2021-2022

CONAMS
Wesleyan University Philippines
MEDICAL-SURGICAL NUSING CHECKLIST 2021-2022
 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

PERFORMANCE EVALUATION TOOL
NCM 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance,
Nutrition and Metabolism and Endocrine

NAME OF STUDENT:
Block #______

I. Procedure: Applying Transdermal Patch

Purposes 3 2 1 REMARKS
1 1. To deliver medication..
2 2. Used to deliver hormones, narcotic
analgesics, cardiac medications, and
nicotine.
I. Assessment:
Assess for the following
3 1. Patient’s allergies
4 2. Expiration date before administering
medication
5 3. Review assessment and laboratory data
that may influence drug administration.
6 4. Site should be clean, dry and free of hair.
II. Planning
7 Gather and prepare the needed materials
8 a. Medication patch
9 b. gloves
10 c. scissors (optional)
11 d. washcloth, soap, and water
12 e. Patient chart/Medication Administration
Record (MAR)
13 f. Additional PPE, as indicated
III. Procedure/Implementation
14 1. Gather equipment. Check medication order
against the original order in the medical
record. Check patient's chart for allergies.
15 2. Perform hand hygiene.
 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

16 3. Prepare medications for one patient at a
time. Check expiration dates and perform
calculations, if necessary.
17 4. Identify the correct patient.

5. Complete necessary assessments before

18
administering medications. Check patient for
allergies and explain the purpose and
action of each medication to the patient.
6. Put on gloves.
19
7. Assess the patient's skin where patch is to be
20 placed, looking for any signs of irritation or
breakdown. Site should be clean, dry, and
free of hair. Rotate application sites.
8. Remove any old transdermal patches from
21 the patient's skin. fold the old patch in half
with the adhesive sides sticking together and
discard according to facility policy. Gently
wash the area where the old patch was with
soap and water.
9. Remove the patch from its protective
22
covering. Initial and write the date and time
of administration on the label side of the
patch.
10. Remove the covering on the patch without
23 touching the medication surface. Apply the
patch to the patient's skin. Use the palm of
your hands to press firmly for about 10
seconds. Do not massage.
11. Remove gloves and additional PPE, if used.
24
Perform hand hygiene.
25
12. Document the administration of the
medication immediately after administration.
13. Evaluate the patient's response to medication
26 within the appropriate time frame.
TOTAL SCORE:
 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

Student’s Signature:_______________ Instructor’ Signature________________

Date :_____ Date:__________

Comments/Suggestions: __________________________________________________
______________________________________________________________________

PERFORMANCE EVALUATION TOOL

NCM 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance,
Nutrition and Metabolism and Endocrine

NAME OF STUDENT:_____________________
Block #______

I. Procedure : Clean Catch/Midstream Urine Collection

 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

1 II. Purposes: 5 4 3 2 1 REMARKS
1. To minimize contamination of the specimen
2 by organism of the skin.
2. To confirm alteration in metabolism,
3 infection and fluid volume problem
3. To determine appropriate antibiotic to
4 administer to specific patient
5 III. Assessment:
6 Assess for the following
7 5. Doctor’s order
6. Client’s level of consciousness and level
8 of knowledge and understanding
7. Ability of the client to collect their own
9 urine
10 IV. Planning
11 Gather the following materials
12 a. Properly labeled specimen bottle
13 b. Soap
14 c. Wash cloth
15 d. Antiseptic swab or cotton balls
16 e. Bed pan
17 f. Non sterile gloves
18 g. Bed protector pad
19 V. Procedure:/Implementation
For patient who has an ability to collect
20 their own urine.
1. Give specimen bottle, to patient to be used
21 for urination as well as the soap, wash cloth,
antiseptic swab or cotton balls
2. Instruct patient to wash/wipe with
22 disinfectant the vagina or penis before
urinating in the specimen bottle.

VI. Procedure:/Implementation
3. When opening the cover of the specimen
23 bottle, instruct the client to be careful not to
touch the lid of the specimen bottle
 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

4. When urinating, place the specimen bottle
24 during the middle of voiding under the stream
of urine. Try to collect at least 2 tbsp. of
urine)
5. Once completed, cover container and wash
25 their hands
6. Send the collected urine specimen
26 immediately to the laboratory together with
the properly filled up laboratory request
For patient who has no ability to collect their
27 own urine. The nurse will do the following:
28 1. Identify the client. Explain the procedure.
29 2. Provide for client’s privacy
3. Set the bed to a comfortable height to work
30 and lower the side rails where you will work.
4. Wash hands and arrange the materials
31 needed
32 5. Wear gloves
6. Place bed protector pad under the client’s
33 buttocks
7. Position patient and place bed pan under the
34 client’s buttocks
8. Wash perineal area with soap and water then
35 pat it dry
9. Clean the genitalia with cotton balls soaked in
36 an antiseptic solution
37 10. For Female client: wipe from front to back
11. For Male Client: clean tip of the penis using
38 circular motion, moving from middle to
outward direction
39 12. Ask client to void:
13. For Female Client: while begins voiding, the
40 health care provider hold the labia with
dominant hand
14. After stream of urine begins, obtain 30 ml of
41 urine specimen for routine urinalysis;
5-10 ml for culture and sensitivity test
 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

VII. Procedure:/Implementation
 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

15. Remove container before client stop voiding
42
43 16. Allow client to complete voiding
17. Wash perineal area after urination is
44 completed
45 18. Remove bed pan and bed protector pad
46 19. Discard used materials
20. Provide for client’s safety, comfort and
47 privacy
48 21. Remove gloves and wash hands
22. Send specimen to the laboratory together
49 with the properly filled up laboratory form
23. Evaluate client’s response to the procedure
50
24. Document procedure and other important
51 data on the client’s chart
TOTAL SCORE:

Student’s Signature:_______________ Instructor’ Signature________________

Date :_____ Date:__________

Comments/Suggestions: __________________________________________________
______________________________________________________________________

PERFORMANCE EVALUATION TOOL

NCM 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolyte Balance,
Nutrition and Metabolism and Endocrine

NAME OF STUDENT:_____________________
Block #______

I. 24 Hour Urine Specimen Collection

1 II. Purposes: 5 4 3 2 1 REMARKS

 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

1. To provide means to detect the
2 concentration of dilution of urine
3 2. To check the functions of the kidneys
3. To measure any products present in the
4 urine
5 III. Assessment:
6 Assess for the following
7 1. Doctor’s order
2. Client’s level of consciousness and level of
8 knowledge and understanding
9 3. Refrigerator is functioning well
10 IV. Planning
11 Gather the following materials
a. Special specimen container properly labeled
12
13 b. Signs that the urine collection is in progress
14 c. Additives if required/preservatives
15 d. Refrigerator
16 V. Procedure/Implementation
17 1.Assemble all the needed materials
18 2.Identify the client. Explain the procedure
3.Place sign in client’s bathroom stating that “24
19 HOUR URINE COLLECTION” is in progress with date
and time
20 4.Discard first voided urine
5.Instruct client to start voiding to the specimen
21 container (usually start in the morning) according to
the policy and store it at a cool temperature or
refrigerate

Procedure/Implementation 5 4 3 2 1 REMARKS
6.Label each specimen thereafter until same time
21 the following day
7.After the last voided specimen is placed in the
22 container, cover and send the entire specimen to
the laboratory promptly following the agency
protocol
8.Always wash hands and wear gloves before and
 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

23 after the collection of specimen
9.Remove signs in the bathroom and inform client
24 that the procedure is completed
10.If the specimen is accidentally discarded, obtain a
25 new container, note the new date and time and
restart the procedure
11.Evaluate physical response of client, specimen
26 and laboratory requisition
12.Document the procedure and other important
27 data on the client’s chart
TOTAL SCORE:

Student’s Signature:_______________ Instructor’ Signature________________

Date :_____ Date:__________

Comments/Suggestions: __________________________________________________
______________________________________________________________________