thermometer without any serious
anus. pain
34. Instruct client to make a deep breath. Turn To avoid internal bleeding and
on and insert thermometer probe gently into hurting the patient
anus: infant, 1.27 cm or 0.5 inches; adult, 3.81
To relax the patient
cm to 1.5 inches. If resistance is felt, do not
force insertion.
35. Hold in place up until thermometer signals To know the result and record it
(beep) when a constant temperature registers. directly
36. Wipe secretions of probe with a tissue To remove infectious

paper. Dispose tissue paper in a receptacle. microorganisms
37. Read measurement and inform client of To share his/her data and provide
temperature reading. care needed immediately
38. While holding the thermometer in one To apply sanitation and good
hand, use other hand to wipe anal area with hygiene to the client
tissue to remove lubricant or feces. Dispose of
soiled tissue paper. Cover client.
39. Cleanse the probe of the thermometer with To prevent the spread of infection
soap & water, rinse under cold water, and
return to storage container.
40. Remove and dispose of gloves in receptacle. For sanitation and removal of
infectious microorganisms
41.After care. For sanitation purpose and to

promote cleanliness
42. Wash Hands. To prevent the spread of infection
43. Record. Documentation provides ongoing

data collection and coordination
of care
44. Accepts constructive suggestions and Attaining such attitude leaves

care in the future

responsibility
Source:
United States: Delmar, 2004, pp. 566 – 571.
SCORING: 1 x _____ = _______

2 x _____ = _______
3 x _____ = _______
4 x _____ = _______
5 x _____ = _______
COMMENTS:
______________________________________________________________________________________
______________________________________________________________________________________
_______________________ ________________________
_________________________
DATE
College of Nursing
Cebu City
BLOOD PRESSURE
DEFINITION:
It is the measurement of pressure exerted against the blood vessel walls during systole and
diastole measured in terms of millimeters of mercury (mm Hg). Systole is the pressure phase when
myocardial fibers contract and tighten to eject blood from the ventricles, primarily a reflection of
cardiac output. Diastole is the period of relaxation that reflects the pressure remaining in the blood
vessels after the heart has pumped, primarily a reflection of peripheral vascular resistance.
PURPOSE:
Provides clinical data relative to the client’s cardiovascular and fluid volume status.
Stethoscope 1 - Excellent
Sphygmomanometer with bladder and cuff
2 – Very Satisfactory
Alcohol swab 3 – Satisfactory
Gloves, if required 4 –Needs Improvement
5 – Poor
E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
1. Wash hands To prevent the spread of infection
2. Prepare equipment To promote efficient time

management
AUSCULTATION METHOD BRACHIAL

ARTERY
4. Determine which extremity is most To obtain data consistent with the

appropriate for reading. Do not take a pressure client’s true blood pressure
reading on an injured or painful extremity or
one in which an intravenous line is running
5. Select a duff size that completely encircles Cuff must be proper size and put
upper arm without overlapping. on arm correctly so amount of
pressure on artery is correct. If
not, reading will be falsely high or
low
6. Move clothing away from upper aspect of To provide easy access to the
arm. brachial pulse easily and measure
accurately
7. Position arm at heart level; extend elbow Ideally, the arm is at heart level
with palm turned upward. for accurate measurement. Rotate
the arm so the brachial pulse is
easily accessible.
8. Make sure bladder cuff is fully deflated and To obtain best results and avoid
pump valve moves freely. inaccurate reading
9. Locate brachial artery in the antecubital For correct placement of

space. equipment along brachial artery
10. Apply cuff snugly and smoothly over upper Center the bladder to ensure even
arm, 2.5 cm or 1 inch above antecubital space cuff inflation over the brachial
with center of cuff over brachial artery. artery. Loose-fitting cuff causes
false high readings.
11. Connect bladder tubing to manometer Improper height can alter
tubing. If using it portable mercury – filled perception of reading
manometer, position vertically at eye level.
12. Palpate brachial artery, turn valve Palpation identifies the

clockwise to close and compress bulb to inflate approximate systolic reading.
cuff to 30 mm Hg above point where palpated Estimating prevents false low
pulse disappears, then slowly release valve readings, which may result in the
(deflating cuff), noting reading when pulse is presence of an auscultory gap.
felt again.
13. Insert earpieces of stethoscope into ears To facilitate hearing and ensure
with a forward tilt, ensuring diaphragm hangs optimal sound reception
freely.
14. Relocate brachial pulse with your non – For best sound transmission
dominant hand and place bell chest piece
directly over pulse. Chest piece should be in
direct contact with skin and not touch cuff.
15. With dominant hand, turn valve clockwise To ensure the systolic reading is
to close. Compress pump to inflate cuff until not underestimated
manometer registers 30 mm Hg above
diminished pulse point previously identified in
step 10.
16. Slowly turn valve counterclockwise so that To record the data of the systolic
mercury falls at a rate of 2-3 mmHg per pressure and diastolic pressure
second. Listen for the five phases of reading
Korotkoff’s sounds while noting manometer
reading.
I – a faint clear tapping sound appears and

increases in intensity
II – swishing sound
III – intense sound
IV – abrupt, distinctive muffled sound
V – sound disappears
17. Deflate cuff rapidly and completely. To avoid arterial occlusion

resulting in numbness and
tingling of client’s arm
18. Remove cuff wait 2 minutes before taking To ensure accurate reading
a second reading
19. Inform client Reading To share his/her data and provide

20. After care. For sanitation purpose and to

promote cleanliness
21. Wash Hands. To prevent the spread of infection
22. Record reading Documentation provides ongoing

of care

care in the future

responsibility
Source:
United States: Delmar, 2004, pp. 566 – 571.
SCORING: 1 x _____ = _______

2 x _____ = _______
3 x _____ = _______
4 x _____ = _______
5 x _____ = _______
COMMENTS:
______________________________________________________________________________________
______________________________________________________________________________________
_______________________ ________________________
_________________________
DATE
College of Nursing
Cebu City
CHANGING LINENS IN AN UNOCCUPIED BED
Name: _Trisha Faye Y. Pasay_________ Year & Section: _BSN 1-I___ Grade: __________
DEFINITION:
The provision of clean linens for clients who are able to get out of the bed, or is prepared in a
hospital room before a new client is admitted to the room. An unoccupied bed can be closed or open.
PURPOSE:
1. Linens are changed to promote comfort for clients.
2. To prepare the bed for admission.
Bedspread /Blanket Top sheet 1 - Excellent
Rubber sheet/ Absorbent pad Draw sheet 2 – Very Satisfactory
Bottom sheet (fitted if available) Pillowcase 3 – Satisfactory
Disposable Gloves Disinfectant spray/ solution 4 –Needs Improvement
Wash cloth and basin 5 – Poor
E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
1. Perform hand hygiene. To prevent the spread of infection
2. Gather equipment, fold and arranged fresh To promote efficient time

linens inreverse order in a clean tray for return management
demonstration. (pillowcase, bedspread, top
sheet, draw sheet, rubber sheet, bottom sheet)
PROCEDURE
4. Place hamper by the client’s door. To preserve the cleanliness
5. If the client is in bed, prior to performing To be sure you are carrying out
the procedure, Introduce self and verify the the procedure for the correct
client’s identity by checking the ID bond or patient. Thus, promotes client’s
bracelet. cooperation and participation.
6. Place tray with fresh linens on a clean, dry To prevent transmission of

surface in the client’s bedside. microorganisms from one client to
another through cross
contamination
7. Inquire about the client’s toileting needs To assess client’s necessity

and attend as necessary.
8. Assist client to a safe, comfortable chair. To promote client’s comfort and

safety
9. Apply clean gloves. To prevent the spread of infection
10. Position the bed flat, side rails down and To help avoid injuries and
adjust bed towaist level or a comfortable improve client’s circulation
working height. Place bedside chair near the
foot of the bed.
11. Remove soiled pillowcase by grasping the To prevent contamination with

close end with one hand and slipping the infectious microorganisms and
pillow out with the other. Place pillow on the bodily fluids
bedside chair near the foot of thebed.
12. Remove and fold bedspread/ blanket in half To put dirtiest surface of linen
by bringingthe top edge even with the bottom inward, lessening contamination
edge, and then graspit at the center of the
middle fold and bottom edges and place on
clean work area. (If clean and reusable, If
soiledplace in hamper)
13. Remove soiled linens: Start on the side of To prevent contamination with
the bed closest to you, loosen soiled linens infectious microorganisms and
from the head of the bed to foot of bed and roll bodily fluids
to the middle of the bed.
14. Go to the other side of the bed and repeat This allow procedure to be
the action. Then fold soiled linens from the
completed faster and reduces
head of the bed to the middle, then foot of the
strain on nurse
bed to middle. Hold soiled linens away from
the uniform and place in hamper.
15. Check mattress. Leatherette mattress clean To reduce transmission of

with disinfectant solution and dry thoroughly. microorganisms
Cloth mattress apply disinfectant spray or
vacuum.
16. Remove soiled gloves and wash hands. To prevent the spread of infection
17. Unfold the bottom sheet with the seamed To easily place symmetrically the
side towardthe mattress. Align the bottom sheet upon the mattress
edge of the sheet withthe edge of the mattress
at the foot of the bed.
18. Allow the sheet to hang 10 inches on the To develop skill in the nurse’s
side and at the head of the bed. Fan fold to the body mechanics in bed-making
center of the bed.
19. Miter the corner at the head of the bed A mitered corner has a neat
using the following technique. Face the side of appearance and keeps the sheet
the bed and liftand lay the top edge of the sheet securely under the mattress.
onto the bed to form a triangular fold
20. . Position yourself diagonally toward the To fold it neatly in half so it is

head of thebed. Lift the top of the mattress tight and smooth
corner with the handclosest to the bed and
smoothly tuck the sheet under the mattress.
21. With your palms down, tuck the lower To keep the sheet securely under
edges of sheet hanging free at the side) under the mattress
the mattress.
22. Facing the bed, place the rubber sheet or To protect the bottom sheet from
absorbent pad on the bottom sheet, fanfold it to soothing due to client’s secretions
the middle crease. Then apply the cotton draw
sheet and do the same.
23. Tuck both the rubber sheet and cotton To secure the bottom sheet on one
draw sheet under the mattress. Ensure that the side of the bed.
bottom sheet is tuckedsmoothly under the
mattress all the way to the foot ofthe bed.
24. Place the top sheet (hem side up) on the Tucking all these pieces together
head of the bed and unfold lengthwise facing saves time and provides a neat
the foot of the bed. Fanfold towards the center appearance.
of the bed. Tuck at the foot part of the bed and
miter. Leave the sides to hang freely atthe side
of the mattress.
25. Go to the other side of the bed, grasp the This allow procedure to be
bottom sheet, rubber sheet, cotton draw sheet,
completed faster and reduces
top sheet, bed spreadand repeat the action.
strain on nurse
26. Apply clean pillowcase by grasping with To tend to the patient's needs
one hand the closed end of the pillowcase at
To provide a safe and comfortable
the center. Gather upthe sides of the
bed to ensure the patient's safety
pillowcase and place them over thehand
grasping the case. Then grasp the center of
oneshort side of the pillow through the
pillowcase. With thefree hand pull the
pillowcase over the pillow.
27. Place the bed spread the same way as the To provide a smooth, wrinkle-
top sheet and let it hang over 6 inches on the free bed foundation, thus
head part for a CLOSED BED. minimizing sources of skin
irritation.
28. Return the bed to the lowest position and To prevent patient from falling
elevate the head of the bed 30 to 40 degrees. out of bed
Put side rails up on the far side from the client.
29. Inquire about toileting needs of the client To meet the patient’s needs
and assist if necessary then assist client back to
bed and pull up side rails nearest you, place the
call light in reach. Takeclients vital signs.
30. Do after care. For sanitation purpose and to

promote cleanliness
31. Perform Hand Hygiene. To prevent the spread of infection
32. Documentation. Documentation provides ongoing

of care

care in the future

responsibility
SCORING: 1 x _____ = _______

2 x _____ = _______
3 x _____ = _______
4 x _____ = _______
5 x _____ = _______
COMMENTS:
______________________________________________________________________________________
______________________________________________________________________________________
_______________________ ________________________
_________________________
DATE
College of Nursing
Cebu City
OCCUPIED BEDMAKING
DEFINITION:
The provision of clean linens for clients who are unable to get out of the bed.
PURPOSE:
Linens are changed to promote comfort for clients.
Top sheet Draw sheet 1 - Excellent
Rubber sheet/ Absorbent pad 2 – Very Satisfactory
Bottom sheet (fitted if available) 3 – Satisfactory
Pillowcase Disposable Gloves 4 –Needs Improvement
5 – Poor
E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
2. Gather equipment, fold and arranged fresh To promote efficient time

linens inreverse order in a clean tray for return management
demonstration. (pillowcase, bedspread, top
sheet, draw sheet, rubber sheet, bottom sheet)
PROCEDURE
4. Place hamper by the client’s door. To preserve the cleanliness
5. Prior to performing the procedure, To be sure you are carrying out

introduce self andverify the client’s identity by the procedure for the correct
checking the ID bond or bracelet and inform patient. Thus, promotes client’s
client of the procedure. cooperation and participation.
6. Place tray with fresh linens on a clean, dry To prevent transmission of

surface in the client’s bedside. microorganisms from one client to
another through cross
contamination
7. Apply clean gloves. To prevent the spread of infection
8. Position the bed flat, lower side rails nearest To help avoid injuries and
you and adjust bed to waist level or a improve client’s circulation
comfortableworking height. Place bedside chair
near the foot of the bed.
9. Position client on the side, facing away from To promote client’s comfort and
you, with siderails up. Let patient hold on to relieve the pressure on affected
it. Reposition pillow underthe head. areas
10. Remove soiled linens: Start on the side of To prevent contamination with
the bed closest to you, loosen soiled linens infectious microorganisms and
from the head of thebed to foot of bed and roll bodily fluids
to the middle of the bed closeto the client.
11. Unfold the bottom sheet with the seamed To promote freshness and
side towardthe mattress. Align the bottom cleanliness
edge of the sheet withthe edge of the mattress
at the foot of the bed.
13. Allow the sheet to hang 10 inches on the To develop skill in the nurse’s
side and at the head of the bed. Fan fold to the body mechanics in bed-making
center of the bed.
14. Position yourself diagonally toward the To provide client with clean bed
head of the bed. Lift the top of the mattress and to make the bed tight and
corner with the hand closestto the bed and clear from wrinkles
smoothly tuck the sheet under the mattress.
15. Miter the corner at the head of the bed To prevent client’s head from
using the following technique. Face the side of being restricted by or tangled in
the bed and liftand lay the top edge of the sheet linen when getting in or out of
onto the bed to form a triangular fold. bed
16. With your palms down, tuck the lower For a neat appearance and keeps
edges of sheet hanging free at the side under the sheet securely under the
the mattress. mattress
17. Facing the bed, place the rubber sheet or To reduce complications such as
absorbent pad on the bottom sheet, fanfold it to pressure sores of a prolonged
the middle crease. Then apply the cotton draw bedridden patient
sheet and do the same.
18. Tuck both the rubber sheet and cotton To keep the sheet from slipping
draw sheet under the mattress. Ensure that the off the mattress while the bed is in
bottom sheet is tuckedsmoothly under the use
mattress all the way to the foot ofthe bed.
19. Place the top sheet (hem side up) on the To guarantee the needs of the
head of the bed and unfold lengthwise facing patient by having a safe and
the foot of the bed. Fanfold towards the center comfortable bed
of the bed. Tuck at the foot partof the bed and
miter. Fold the top sheet to the middle ofthe
bed, then from middle fold to the foot part of
the bed.
20. Log roll client over onto side facing you. To develop skill in the body
Raise side rail. mechanics of the client
21. Go to the other side of the bed, grasp To prevent contamination of the
soiled linens (bottom sheet, rubber sheet, air, surfaces and nursing staff
cotton draw sheet, top sheet) roll and place in
hamper.
22. Grasp clean bottom sheet, rubber sheet, Tucking all the pieces together
cotton draw sheet, top sheet and repeat tucking saves time and provides a neat
this side. appearance
23. Apply clean pillowcase by grasping with To tend to the patient's needs
one hand the closed end of the pillowcase at
To provide a safe and comfortable
the center. Gather up the sides of the
bed to ensure the patient's safety
pillowcase and place them over thehand
grasping the case. Then grasp the center of
oneshort side of the pillow through the
pillowcase. With the free hand pull the
pillowcase over the pillow.
24. Return the bed to the lowest position and To prevent patient from falling
elevate the head of the bed 30 to 40 degrees. out of bed
Put side rails up on the far side from the client.
25. Inquire about toileting needs of the client To meet the patient’s needs
and assist if necessary then pull up side rails
nearest you, place thecall light in reach. Take
clients vital signs.
26. After Care. For sanitation purpose and to

promote cleanliness
27. Perform Hand Hygiene. To prevent the spread of infection
28. Documentation. Documentation provides ongoing

of care

care in the future

responsibility
SCORING: 1 x _____ = _______

2 x _____ = _______
3 x _____ = _______
4 x _____ = _______
5 x _____ = _______
COMMENTS:
______________________________________________________________________________________
______________________________________________________________________________________
_______________________ ________________________
_________________________
DATE

College of Nursing
Cebu City
ORAL CARE
Name: _Trisha Faye Y. Pasay_________ Year & Section: _BSN 1-I_____ Grade: __________
DEFINITION:
It is the preventive measures which consist of fluoride rinsing, flossing, and brushing of the oral cavity.
PURPOSE:
To maintain the integrity of the mucous membranes, teeth, gums, and lips.
BRUSHING AND FLOSSING DENTURE CARE 1 - Excellent
Toothbrush Denture brush 2 – Very Satisfactory
Toothpaste Denture cleaner 3 – Satisfactory
Emesis basin Emesis basin 4 – Needs Improvement
Towel Towel 5 – Poor
Cup of water Cup of water
Nonsterile gloves Nonsterile gloves
Dental floss Tissue
Dental floss holder Denture cup
Mirror
Lip moisturizer
Special care items for clients with impaired physical mobility or who are unconscious
Soft toothbrush or toothette Milk of magnesia
Tongue blade Cotton-tip applicators
3x3 gauze sponges Plastic asepto syringe
Suction machine and catheter
E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
PREPARATION
1. Wash hands. To prevent the spread of
infection
2. Gather equipment for demonstration. To promote efficient time

management
3. Provide Privacy. To protect client from
psychological harm like
embarrassment or distress
SELF-CARE CLIENT: FLOSSING AND
BRUSHING
4. Place client in a fowler’s position. To promote client’s
comfort and safety and
effectiveness of the care
including oral inspection
and assessment
5. Wash hands and apply gloves. To prevent the spread of
infection
6. Arrange articles within client’s reach. To save time and promote
effective care
7. Assist client flossing and brushing as necessary. To ensure that brushing
Position mirror, emesis basin, and water with straw and flossing is done
near the client and a towel across the chest. accordingly
8. Assist client with rinsing mouth. To make comfort and
suspend remaining fluid
and debris
9. Reposition client, raise side rails, and place call To ensure client’s comfort,
button within reach. to avoid the risk of falling,
and to position the call
button near the client for
emergency assistance.
SELF-CARE CLIENT: DENTURE CARE
10. Assist client to a high fowler’s position. To promote client’s
infection
12. Assist client with denture removal. With tissue, To ensure proper removal
grasp top denture with thumb and forefinger and pull of denture and to keep
downward. them from slipping out of
the hand
13. Place in denture cup. To ensure that the
dentures are safe and to
prevent damage
14. Place thumbs on the gums and release the bottom To properly remove the
denture. Grasp denture with thumb and forefinger and denture
pull upward.
15. Place in denture cup. To ensure that the
dentures are safe and to
prevent damage
16. Apply toothpaste to brush, and brush dentures To remove food and
either with cool water in the emesis basin or under plaque on the dentures and
running water in the sink. Pad sink with towel to to avoid damaging the
protect dentures in case they are dropped. plastic or bend
attachments
17. Rinse thoroughly. To remove cleaning
solution and debris
18. Assist client with rinsing mouth and replacing To make comfort and
dentures. remove remaining fluid
and debris
19. Reposition client, with side rails up and call button To provide for the client’s
within reach. comfort and safety
FULL-CARE CLIENT: BRUSHING AND
FLOSSING
To promote client’s
20. Position client as condition allows: high fowler’s;
or lateral position, head turned toward side.
21. Place towel across client’s chest or under face and To avoid spilling or
mouth if head is turned to one side. wetting the client
22. Moisten toothbrush, apply small amount of To remove plaques and
toothpaste, and brush teeth and gums. debris between the teeth
23. Grasp the dental floss in both hands or use a floss To ensure removal of
holder and floss between all teeth, holding floss remaining debris between
against tooth while moving floss up and down sides of the teeth
teeth.
24. Assist the client in rinsing mouth. To make comfort and
remove remaining fluid an
debris
25. Reapply toothpaste and brush the teeth and gums To ensure removal of
using friction in a vertical or circular motion. On inner debris and dental plaque
and outer surfaces of teeth, hold brush at 45 degree from teeth and gingival
angle against teeth and brush from sulcus to crowns of area
teeth. On biting surfaces, move brush back and forth
in short strokes. All surfaces of teeth should be
brushed from every angle.
26. Assist the client in rinsing and drying mouth. To make comfort and
remove remaining fluid
and debris
27. Apply lip moisturizer, if appropriate. To moisturize lips and
reduce risk for cracking
28. Reposition client, raise side rails, and place call To provide for the client’s
button within reach. comfort and safety
CLIENTS WHO ARE UNCONSCIOUS
29. Provide privacy. To promote client’s safety
and confidentiality
infection
31. Explain the procedure to the client. Providing information
fosters cooperation
32. Place the client in a lateral position, head turned To prevent back strain and
toward side. allow fluid to drain out of
the client’s mort to
prevent aspiration.
33. Use a floss holder and floss between all teeth. To remove plaques and
debris between the teeth
34. Moisten toothbrush, and brush the teeth and gums To avoid bleeding and to
using friction in a vertical or circular motion. effectively dislodge
Do not use toothpaste. On inner and outer surfaces of plaques and debris from
teeth, hold brush at 45 degree angle against teeth and teeth
brush from sulcus to crowns of teeth. On biting
surfaces, move brush back and forth in short strokes.
All surfaces of teeth should be brushed from every
angle.
35. After flossing and brushing, rinse mouth with an To remove cleaning
Asepto syringe (do not force water into the mouth) solution and debris
and perform oral suction.
36. Dry the client’s mouth. To promote client’s
comfort
37. Apply lip moisturizer. To moisturize lips and
reduce risk for cracking
38. Leave the client in a lateral position with head To make comfort and
turned toward side for 30 to 60 minutes after oral remove remaining fluid
hygiene care. Suction one more time. Remove the and debris
towel from under the client’s mouth and face.
39. Dispose of any contaminated items in a biohazard To maintain standard
bag. precautions
40. After Care. For sanitation purpose and
to promote cleanliness
41. Remove gloves. To reduce transmission of
microorganisms
42. Wash hands. To prevent the spread of
infection
43. Document care. Documentation provides
ongoing data collection
and coordination of care
22. Accepts constructive suggestion and criticisms. Attaining such attitude
leaves room for
improvement and better
care in the future
23. Assumes accountability. To cultivate a positive
attitude of willingness to
accept responsibility
Source:
SCORING: 1 x _____ = _______

2 x _____ = _______
3 x _____ = _______
4 x _____ = _______
5 x _____ = _______
COMMENTS:
______________________________________________________________________________________
______________________________________________________________________________________
_______________________ ________________________
_________________________
DATE

College of Nursing
Cebu City
BATHING A CLIENT IN BED
Name: _Trisha Faye Y. Pasay________ Year & Section: _BSN 1-I___ Grade: __________
DEFINITION:
It is an essential component of nursing care which cleanses the patient’s body parts that would
cause discomfort or odor if neglected.
PURPOSE:
It is provided as a routine client care to assure that the hygiene needs of the patient is met.
Bath towels Powder Soap dish 1 - Excellent
Bath blanket Clean linen Deodorant 2 – Very Satisfactory
Soap Washcloths Clean gown 3 – Satisfactory
Lotion Washbasin Disposable gloves 4 –Needs Improvement
5 – Poor
E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
2. Gather equipment for demonstration. To promote efficient time

management
PROCEDURE
3. Assess the client’s preferences about bathing. To encourage the client to assist
with care and to promote
independence
4. Explain procedure to client. Providing information fosters

cooperation
5. Prepare environment. Close doors and To prevent rapid loss of body heat
windows, adjust temperature, provide time for during bathing and to ensure
elimination needs, and provide privacy. privacy
6. Wash hands. Apply gloves, as needed. Gloves To reduce transmission of

should be changed when emptying water basin. microorganisms
7. Lower side rail on the side close to you. To aid nurse’s access to client
Position client in a comfortable position close to
the side near you. To maintain client’s comfort
8. If bath blankets are available, place bath Removal of top linens prevents
blankets over top sheet. Remove top sheet from them from becoming soiled or
under bath blanket. Remove client’s gown. Bath moist during bath
blanket should be folded to expose only the area
being cleaned at that time. (Top sheets or towels Blanket provides warmth and
may also for bath blankets). privacy
Removing the cloth permits easier

access when washing the client’s
upper body
9. Fill wash basin two-thirds full. Permit client to Warm water promotes comfort
test temperature of water with hand. Water and prevents chilling. Testing
should be changed when soap film develops or temperature prevents accidental
water becomes soiled. burning of client’s skin.
10. Wet the washcloth and wring it out. To reduce transfer of

microorganisms
11. Make a bath mitten with the washcloth. To To retain water and heat better
make a mitten, grasp the edge of the washcloth than loosely held washcloth, keep
with the thumb; fold a third over the palm of the cold edges from brushing against
hand; wrap remainder of cloth around hand in client, and prevents splashing.
across palm, grasping the second edge under the
thumb; fold the extended end of the washcloth
onto the palm and tuck under the palm surface of
the cloth.
12. Wash the face. Ask the client about Use of separate sections of mitt
preference for using soap on the face. Use a reduces infection transmission.
separate corner of the washcloth for each eye,
wiping from inner to outer canthus. Wash neck Bathing the eye from inner to
and ears. Rinse and pat dry. Male clients may outer canthus prevents secretions
want to shave at this time. Provide assistance from entering nasolacrimal duct.
with shaving as needed.
13. Wash arms, forearms, and hands. Wash Washing the far side first
forearms and arms using long, firm strokes in the eliminates contaminating a clean
direction of distal to proximal. Arm may need to area once it is washed.
be supported while being washed. Wash axilla.
Rinse and pat dry. Apply deodorant or powder if Gentle friction stimulates
desired. Immerse client’s hand into basin of water. circulation and helps remove dirt,
Allow hand to soak about 3 to 5 minutes. Wash oil and organism.
hands, interdigit area, fingers and fingernails. Deodorant controls body odor.
14. Wash chest and abdomen. Fold bath blanket Spreading the towel across the
down to umbilicus. Wash chest using long, firm client’s chest will avoid
strokes. Wash skin fold under the female client’s unnecessary exposure and
breast by lifting each breast. Rinse and pat dry. chilling.
Fold bath blanket to suprapubic area. Use
another towel to cover chest area. Wash abdomen
using long, firm strokes. Rinse and pat dry.
Replace bath blanket over chest and abdomen.
Cover chest or abdomen area between washing,
rinsing, and drying to prevent chilling.
15. Wash legs and feet. Expose leg farthest from To prevent soiling of linen
you by folding bath blanket to midline. Bend the
leg at the knee. Grasp the heel, elevate the leg To support joint and extremity
from the bed, and cover bed with bath towel. during lifting and prevent strain
Place washbasin on towel. Place client’s foot into on musculoskeletal structure.
washbasin. Allow foot to soak while washing the Proper positioning of foot
leg with long, firm strokes in the direction of prevents pressure from being
distal to proximal. Rinse and pat dry. Clean soles applied from edge of basin against
interdigits, and toes. Rinse and pat dry. Perform calf.
same procedure with the other leg and foot.
16. Wash back. Assist client into prone or side- To prevent contact with
lying position facing away from you. Wash the microorganism in body secretions
back and buttocks using long, firm strokes. Rinse
and pat dry. Give back rub and apply lotion. To remove fecal secretions in
anus that harbor microorganism.
17. Perineal care: Assist client to supine position. Improves circulation to the tissues
Perform perineal care. and aids in relaxation. Perineal
care promotes patient comfort and
removes secretions and odors
19. After Care For sanitation purpose and to

promote cleanliness
20. Wash Hands To prevent the spread of infection
21. Documentation Documentation provides ongoing

of care
22. Accepts constructive suggestion and Attaining such attitude leaves

care in the future

responsibility
Source:
SCORING: 1 x _____ = _______

2 x _____ = _______
3 x _____ = _______
4 x _____ = _______
5 x _____ = _______
COMMENTS:
______________________________________________________________________________________
______________________________________________________________________________________
_______________________ ________________________
_________________________
DATE

College of Nursing
Cebu City
BED SHAMPOO
Name: _Trisha Faye Y. Pasay________ Year & Section: _BSN 1-I___ Grade: __________
3 Bath towels Rubber or Kelly pad 1 - Excellent
2 pitchers (1 cold and 1 warm) Bath thermometer 2 – Very Satisfactory
Cotton balls Patient’s comb or hair brush 3 – Satisfactory
Soap or Shampoo (any) Pail or basin 4 –Needs Improvement
Waste receptacle 5 – Poor
E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
PREPARATION:
1. Prepare soap or shampoo solution. To keep time, energy, and quality

of work
2. Fill pitcher with water. To keep time, energy, and quality

of work
3. Bring equipment to bedside and arrange To save time and make procedure
them conveniently on the table. more organized
PREPARATION OF PATIENT:
4. Explain to patient what you are going to do. Providing information fosters
cooperation
5. Close windows and screen bed. To maintain client’s privacy
6. Move bedside table away from head of bed. To enable nurse to move freely in
the bed space
7. Remove pillows. To avoid getting wet
8. Have patient lie diagonally across bed with To promote client’s standard
head near the edge of bed. position considering the body
mechanics
9. Place a bath towel or folded blanket under To prevent undue strain and
patient’s neck. discomfort during hair washing
process
10. Place a bath towel under patient’s head. To promote client’s comfort and
safety
11. Make rubber sheet into improvised Kelly To absorb moisture and prevent
pad and place it under patient’s head. soothing of bed
12. Place pail on chair lined with paper and To catch wastewater from the
adjusts through in place. shampoo tray
13. Comb hair and massage scalp. To remove dandruff and fallen
hairs, and make the hair easier
washing
14.Protect ears with cotton balls and eyes with To prevent water from entering
wash cloth. into the ears
15. Pour water slowly and carefully on scalp To avoid spilling
and hair.
16.Pour solution or shampoo slowly and To increase circulation of the

carefully on scalp and massage gently. scalp and promote sense of well-
being
17.Rinse hair with warm water and repeat as Rinsing prevents leaving shampoo
often as necessary. in the hair which gives the hair a
dull appearance if left in the scalp
and prevents irritation
18.Do final rinsing with cold water. To help close the cuticles
19. Squeeze out excess water from hair and To remove excess moisture and
remove ear plug. dry hair quickly
20. Pull rubber sheet, fold carefully and place To contain any elements and for
on the tray. sanitation purpose
21. Rub hair with towel until hair is partly dry. To avoid hair breakage and hair
fall
22. Replace pillow protected with dry towel. To provide clean environment and
promote client’s comfort
23. Comb patient’s hair. To maintain client’s body image
24. Straighten beddings and make patient To promote client’s comfort and
comfortable. safety
25. Tidy the unit. To provide clean environment and

comfort to the patient
AFTER CARE EQUIPMENT:
26. Bring equipment to the utility room. Clean To organize and be prepared for
and return to proper places. future usage
27. Wash and rinse patient’s comb and return To promote cleanliness
to bedside.
CHARTING:
28. Time shampoo was given. To ensure the well-being of the

patient
29. Reaction of patient. To understand patient’s needs and

necessary care
SCORING: 1 x _____ = _______

2 x _____ = _______
3 x _____ = _______
4 x _____ = _______
5 x _____ = _______
COMMENTS:
______________________________________________________________________________________
______________________________________________________________________________________
_______________________ ________________________
_________________________
DATE

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University of Cebu – Banilad

1. Prepare materials. To promote efficient time

2. Remove jewelry. Push sleeves of uniform To facilitate proper cleaning of

11. After Care To prepare the hand washing area

ATTITUDE OF THE STUDENT:

12. Accepts constructive suggestion and Attaining such attitude leaves

13. Assumes accountability. To cultivate a positive attitude of

United States: Delmar, 2004, pp. 518-519.

SCORING: 1 x _____ = _______

1. Wash hands. To prevent the spread of infection

2. Prepare Equipment To promote efficient time

CEILING, WALLS AND DOORS

6. Change solution. To keep it diluted for effective

10. Polish Glass. To keep it smooth and for neat

FURNITURE’S AND FIXTURES

11. Change solution. To keep it diluted for effective

14. Empty waste baskets To avoid waste from

15. Change solution. To keep it diluted for effective

17. Damp the floor To prepare for applying of floor

18. Apply wax to the area To keep it smooth and protect

19. Polish the floor For clean and spotless appearance

20. Sweep again the area To completely remove dirt and

21. Return furniture to position To avoid damage and for

22. After Care For sanitation purpose and to

23. Wash Hands To prevent the spread of infection

SCORING: 1 x _____ = _______

1. Review patient’s medical record for baseline To avoid misreading of the

3. Assess client’s toileting needs. To be able to prioritize the nursing

4. Wash hands before preparing materials. To prevent the spread of infection

5. Gather equipment. To promote efficient time

6. Provide for privacy. To maintain client’s privacy

8. Position the client in a sitting or lying To promote client’s comfort and

9. Remove thermometer from storage container To refresh the thermometer from

11. Turn on thermometer To prepare thermometer for

15. Read the temperature. Read measurement To ensure an accurate reading

17. Remove and dispense of gloves in a To prevent the spread of infection

18. Record reading according to institution’s Documentation provides ongoing

Do STEPS 1 – 8 first To assess and facilitate proper

21. Prepare thermometer. Cleanse with To prevent the spread of infection

22. Turn on and place thermometer or probe To maintain proper position of

24. Remove and read thermometer. To ensure an accurate reading

27. Assist client temperature reading. To give the prescribed medication

28. Record reading according to institution’s A careful record is important for

Do STEPS 1 – 8 first To assess and facilitate proper

30. Place tissues in ease reach. For easy access on tissues

31. Prepare the thermometer. To check the core body

32. Lubricate tip of rectal thermometer. To easily slide the rectal

36. Wipe secretions of probe with a tissue To remove infectious

41.After care. For sanitation purpose and to

42. Wash Hands. To prevent the spread of infection

43. Record. Documentation provides ongoing

ATTITUDE OF THE STUDENT:

44. Accepts constructive suggestions and Attaining such attitude leaves

45. Assumes accountability. To cultivate a positive attitude of

SCORING: 1 x _____ = _______

1. Wash hands To prevent the spread of infection

2. Prepare equipment To promote efficient time

SCORING: 1 x _ = ___

SCORING: 1 x _ = ___

SCORING: 1 x _ = ___

SCORING: 1 x _ = ___

SCORING: 1 x _ = ___

SCORING: 1 x _ = ___

SCORING: 1 x _ = ___

SCORING: 1 x _ = ___