DMC COLLEGE FOUNDATION, INC.

College of Nursing

PERFORMANCE CHECKLIST

Name:
Year and Section:

U F S
GLOVING N A A
S I T
Definition: A R I
T S
I F
S A
F C
Purposes: A T
C O
T R
O Y
R
Y
1. Remove jewelry.
2. Wash hands.
3. Tear the sterile package and open side of the folder either L or R touching only
the center lower corner.
4. Pick up the exposed glove with your opposite hand.
5. Step back from the table.
6. Insert your free hand into the glove without touching the skin to the outside of
the glove (the L glove with the RIGHT hand or the R glove with the LEFT hand).
7. Be careful to touch only the folded cuff.
8. Open the second side of the folder with your ungloved hand exposing the
second glove.
9. Pick up the glove with your gloved hand from under the cuff which is the
outside portion.
10. Be sure to keep the thumb of the gloved hand rigidly extended outward or
folded against the palm.
11. Hold the glove under its cuff by your gloved fingers and step back from the table.
12. Carefully maneuver the second hand into the glove.
13. When both gloves are on, turn the cuffs up by flipping them, taking care not to
roll the outside of the gloves onto your skin.
14. Make necessary adjustments.

____________________________________
Clinical Instructor / PCI

___________________________________
Date and Grade
 DMC COLLEGE FOUNDATION, INC.
College of Nursing

PERFORMANCE CHECKLIST

Name:
Year and Section:

U F S
ISOLATION TECHNIQUE N A A
S I T
Definition: A R I
T S
I F
S A
F C
Purposes:
A T
C O
T R
O Y
R
Y
Procedure:
I. Preparing the room:

1. Post sign outside indicating type of isolation.

2. Be sure a stand is outside with appropriate supplies (disposal bags, gowns,
mask, and gloves as needed).
3. Have a laundry hamper inside the room.
4. Be sure a thermometer, blood pressure apparatus with stethoscope are inside
the room.
II. Entering the room:

5. Obtain all needed equipment.

6. Wash hands.
7. Put your watch on a plastic bag.
8. Explain procedure to patient/relatives.

9. Put on gown:
a. With palms together, open gown at neck, slide hands and arms down the
sleeves.
b. Tie strings at back of neck.
c. Overlap gown at back, bring two edges of gown together until it fits
body closely.
d. Secure waistband snugly.
10. Put on mask over nose and mouth.
11. Put on clean gloves by tucking on sleeves of gown securely the inside of gloves.
12. Do nursing care as called for.

13. Remove soiled gloves by turning inside out as you pull gloves off
a. Peel the first glove off, touching only the outside with the other gloved
hand.
b. Slide ungloved fingers inside of second glove and turn glove inside out
over first the glove while removing it.

14. Remove gown with technique:

a. Untie the waist belt.
b. Untie neckband of gown without touching the outside.
c. Fold gown flatly together, with the clean side inside.
d. Hang gown with shoulders of gown together so that they can be fitted
over the hook.
15. Wash hands outside the room.

16. Document appropriately.

______________________________________
Clinical Instructor / PCI

____________________________________
Date and Grade