NCM 103

Fundamentals of Nursing
SY 2020-2021
HAND HYGIENE PERFORMANCE CHECKLIST

Name: ___________________Year and Section: ______________Date:_____________

Criteria 4 3 2 1 0 Remarks
ASSESSMENT
1. Inspected surface of hands for breaks or cuts in skin, cuticles,
covered lesions with dressing before providing care, determined if
lesions were too large to cover.
2. Inspected condition of nails, ensured nails were short and smooth
PLANNING
1. Identified expected outcomes
2. Gather all articles needed before starting the procedure
IMPLEMENTATION
1.Removes wristwatch and rolls long uniform sleeves above wrists.
2. Stand in front of the sink, keeping hands and uniform away from
the sink.
3. Turned on water; regulate the flow of water, avoids splashing of
water against uniform
4. Wet hands and wrists thoroughly under running water, kept hands
and forearms lower than elbows
5. Lather hands thoroughly, wash the soap and return the soap
without touching the soap dish.
6. Washed hands properly giving special attention to areas between
fingers and nails.
7. Wash the wrist using firm rubbing and rotating motion, and so with
the other arm
8. Soap the knob of faucet, rinse the soap and return to the soap dish
9. Rinse thoroughly from the wrist down to the hands. Hands should
always be lower than the elbows
10. Rinses faucet and turn off the faucet.
11. Dry hands thoroughly using one corner of the towel
12. Returns the towel to the Rack, without touching the rack
EVALUATION
1.. Inspected surface of hands for obvious signs of dirt and other
contaminants

NCM 3N

DONNING AND REMOVING STERILE GLOVES PERFORMANCE CHECKLIST

Name: ___________________Year and Section: ______________Date:_____________

DONNING A STERILE GLOVES

Criteria 4 3 2 1 0 Remarks
1. Performed hand hygiene
2. Removed outer glove wrapper by peeling sides apart
3.Grasp inner package on workspace, opened package, kept gloves on
inside surface wrapper
4. Identified right and left glove, gloved dominant hand first
5.Grasp Glove for dominant hand by touching only glove’s inside
surface
6.Pulled glove over dominant hand, ensured cuff does not roll up
wrist
7. Slipped fingers of gloved hand underneath second glove’s cuff
8. Pulled second glove over non dominant hand
REMOVING A USED GLOVES
9 Grasped the outside of one cuff with the other gloved hand,
avoided touching the wrist.
10. Pulled glove off by turning it inside out, placed glove in gloved
hand.
11. Peeled glove off inside out and over previously removed glove,
discarded both gloves in receptacle.
12. Performed thorough hand hygiene

NCM 3

TRANSFERRING BETWEEN BED AND CHAIR PERFORMANCE CHECKLIST

Name: ___________________Year and Section: ______________Date:_____________

Assessment:
Criteria 4 3 2 1 0 Remarks
1. Plan what to do and how to do it .
2. Identify expected outcomes
3. Check medications the patient is receiving, because certain
medications may hamper movement and alertness of the client
4. Assistance required from other health care personnel.
5. Gather all the materials needed.
Implementation:
6. Perform Hand hygiene
7. Introduce self and explain procedure to the patient.
8. Provide privacy.. Remove obstacles from the area so clients do not
trip.
10. Position the equipment appropriately . Lower the side rails.
Lower the bed to it’s lowest position, so patient’s foot will rest flat on
the floor.
11. Place the wheelchair parallel to the bed and as close to the bed as
possible. Lock the wheels of the wheelchair and raise the footplate.
12., Assist client to a sitting position on the side of the bed. Assess for
patient for dizziness, orthostatic hypotension before moving the
client form the bed.
13. Place gait belt snugly around the client’s waist.
14. Ask the client to move forward and sit on the edge of the bed with
the feet placed on the floor.
15. Place the foot of the stronger leg beneath the edge of the bed and
put the other foot forward.
16. Place the client’s hands on the bed surface so that client can push
while standing.
17. Position yourself correctly by standing directly in front of the
client.
18. Hold the gait belt/ transfer belt with the nearest hand and the
other hand supports the back of the client’s shoulder
19. Assist the client to stand, then move together towards the
wheelchair or sitting area to which you wish to transfer the client.
Verbal instructions of “ ready-steady-stand” and on the count of “
three” ask the client to push the mattress/ side of the bed while you
transfer your weight from one foot to the other
20. Support the client to standing position. Together pivot on your
foot farthest from the chair or take a few steps towards the
wheelchair, bed, chair.
21. Assist client to sit on the wheelchair/ chair while you bend your
knees/ hips and lower the client on the wheelchair seat.
22. Ensure client safety. Ask the client to push back into the
wheelchair seat.
23. Remove the gait/ transfer belt. Lower the footplates and place
clients foot on them
24. Validate patient’s reaction
25. Document relevant information.

NCM 3N

TURNING CLIENT TO LATERAL POSITION PERFORMANCE CHECKLIST

Name: ___________________Year and Section: ______________Date:_____________

Assesment:

Criteria 4 3 2 1 0 Remarks

1. Determine any assistive devices that will be used on turning.

2. Assess encumbrances to movement such as an IV or an indwelling

catheter.

3.Medications the patient is receiving, because certain medications

may hamper movement and alertness of the client

4. Assistance required from other health care personnel.

Planning:

5.Identify expected outcomes

6. Gather all the materials needed.

Implementation:

7. Perform Hand hygiene

8. Introduce self and explain procedure to the patient.

9. Provide privacy. Adjust the bed to working height,

10. Lower the side rails. Loosen the top sheet.

11. Adjust the pillow near you, position your self, Position the client’s
arms and legs by crossing the patient’s arm on the chest and putting
the far leg over the near leg.

12., Move the client’s head, then the patient’s body by segment near
the side, opposite the side the client will face when turned.

13. Raise the side rails before going to the opposite side where
the client will face when turned. Lower the side rails.

14. Position the arms and legs of the client, by abducting the patient’s
near arm and putting the patient’s far leg over the patient’s near leg.
Position your self before moving the client by body mechanics.

15. Turn the patient by grabbing the patient’s shoulder and buttocks
part.

16. Support the arms and legs by placing a pillow In between the arms
and legs.

17. Fix bed linens and raise the side rails.

18. Validate patient’s reaction.

19. Perform Hand hygiene.

20. Document the procedure or any findings.

NCM 3N
BED STRIPPING PERFORMANCE CHECKLIST

Name: ___________________Year and Section: ______________Date:_____________

CRITERIA

1. Loosen all linens on all sides of the bed

2. Removed pillow case correctly, making sure the contaminated part

will be confined inside.

3. Removed soiled linen one at a time from the foot part of the bed
starting from the top sheet, folds it correctly.

4. Removed the soiled draw sheet, rubber sheet or water proof pad
contaminated part contained inside

5. Does the same with the bottom sheet

6. Has rolled the sheet observing proper medical asepsis, keeping the
uniform away from nurse’s uniform.

7. Places soiled linen inside the pillow case without dragging the
linens on the floor

8. Observes proper body mechanics during the entire procedure

9. Carried the soiled linen away from the uniform and places it on the
linen hamper

10. Performs hand hygiene

NCM 3N
BEDMAKING ( UNOCCUPIED BED) PERFORMANCE CHECKLIST
Name: ___________________Year and Section: ______________Date:_____________
Criteria 4 3 2 1 0 Remarks

CLOSE AND OPEN BEDMAKING

PLANNING

1. Performed hand hygiene

2. Gather all materials

3. Assessed environment for safety, checked position of chair for

safety, transfer of patient if able

4. Lowered side rails, raised bed to working position

5. Applied smooth( right ) side of bottom sheet starting from the foot
part

6. Tucks the head part and does miter correctly

7.Tuck the bottom sheet starting from the mitered corner going
to the foot part

8. Applied rubber sheet or a waterproof pad and draw sheet

according to client’s need and tucks the rubber or waterproof pad
and draw sheet.

9. Applied the top sheet starting from the head part, with excess at
the foot part

10. Tucks the top sheet at the foot part, does miter correctly.

11. Moved to the opposite side of bed, spread the bottom sheet over
the edge of the mattress from head to foot

12. Smoothed the folded rubber sheet or waterproof pad and

draw sheet, stretching the linens well, before tucking it.

13. Does the same with the top sheet, making sure the linens are
stretched well.

14. Put the pillow case and place the pillow with the opening away
from the door.

15. Cover the entire bed with the top sheet for a closed bed.

16. Use the Correct technique in folding the top sheet for an
open bed.

17. Makes a wrinkle free bed and observes proper body mechanics
the entire procedure

TOTAL SCORE

SURGICAL BED

1. Place pillow on the head rails of the bed.

2. Loosen the top sheet and place the blanket over the top sheet

3. Fanfolds the blanket and the top sheet correctly and neatly.

4. Place towel and kidney basin at the head part or according to the
 needs of the client.

5. Performs hand hygiene.

NC 3N
Fundamentals of Nursing
BED SHAMPOO PERFORMANCE CHECKLIST

Name: ___________________Year and Section: ______________Date:_____________

Criteria 4 3 2 1 0 Remarks
ASSESSMENT
1. Assessed environment for safety, patients fall risk status.
2. Determine that there were no contraindications to procedure
before washing client’s hair.
3. Inspected hair and scalp before shampooing, determined special
treatments if necessary
4. Reviewed orders for specific precautions concerning client’s
movement or positioning.
PLANNING
1. Identified expected outcomes
2. Gather all articles needed before starting the procedure
3. Adjusted room temperature and ventilation
4. Provide privacy
IMPLEMENTATION
1. Perform hand hygiene
2.. Explained the procedure to the patient
3. Adjust the bed to working height, lowered the side rails
4.Loosens the top sheet. Places clients’ head near the edge of the bed
by placing her diagonally across the bed.
5. Remove pillow, line’s pillow with waterproof pad and bath towel
and place it under client’s neck and shoulder
6. Insert the Kelly pad under the patient’s head with the trough
directed towards the pail.
7. Places rolled towel under neck across shoulder
8. Brushes or comb the clients hair
9. Places cotton balls on the client’s ear
10. Covers the eyes with a folded face towel ( damp towel )
11 Wet hair thoroughly starting from the hairline going to the back
and sides of the head
12. Mix small amount of shampoo in a small amount of water
13. Pour shampoo carefully alongside of the hairline of the client’s
head
14. Lather hair with both hands while massaging the scalp of the
client. Started at the hairline worked towards the neck, lifted head
slightly to wash back of head, and sides of the head.
15. Rinse hair with water, repeat process until hair is thoroughly
cleansed, avoiding undue jarring or frequent turning of the head.
16. Squeeze off the excess water from the hair
17. Remove the eye cover first and then the ear plug
18. With ne hand, raise the head while the other remove the Kelly
pad. Drop it to the pail, then wrap the hair with the bath towel across
clients neck.
19. Position the client on the center of the bed and readjust the
pillow
20. Dry the hair well. Comb clients hair.
21. Fix bed linens, make client comfortable
22. Validate client’s reaction
23. Does after care of the materials used.
28. Performed Hand Hygiene

EVALUATION
1. Recorded the procedure, including patient’s participation and how
patient tolerated the procedure
3. Recorded condition of the head and scalp and other significant
findings
4. Reported evidence of alterations in head and scalp to the nurse in
charge.

NCM 3N
Fundamentals of Nursing
BED BATH PERFORMANCE CHECKLIST

Name: ___________________Year and Section: ______________Date:_____________

Criteria 4 3 2 1 0 Remarks
ASSESSMENT
1. Assessed environment for safety, patients fall risk status.
2. Assessed for patient’s visual status, ability to sit without support,
hand grasp, Range of motion
3. Assessed for patient’s bathing preferences
4. Assessed for patient’s skin condition, taking note for risk for skin
impairment, noted presence of dryness or excessive moisture.
5. Reviewed orders for specific precautions concerning patient’s
movement or positioning.
PLANNING
1. Identified expected outcomes
2. Gather all articles needed before starting the procedure
3. Adjusted room temperature and ventilation
4. Explained the procedure to the patient
IMPLEMENTATION
1. Provide Privacy
2. Offered patient bedpan or urinal
3.Performed Hand Hygiene
4. Raised bed working height, lowered side rail, loosen the top sheet,
places patient near the nurse
5. Remove patients gown and places on top of patient’s chest
6. Place towel horizontally on the chest
7. Wets face towel
8. Makes a bath mitt
9. Wipes the eyes from inner canthus to outer canthus
10. Washes face in S shape and then dry
11. Washes ears and neck and then dry, paying particular attention to
underarms
12. Places towel under far arm
13. Wet, soap, rinse and then dry, does the same with the other arm
14. Places towel over patient’s chest, then wets, soap rinse and dry,
paying particular attention to patients umbilicus and under breast
15. Change’s client’s gown
16. Changes water as necessary
17. Places client on side lying position, places towel
18. Wets back, soap, rinse and then dry starting from the nape down
to the lower buttocks
19. Does back massage correctly.
20. Repositions patient in supine position, then flexes the knee far
from you
21. Places towel under the far leg, wet, soap rinse and dry, does the
same with the other leg.
22. Flexes both knees, drapes the patient properly
23. Soaks patients feet in a basin, soaps rinse and dry.
24. Assisted patients grooming, oral hygiene, Combs, hair, cut
fingernails if necessary
25. Fixes bed linens, stretches well. Changed linens if necessary.
26. Validates patient’s reaction. Makes patient comfortable.
27. Does after care of the materials.
28. Performed Hand Hygiene
EVALUATION
1. Observed skin, especially areas that were previously showing signs
of breakdown
2. Recorded the procedure, including patient’s participation and how
patient tolerated the procedure
3. Recorded condition of the skin and significant findings
4. Reported evidence of alterations in skin integrity to the nurse in
charge.

PERINEAL CARE (FEMALE) PERFORMANCE CHECKLIST

Student’s Name: _________________________ Date: _____________________

Criteria 4 3 2 1 0 Remarks
ASSESSMENT:
1. Assesses client’s status: level of consciousness, ability to
ambulate, ability to perform self-care.
2. Assesses environment for safety, patients fall risk status.
PLANNING:
3. Identifies plans and expected outcomes of the procedure.
4. Performs hand hygiene and gathers all materials.
IMPLEMENTATION:
5. Introduces self and explains the procedure.
6. Lowers side rails, adjusts bed to working position.
7. Provides privacy
8. Loosens top sheet, places the patient in dorsal recumbent position
9. Drapes patient properly using diamond drape.
10. Covers the vulva by unfolding the other half of the pointed end
of the top sheet.
11. Dons clean gloves.
12. Places the rubber sheet and bedpan, places the tray with kidney
basin, forceps in a forceps holder, container with cotton balls in
a soap suds solution, flushing cup, napkin and tissue on the bed,
near the patient’s vulva.
13. Wets the vulva by retracting the labia with the use of forceps
with cotton balls and pour water over the vulva.
14. Gets the forceps and starts cleaning the area with gentle
downward strokes from top and bottom
15. Cleans the other half the vulva using figure of seven strokes
16. Cleans the other half of the vulva using the inverted seven
strokes
17. Rinses the vulva by retracting the labia with the use of forceps
 with cotton balls or gauze and pour water over the vulva.
18. Dries vulva thoroughly using the downward strokes
19. Removes bedpan and rubber protector
20. Removes gloves properly.
21. Puts on patient’s underwear with napkin or diaper.
22. Repositions the patient into a comfortable position, fixes the
linen and stretches well.
EVALUATION and DOCUMENTATION
23. Validates patients reaction and feelings of comfort.
24. Does after care of materials
25. Does handwashing, documents the procedure and reports
untoward findings if any.