Medical-Surgical department

Surgical Unit
Performance Check List ….. The Surgical Scrub
Student’s Name:--------------------------------------------- Date:------------------
Examiner:------------------------------------------------------------------------
Steps Score

(1) put on OR attire, overhead, mask, choose 1

(2) Regulate the flow and temperature of the water. 1

(3) When scrubbing, slightly bend forward; hold hands and arms
1
above the elbow away from the body.

(4) Wet hands and arms for an initial pre scrub wash.
1
(5) Use several drops of surgical detergent; distribute it on the
hands and arms for two inches above the elbow.
2
(6) Lather palm, back of hand, heel of hand, and space between
thumb and index finger. Scrub 9 circular strokes on each
surface. 1

(7) Using surgical detergent then Lather fingertips.

1
(8) Scrub the spaces under the fingernails of the right or left hand 9
circular strokes.
1
(9) Lather digits scrub 9 circular strokes for each four sides of each
finger.
1
(10) Scrub the forearm ending two inches above the elbow, 9
circular strokes on all four sides.

(11) Rinse hands and arms without retracing and/or contaminating.

(12) Allow the water to drip from your elbows before entering the
operating room.

1
(13) Slightly bend forward, pick up the hand towel from the top of 1
the gown pack and step back from the table.

(14) Holding one end of the towel with one of your hands,
1
(15) Dry your other hand and arm with a blotting, rotating motion.
Work from your fingertips to the elbow. 1

(16) Grasp the other end of the towel and dry your other hand and
arm in the same manner as above. 1
(17) Discard the towel into a linen receptacle.
1

Student’s score 18

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2
Medical-Surgical department
Surgical Unit

Performance Check List ….. Surgical Gown Technique

Student’s Name:---------------------------------------------------------
Steps Score

3
 1. With one hand, pick up the entire folded gown from the 1
wrapper.

2. Hold the gown, near the gown's neck, and allow it to 1

unfold.
1
3. Grasp the inside shoulder seams and open the gown with the
armholes facing you.  
1
4. The circulator positions the gown over your shoulders by
grasping the inside surface of the gown at the shoulder
seams 1

5. The circulator then prepares to secure the gown. Then ties the
gown at waist level at the back.
1
after gloving do the following:

6. The scrub will take hold of the paper tab that holds the belt and
belt tie located at waist level and pull the tab away from the 1
belt tie.

7. The scrub will pass the paper tab that holds the belt to the 1
circulator.

8. The circulator will take hold of the paper tab, and move to the 1
side or behind the scrub.
1
9. The scrub will take hold of the belt only and pull on the belt.

10. Now the scrub will take hold of the belt tie that is at waist
level and tie the belt to it.
Student’s score 10

Comment:-----------------------------------------------------------------------------------------------
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Medical-Surgical department
Surgical Unit

Performance Check List …..Closed Surgical Glove Technique

4
Student’s Name:------------------------------- Date:--------------------------
Clinical instructor:
Steps Score
1
(1) Open the inner package containing the gloves.
1
(2) Pick up one glove by the folded cuff edge.
2
(3) Place the glove on the opposite gown sleeve, palm down,
with the glove fingers pointing toward your shoulder.
1
(4) Place the gloves rolled cuff edge at the seam that connects
the sleeve to the gown cuff.

(5) Grasp the bottom rolled cuff edge of the glove with your 1
thumb and index finger.

(6) While holding the glove's cuff edge with one hand, grasp the 1
uppermost edge of the glove's cuff with the opposite hand.
1
(7) Continuing to grasp the glove.
1
(8) Using the opposite sleeve- covered hand, grasp both the
glove cuff and sleeve cuff seam and pull the glove onto the
hand.
1
(10) Using the hand that is now gloved, put on the second glove
in the same manner.
Student’s score 10

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5
 Performance Check List---------- Open Surgical Glove Technique

Student’s Name:--------------------------------------------Date:----------------------
Clinical instructor:
Steps Score

Glove application:
1
(1) Perform through hand hygiene or scrubbing.
(2) Remove outer glove package wrapper by carefully 1
separating and peeling apart sides
(3) Grasp inner package, and lay it on clean, dry, flat surface 1
at waist level.
(4) Open package, keeping gloves on wrapper's inside
surface. 1
(5) Identify RT and Lt Glove. Each glove has a cuff
approximately 5cm wide, glove dominant hand first.
1
(6) With thumb and first two fingers of non-dominant hand,
grasp edge of cuff of glove for dominant hand. Touch
only glove's inside surface.
1
(7) Carefully pull glove over domi9nant hand, leaving cuff
and being sure cuff does not roll up wrist
(8) With gloved dominant hand, slip fingers underneath 1
second glove's cuff
(9) Carefully pull second glove over nondominant hand. 1
(10) After second glove is on interlock hands together, above
waist level. 1

6
 Glove disposal

(1) Grasp outside of one cuff with other gloved hand, avoid
touching wrist 1
(2) Pull glove off, turning it inside out. Discard in receptacle
(3) Take fingers of bare hand and tuck inside remaining
1
glove cuff. Peel glove off inside out. Discard in
receptacle. 1

Student’s score 13
Comment:
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