Lipa City Colleges

College of Nursing
(G.A Solis St., Lipa City, (043)756-5974, www.lipacitycolleges.net)
Performance Evaluation
In Accordance with PRC Board of Nursing Memorandum No. 01 Series 2009

Name of Student:
Year/Clinical Group:
School Year:
Semester/ Term: first Semester Second Semester Summer
Inclusive Dates of Clinical Rotation:

APPLYING AND REMOVING CAP, MASK, AND PROTECTIVE EYEWEAR

Performance Checklist Skill 9.1

4 3 2 1 0
ASSESSMENT
1. Reviewed type of sterile procedure to be
performed, consulted agency's policy for use
of protection.
2. Avoided participating in procedure if you
have symptoms of a respiratory infection.
3. Assessed patient's risk of infection.
PLANNING
1. Identified expected outcomes.
2. Prepared equipment, inspected packaging for
integrity and exposure to sterilization.
IMPLEMENTATION
1. Performed hand hygiene.
2. Applied gown appropriately, ensured gown
covers all outer garments.
3. Applied a cap:
a. Combed back and secured long hair.
b. Secured hair in place with pins.
c. Applied cap properly, ensured all hair fit
under edges of cap.
4. Applied a mask:
a. Ensured metal strip was along the top edge
of the mask.
b. Held mask by top strings, kept top edge
above bridge of nose.
c. Tied top strings appropriately.
d. Tied lower ties properly with mask under
chin.
e. Pinched metal band around bridge of nose.
5. Applied protective eyewear:
a. Applied protective glasses, goggles, or face
shield properly. checked that vision was
clear.

b. Ensured face shield fit snugly.

6. Applied sterile gloves if needed.
7. Removed protective barriers:

a. Removed gloves first if worn, discarded

them in the appropriate container.

b. Removed eyewear, avoided placing hands

over soiled lens.

c. Removed and discarded gown properly.

d. Removed and discarded mask properly.

e. Grasped outer surface of cap, lifted away

from hair.

f. Discarded cap appropriately, performed

hand hygiene.
EVALUATION
1. Assessed area of body treated for drainage,
tenderness, edema, and skin changes.
2. Identified unexpected outcomes.
 Lipa City Colleges
College of Nursing
(G.A Solis St., Lipa City, (043)756-5974, www.lipacitycolleges.net)
Performance Evaluation
In Accordance with PRC Board of Nursing Memorandum No. 01 Series 2009

Name of Student:
Year/Clinical Group:
School Year:
Semester/ Term: first Semester Second Semester Summer
Inclusive Dates of Clinical Rotation:

PREPARING A STERILE FIELD

Performance Checklist Skill 9.2

4 3 2 1 0
ASSESSMENT
1. Identified patient using two identifiers, com-
pared identifiers with information in MAR.
2. Verified that procedure requires surgical aseptic
technique.
3. Assessed patient's comfort, oxygen
requirements, and elimination needs before
preparation.
4. Instructed patient not to touch work surface or
equipment during the procedure.
5. Assessed for latex allergies.
6. Checked sterile package integrity or for
sterilization indicator.
7. Anticipated number and variety of supplies
needed for procedure.
PLANNING
1. Identified expected outcomes.
2. Completed all other nursing interventions
before procedure.
3. Asked visitors to step out, discouraged
movement by assisting staff.
4. Prepared equipment at bedside.
5. Positioned patient comfortably and
appropriately with assistance of NAP if necessary.
6. Explained purpose of procedure and importance
of sterile technique.
IMPLEMENTATION
1. Applied PPE as needed.
2. Selected an appropriate workspace above
waist level.
3. Performed hand hygiene.
4. Prepared sterile work surface:

a. Used sterile commercial kit or pack.

(1) Placed kit or pack on workspace.

(2) Opened outside cover, removed pack-

age and placed on surface.

(3) Grasped outer surface or tip of outer-

most flap.

(4) Opened outermost flap away from body

and sterile field.

(5) Grasped outer surface of edge of first

side flap.

(6) Opened side flap, allowed it to lie flat

on table, kept arm away from sterile
surface.

(7) Repeated for second flap.

(8) Grasped outside border of last flap,

stood away from package, folded flap
back, allowed it to fall on the table.

b. Opened a sterile linen-wrapped package.

(1) Placed package on workspace.

(2) Removed seal, unwrapped both layers,

following same steps as with sterile kit.

(3) Used open package wrapper as sterile

field.

c. Prepared sterile drape.

(1) Placed pack containing drape on work-
space and opened following same steps
as with sterile kit.

(2) Applied sterile gloves.

(3) Picked up folded top edge of drape with
fingertips of one hand, lifted without
touching any object, discarded wrapper
with other hand.

(4) Kept drape above waist and work sur-

face and away from body as unfolded,
discarded wrapper with other hand.

(5) Held drape, positioned bottom half over

top half of intended work surface.

(6) Allowed top half of drape to be placed

over bottom half of work surface.
5. Added sterile items to sterile field:
a. Opened sterile item while holding outside
wrapper in nondominant hand.

b. Carefully peeled wrapper over nondominant

hand.

c. Placed item on field at an angle, ensured

wrapper and arm were not over sterile field.

d. Disposed of outer wrapper.

6. Poured sterile solutions:
a. Verified contents and expiration date of
solution.

b. Ensured receptacle was located near work-

space edge.

c. Removed sterile seal and cap properly.

d. Poured needed amount of solution properly

into container.
EVALUATION
1. Observed for break in sterile technique.
2. Identified unexpected outcomes.
 Lipa City Colleges
College of Nursing
(G.A Solis St., Lipa City, (043)756-5974, www.lipacitycolleges.net)
Performance Evaluation
In Accordance with PRC Board of Nursing Memorandum No. 01 Series 2009

Name of Student:
Year/Clinical Group:
School Year:
Semester/ Term: first Semester Second Semester Summer
Inclusive Dates of Clinical Rotation:

STERILE GLOVING
Performance Checklist Skill 9.3

4 3 2 1 0
ASSESSMENT
1. Considered type of procedure to be per
formed, consulted agency policy on use of
sterile gloves.
2. Considered patient's risk for infection.
3. Selected correct size and type of gloves, examined
glove package to determine if it was dry
and intact with no water stains.
4. Inspected condition of hands, determined in
presence of lesions prevented participation in
a procedure.
5. Assessed patient for risk factors before applying
latex gloves:
a. Previous reaction to other items containing
latex.
b. Personal history of asthma, contact dermatitis,
eczema, urticaria, or rhinitis,
c. History of food allergies,
d. Previous history of adverse reactions during
surgery or dental procedure.
e. Previous reaction to latex products.
PLANNING
1. Identified expected outcomes.
IMPLEMENTATION
1. Applied gloves:
a. Performed thorough hand hygiene, placed
glove package near work area.

b. Removed outer glove wrapper by peeling

sides apart.

c. Grasped inner package on appropriate

workspace, opened package, kept gloves on
inside surface of wrapper.

d. Identified right and left glove, gloved

dominant hand first.

e. Grasped glove for dominant hand by

touching only glove's inside surface.

f. Pulled glove over dominant hand, ensured

cuff did not roll up wrist.

g. Slipped fingers under cuff of second glove

with dominant hand.

h. Pulled second glove over nondominant

hand.

i. Interlocked hands once both gloves were on,

held hands away from body until beginning
procedure.
2. Performed procedure.
3. Removed gloves:
a. Grasped outside of one cuff with other
gloved hand, avoided touching wrist.

b. Pulled glove off by turning it inside out,

placed glove in gloved hand.

c. Placed fingers of bare hand inside remaining

glove cuff, peeled glove off inside out and
over previously removed glove, discarded
both gloves in receptacle.

d. Performed thorough hand hygiene.

EVALUATION
1. Assessed patient for signs of infection.
2. Assessed patient for signs of latex allergy.
3. Identified unexpected outcomes.
RECORDING AND REPORTING
1. Recorded any patient response indicating a
latex allergy.