PERFORMANCE CRITERIA CHECKLIST

CLEANLINESS AND SKIN CARE

Name: _______________________ Date: ___________________________

CRITERIA YES NO
CRITERIA Did you……
A. ORAL CARE (CONSCIOUS)
1. Assess client’s ability to brush his/her teeth.
2. Gather equipment. Place on an over bed table or patient’s side table
3. Do hand washing.
4. Provide privacy for the patient.
5. Position the patient in a semi-Flower’s position
6. Place a towel under patient’s chin, tucking it behind the shoulders/
7. Let the patient sip water and gargle
8. Hold the toothbrush over the emesis basin, pour a small amount of water
over it and apply toothpaste
9. If the patient is able to brush his/her teeth allow him to do it.
10. Allow the client to rinse mouth with several sips of water and spit into the
emesis basin.
11. Offer mouthwash or dental floss if available
12. Help the client to wipe the mouth.
13. Remove equipment used. Return to its proper place
14. Turn/ place the patient to a comfortable position
15. wipe the over bed
16. Wash your hands.
17. Document the procedure.
B. ORAL CARE (UNCONSCIOUS)
1. Check the patient’s chart and nursing care plan for any information related
to patient’s condition.
2. Gather equipment. Place on an over bed table or patient’s side table.

4. Do hand washing
5. Raise the bed to a comfortable working height. Place patient in a semi-
Fowler’s position with head turned toward you.
6. Place a towel under patient’s chin, tucking it beneath the shoulders.
7. Put on clean gloves.
8. Place padded tongue blade/depressor wrapped with gauze and with gauze
and taped securely, in the patient’s mouth.
9. Moisten toothbrush and apply very lightly the toothpaste.
10. Brush all tooth surfaces, including the tongue.
11. Use a cotton-tipped applicator to clean all surfaces of the mouth, palate,
inner cheeks and tongue.
12.Rinse patient’s mouth with small amount of water, allowing it to drain into
the emesis basin or use Asepto syringe.
13. Wipe patient’s mouth with the towel placed under chin.
14. Lubricate lips as needed.
15. Do after care of equipment.
16. Remove gloves. Wash hands.
17. Document.
C. DENTURE CARE ( Oral questioning)
D. MUSTACHE SHAVING (Oral questioning)
E. PERINEAL CARE MALE AND FEMALE (Oral questioning)
F. HAIR SHAMPOO
1. Bring all necessary equipment to the patients unit
Place newspaper on the floor under the pail; place other articles on the
bedside table
2. Move patient’s head and shoulder to the edge of the bed next to self.
3. Place rubber sheet over the pillow and cover it with bath towel.
4. Place Kelly pad over the pillow, let the end extend to the pail. If Kelly pad is
not available, improvise a tough. Get a large plastic sheet and roll a towel into
each side.
5. Place one hand towel around the neck of the patient and pin in front. The
other hand towel should be placed over the chest of the patient.
6. Comb hair well before shampooing.
7. Place a piece of cotton in the patient’s ear
8. Fold the washcloth and place it over the eyes of the patient.
9. Put water into a container, let patient feel the water.
10. Inform patient that you are about to pour water
11. Pour warm water over the head. Wet hair thoroughly.
12. Make a lather with shampoo, rinse thoroughly and repeat it if necessary.
Remove Kelly pad.
13. Using a dry towel, pat hair dry and wrap turban style.
14. Remove cotton from the ears, discard. Dry ears, forehead and neck.
15. Rub hair and scalp and bath towel until dry. Comb hair and make patient
comfortable.
16. Care for used equipments. Keep patient’s unit clean.
17. Do after care of equipments. Wash hands. Document the procedure.
G. BED BATH
1. Inform the patient and explain procedure. Allow the patient to ask
questions.
2. Prepare environment. Provide time for elimination and privacy.
3. Do hand washing.
4. Prepare articles over the bed table within reach. Arrange them according to
use.
5. Raise the bed to an appropriate working level.
6. Assist the patient to the side of the bed where the nurse will work. Have
him lie on his back/semi-fowlers position.
7. Untuck linens, remove blanket and refold is re-usable. Place it at the back
of the chair.
8. Place the bath blanket over the top linen. Remove the top linen by rolling
inside out towards the patient’s feet. Ask the patient to grasp the flat or hold
top edge of the blanket.
9. Remove pillow, if patient can tolerate. Place it on the head rail. Place bath
towel under the head.
10. Remove the patient’s gown.
11. Soak wash cloth in lukewarm water, squeeze and make a mitt.
a. wash face (s-stroke)
b. eyes-inner to outer canthus
c. ears- inner to outer and back.
d. neck- use downward stroke

12. Place bath towel lengthwise under the arm farther from you. Using long,
firm strokes toward the center of the body, wash the hand, and the axilla
(from distal to proximal)
13. Cover the arm with half of the towel while rinsing out the washcloth.
14. Pat dry the arm thoroughly.
15. Do the same with other arm near you.
16. Soak both hands in a basin. Pay particular attention to the spaces between
the fingers, rub gently the washcloth
17. Pat dry hands with the towel.
18. Fold bath blanket down the waist. Place over the chest. For FEMALE
patient, wash the chest using the figure. For MALE patient, wash the chest in a
long firm stroke from far from shoulder to waist, towards you.
19. Fold the bath blanket down to the pubic bone, leaving the towel over the
chest and extend it over the chest and extend it over the abdomen. Wash the
abdomen in a circular motion, from the umbilicus going outwardly.
20. Remove the blanket from far leg only, tucking it under and around the leg.
21. Place the towel lengthwise under the far leg. Wash and rinse the leg
thoroughly using long firm strokes towards the center of the body. Do not rub
the muscle.
22. Pt dry the leg with the bath towel.
23. Soak the foot carefully with water in the basin, soap the foot, wash each
toe separately and in between the toes.
24. Wash, rinse and dry the near leg and foot in the same way.
25. Change the water. Wash the washcloth and rinse thoroughly.
26. Put the patient in a lateral position facing away from you. Expose the back
of the patient till the buttock.
27. Wash, rinse dry the back of the neck and the back using long firm strokes.
28. At this point, a back rub is rendered. Use lotion or powder. The other dry
parts of the body could also be applied with lotion like the heels, elbows and
feet.
29. Help the patient put on a clean gown or pajamas. Comb or brush the hair.
Do care for fingernails and toenails.
30. Make the occupied bed
31. Do after care of the equipment.
32. Do hand washing

Comment: _______________________________

______________________________
Name and Signature of Trainer