University of Cebu – Banilad

College of Nursing
Cebu City

SKILLS LABORATORY PERFORMANCE CHECKLIST

PROVIDING PATIENT WITH STEAM INHALATION

Name: Year & Section: Grade:

LEGEND:
EQUIPMENT: 1 - Excellent

PITCHER METHOD ELECTRICAL INHALATION METHOD

pitcher on a tray inhaler
boiling water warm water
bath towel bathbladd towel
paper cone paper cone
2 – Very Satisfactory
3 – Satisfactory
4 –Needs Improvement
5 – Poor

PITCHER METHOD
NURSING E VS S NI P
PROCEDURE RATIONALE
RESPONSIBILITY 1 2 3 4 5
1. Prepare all the equipment. Make sure you have To conserve time and
the complete and energy.
correct equipment.
2. Place boiling water in pitcher Fill the pitcher about For inhalation of warm
1/3 to ½ full. air.
3. Explain treatment to the patient. Make sure that the To enhance client’s
explanation is within cooperation and
the patient’s level of promote comfort.
understanding.
4. Assist patient to assume a convenient Position depends on the To enhance client’s
position. patient’s condition, if the cooperation and
patient is conscious and promote comfort.
able, he may sit in
the edge of the bed.
5. Provide privacy. Always ensure patients Hygiene is a personal
dignity as well as matter.
confidentiality. Ensure
doors & windows are
closed and curtains.
6. Instruct patient to inhale steam at a Position inhaler in front of To ensure proper
safe distance. the patient & ask to keep inhalation.
mouth in the mouthpiece
for 8 – 10 inches away
from the water & breathe
in to receive the steam &
breath out removing lips
from mouthpiece.
7. Remove pitcher at the end of the Don’t let the px steam To prevent burns.
prescribed period. (Remove after 15 longer than 5-15 mins.
minutes as ordered).
8. Wipe patient dry. Keep px’s face. dry To prevent drying of
skin.
9. Record intervention and its Document the procedure For legal purposes and
effectiveness. correctly. for client safety.
ELECTRICAL INHALER METHOD
NURSING E VS S NI P
PROCEDURE RATIONALE
RESPONSIBILITY 1 2 3 4 5
1. Gather all equipment. Make sure you have the To conserve time and
Apparatus may be secured from the correct and complete energy.
CSR depending on the institution’s equipment needed.
policy.
2. Place water. Do not fill until the neck. Ensure water is at the right To avoid spillage.
level
3. Explain treatment to the patient. Explain in a way px can To enhance client’s
understand and in a polite cooperation and reduce
way. anxiety.

COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PERFORMANCE CHECKLIST

NEBULIZATION

Name: Year & Section: Grade:

LEGEND:
EQUIPMENT: 1 - Excellent
Nebulizer 2 – Very Satisfactory
Drug ordered (ex. Terbutaline sulfate (ventolin) nebule ) 3 – Satisfactory
Mouth piece or oxygen mask 4 –Needs Improvement
Tubing or nebulizer cap 5 – Poor

E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
1. Gather all equipment. To save time and effort
2. Place the medication and NNS in nebulizer cap. Giving medication is a
dependent interaction
3. Attach tubing to the connector. To have a proper flow
4. Assess the best position for patient. Position may vary depending
a. Place patient on side of bed in sitting on the patient’s condition
position with feet on the floor.
b. Have patient sit on chair.
c. Side lying position.
5. Instruct patient on the following:
a. mouthpiece To have exact dosage of
- keep lips tightly around the mouthpiece medication
- breath only through mouth
- let patient have a “clearing breath” (after
every 5-7 breaths, remove mouthpiece from
mouth and hold breath for at least 5 sec. (10
sec. in better) then exhale slowly. Left medication absorbs more
b. If aerosol mask is used, place the mask over effectively
the mouth and nose, then inhale deeply and
slowly through the mouth; then exhale slowly.
6. Continue treatment until nebulizer is empty Ensures medicine is inhaled
usually about 20 minutes. until the last drop
7. Record. For documentation purposes
- medication
- date
- time

COMMENTS:

Clinical Instructor’s Signature

Date
 GAUZE

TUBING OR NEBULIZER
CAP
DRUG ORDERED (EX.
TERBUTALINE SULFATE
(VENTOLIN) NEBULE )
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PROCEDURE LIST

Name: Year & Section: Grade:

CHEST PHYSIOTHERAPY
LEGEND:
1 - Excellent
2 – Very good
3 – Good
4 – Fair
5 – Poor

PROCEDURE RATIONALE 1 2 3 4 5 REMARKS

POSTURAL DRAINAGE
1. Make the patient comfortable before the For smooth and
procedure starts and as comfortable as possible continuous
while he assumes each position and explain the procedure and to
procedure. have patients
consent.
2. Use a stethoscope to determine the areas of To listen to the
needed drainage. sound and
identify the area
that needs to be
mobilize or loose
secretions.
3. Upper lobes are generally drained by upright To help drain
positions; lower and middle lobes are drained by lung secretion.
head down positions.
4. Have the patient assume left prone and left This will give
oblique (simultaneously). additional
drainage to
middle lobe and
lateral segments
of the right lower
lobe.
5. Assume to be right prone and right oblique Gives additional
(simultaneously). drainage to
middle lobe and
lateral segments
of the lower lobe.
6. Encourage the patient to cough after he has spent Coughing aids in
the allotted time in each position. (20 – 30 mins) the movement
and expulsion of
secretions.
7. Encourage diaphragmatic breathing throughout This helps widen
postural drainage exercises. airways so that
secretions can be
drained.
PERCUSSIONS:
1. Instruct the patient to use diaphragmatic Helps the patient
breathing. to relax and helps
widen airways.
2. Position patient in prescribed postural drainage The patient is
position. The spine should be straight to promote positioned
rib cage expansion. according to the
areas of the lung
that is to be
drained.
3. Percuss (or clap) with cupped hands over the Helps to
chest wall for 1-2 minutes from: dislodged
a. the lower ribs to shoulders in the back. mucous plugs
b. the lower ribs to top of chest in front. and mobilize
 secretions
towards the main
bronchi and
trachea. The air
trapped between
the operator’s
hand and chest
wall will produce
a characteristics
sound.
4. Avoid clapping over the spine, liver, kidneys, Percussion over
spleen, breast, scapula, clavicle, or sternum. the areas may
cause injuries to
the spine and
internal organs.
VIBRATION
1. Instruct the patient to inhale slowly and This sets up a
deeply. Vibrate the chest wall as the patient vibration that
exhales slowly through pursed lips. carries through
a. Place one hand on top of the other over the chest wall
the affected area or place one hand on each side and helps free the
of the rib cage. mucous.
b. Tense the muscles of the hands and arms
while applying moderate pressure and vibrate The maneuver is
hands and arms. performed in
c. Relieve pressure on the thorax as the which the ribs
patient inhales. move upon
d. Encourage the patient to cough, using his expiration.
abdominal muscles after 3 or 4 vibrations.
2. Allow the patient to rest several minutes. To help expand
the lungs and
draw more air
into all areas of
the lungs.
3. Listen with a stethoscope for changes in breath The appearance
sound. of moist sounds
(crackles)
indicates
movement of air
around mucus in
the bronchi.
Note:

Repeat the percussion and vibration cycle according to the patient’s tolerance and his clinical response;
usually 15 – 20 minutes.

COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PERFORMANCE CHECKLIST

CHEST TUBE THORACOTOMY

Name: Year & Section: Grade:

LEGEND:
EQUIPMENT: 1 - Excellent
Closed chest drainage system Vacuum Sterile gloves 2 –
Vaselinized gauze Plaster (Leucoplast) Very good 3
2 Kelly clamps/Hemostant
– Good
4 – Fair
5 – Poor

PROCEDURE RATIONALE 1 2 3 4 5 REMARKS

1. Gather necessary equipment. Promote
efficiency
2. Do medical handwashing. Prevent
contamination
3. Fill the chambers to appropriate level: Regulate proper
*Place funnel in tubing or port leading to suction amount of water
control chamber. Sea pressure
*Pour fluid into suction control port until prevent spillage
designated amount is reached per doctor’s order or of water
to specific line marked on bottle usually indicating Contracts the
the 20 cm water pressure level. amount of
*Fill water seal chamber or drainage system to the suction of
12 cm level. pressure
Allow air to
escape
4. Do on gloves, and connect drainage system to Prevents air
chest tube and suction source, if suction is reflex to chest
indicated. while water seal
MAINTAN STERILY OF CONNECTOR ENDS.
*If changing drainage system, ask the client to
take a deep breath, hold it, bear down slightly
while tube is being changed quickly.
*If indicated, connect tubing from the suction
control chamber to suction source.
5. Adjust suction flow regulator until quiet Regulates flow
bubbling is noted in the suction control chamber. of suction
6. Check the tube connections periodically. To ensure tight
Tape if necessary. fit and patience
*The tube should be approximately 2.5cm (1 in) of the tube
below the water level.
*The short tube is left open at atmospheric air.
7. Mark the original fluid on the outside of the For baseline data
drainage bottle. Mark hourly/daily increments at and know the
the drainage level using tape. amount of fluid
drained
8. Make sure the tubing tubes does not loop or Prevents
interfere with the client's movement. obstruction
9. Discard gloves and dispose materials. Prevents
contamination
10. Position for comfort. Encourage good body Promotes
alignment and frequent position charger. Place call drainage
button within reach.
MAINTAINING A CHEST TUBE
1. Make sure that there is a fluctuation (tidaling) of To facilitate
the fluid level in the water seal. patient tubing
2. Watch for leaks of air in the drainage system as Bubbling
indicated by constant bubbling in water seal bottle. indicates leaks
 PROCEDURE RATIONALE 1 2 3 4 5 REMARKS
3. Observed and report immediately signs of rapid To document
shallow breathing, cyanosis, pressure in the chest, abnormalities
emphysema or symptoms of hemorrhage.
4. Encourage patient to breathe deeply and cough at To allow
regular intervals. expansion of
lungs
5. If the drainage shows or stops, consult agency Re-establish
policy and if allowed, gently milk chest tube (or flow of drainage
strip as last resort). by breathing
6. Assess breath sound every 2 hours. Indicate progress
7. Use the following troubleshooting tips in
maintaining chest tube drainage.
*If drainage system is turned over and over seal is To re-establish
disrupted, reestablish water seal and assess client. water seal.
If drainage decreases suddenly, assess for tube Parents
obstructions and milk tubing. additional air
*Check the gravity drainage systems and suction reflex.
systems are below level of client’s chest.
Determine if
*If dressing becomes saturated, reinforce with
there is blockage.
gauze and tape securely. If permitted, remove
soiled dressing without disturbing petroleum jelly Retains original
gauze seals. Apply new gauze pads. seal around the
*If drainage system becomes broken, clamp tube tube.
with kelly clamp or hemostat and replace
immediately or place end of tube in sterile bottle of
saline solution, place bottle below level of chest, Prevents air from
and replace drainage system immediately. entering the
NOTE: CLAMP CHEST TUBE FOR NO MORE chest.
THAN A FEW MINUTES (SUCH AS DURING Air can enter
SYSTEM CHANGE) pleural cavity
during inspiration
if it can escape it
causes tension.
8. DO documentation: Provides
*System function (type and amount of drainage) evidence of
*Time suction was initiated or system changed. nursing care
*Clients status (RR, breath sounds, pulse oximeter, given
pulse, BP, skin color, temp.)
*Chest dressing status and care done.
*Drainage characteristics and amount.

COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PROCEDURE LIST

PERFORMING LOG ROLLING

Name: Year & Section: Grade:

LEGEND:
1 - Excellent
2 – Very
Satisfactory 3 –
Satisfactory
4 – Needs Improvement
5 - Poor

E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
I. PREPARATION
1. Identify the patient. To ensure right client
is given the procedure.
2. Explain procedure to the patient. To elicit cooperation.
II. PROCEDURE
3. Put bed in flat position. To ensure smooth
performance of
procedure.
4. With help, move patient to side of
bed in one unit. Facilitate the rolling of
4.1 Each person slides his/her arms the patient to the other
under the patient. side.
4.2At a signal (“one, two, three, move!), To foster cooperation
all pull the patient maintaining and ensure client’s
body’s safety.
alignment at all times.
5. Raise siderail on that side of bed. Ensures client’s
safety.
6. All assistants move to other side of bed. To act as guide of
pillows.
7. Place pillows correctly: To ensure client’s
a. Head comfort and provide
b. Along the spine safety.
c. In between legs
8. Assistants reach across and grasp patient’s To provide safety of
body. the client.
9. At a signal, all turn patient in one unit. To allow a smooth
motion when lifting
the client.
EVALUATION
10. Evaluate position for alignment. To promote proper
position for alignment.
11. Evaluate patient comfort. To provide comfort.

COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PROCEDURE LIST

MOVING PATIENT TO HEAD OF THE BED

Name: Year & Section: Grade:

LEGEND:
1 - Excellent
2 – Very
Satisfactory 3 –
Satisfactory
4 – Needs Improvement
5 - Poor

E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
I. PREPARATION OF EQUIPMENT
Hospital bed. For equipment use.
II. STEPS
1. Raise the bed to the high position and lower Levels client’s body
the head of the bed. with the bed.
2. Lower the siderail nearest you, explain To elicit cooperation.
procedure to the patient.
3. Remove the patient’s pillow from under the To prevent any
head, remove any others being use for support. injuries.
4. Ask the patient to bend both knees and to To properly positioned
grasp the head of the bed on siderails with both the client.
hands. If the patient cannot assist, asks a
colleague to help you.
5. Position arm under the patient’s shoulders To support client’s
with your other hand, grasp the upper arm, close weight.
the axilla. Keep your spine straight by bending
at the knees and hips.
6. Ask the patient to push with both feet when To help the nurse from
you say “ready”. pushing client’s body
and prepare the client.
7. When the patient pushes, slide the patient To move patient
toward the head of the bed. upward of the bed.
8. Align the patient’s body and place a pillow To ensure client’s
under the head. comfort.

COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PROCEDURE LIST

TRANSPORTING A PATIENT BY WHEELCHAIR

Name: Year & Section: Grade:

LEGEND:
1 - Excellent
2 – Very
Satisfactory 3 –
Satisfactory
4 – Needs Improvement
5 - Poor

E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
I. PREPARATION OF EQUIPMENT
1. Wheelchair To be used by the
2. Robe client and to save time
3. Slippers and energy
II. STEPS
1. Explain procedure. Place wheelchair parallel to To ease anxiety and
bed, with back of the chair toward the foot of the induce cooperation.
bed. For easy access to the
patient.
2. Raise the footrest pedals. To not obstruct the
patient when sitting.
3. Lock the brakes. So that the wheels
won’t slide away.
4. Assist the patient to sit on the bedside. So, patient can easily
don robe and slippers
5. Assist the patient to don robe and slippers. For the patient to
easily wear it
6. Assist the patient to a standing position. To easily sit on
wheelchair
7. Pivot the patient until the backs of the knee So, the patient can
touch the seat of the chair. lower buttocks to
wheelchair without
difficulty
8. Ask the patient to grasp the arms of the chair. To be guided to the
seat
9. Lower the patient into the chair by giving So, the patient won’t
support under the arms. be strained at the knees
from the body weight
10. Position patients’ feet on the footrests, To avoid any injury in
elevate the leg’s rest if indicated. the patient’s feet
11. Release the brakes. So, the wheelchair can
now freely move
12. Push the chair from behind, except when To have control over
leaving a room or entering or leaving an the patient and the
elevator, then pull the chair backward through wheelchair
the door.
13. To assist the patient out of the wheelchair;
a. lock the brakes. - So, the
b. raise the footrests. wheelchair won’t
c. instruct the patient to exert pressure on slide away
the arms rests and push upward into a - So, patient can
standing position. stand on floor
d. pivot the patient toward the bed. - To support the
body weight by
e. assist patient into the bed.
the wheelchair
 - To have body sit
on the bed
- For care of the
patient

COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PERFORMANCE CHECKLIST

TRANSPORTING PATIENT FROM BED TO STRETCHER

Name: Year & Section: Grade:

DEFINITION:
It is the technique utilized when clients need to lie flat during the transfer (e.g. those who are too
weak to sit upright, those who are unconscious, or those with injuries prohibiting the erect position).

PURPOSE:
To transfer client’s safety who need minimum or maximal assistance.

EQUIPMENT:
Transferring a client with minimum assistance
Stretcher
Bed

Transferring a client with maximal assistance

Bed LEGEND:
Stretcher 1 - Excellent
Pillows 2 – Very Satisfactory
Transfer/slider boards 3 – Satisfactory
Lift Sheet 4 –Needs Improvement
Other qualified personnel to assist 5 – Poor

E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
A. PREPARATION OF STUDENT
1. Wash hands. To reduce transmission of
microorganisms.
2. Gather equipment for return demo. To save time and effort.
TRANSFERRING A CLIENT WITH MINIMUM
ASSISTANCE
3. Inform client about desired purpose and To foster cooperation.
destination.
4. Raise the height of the bed to 1 inch higher than For easy accessibility and
the stretcher and lock brake of bed. ensure client’s safety.
5. Instruct client to move the side of bed close to To reduce risk for falling and
stretcher. Lower siderails of bed and stretcher. further injuries.
Leave rails of opposite side up.
6. Stand at outer side of stretcher and push it To close the distance between
towards bed. the bed and the stretcher.
7. Instruct client to move onto stretcher with To ensure client’s comfort and
assistance as needed. prepare the client.
8. Cover client with sheet or bath blanket. To provide privacy.
9. Elevate siderails on stretcher and secure safety To prevent fall and ensure
belts about client. Release brakes of stretcher. client’s safety.
10. Stand at the head of stretcher to guide it when To properly move the stretcher
pushing. and ensure proper body
mechanics.
TRANSFERRING A CLIENT MAXIMUM
ASSISTANCE
11. Repeat step 3 and 4. To foster cooperation and
client’s safety.
12. Assess amount of assistance required for To ensure client’s safety and
transfer. Usually two or four staff members are enough assistance for transfer.
required for the maximum-assisted transfer.
13. Lock wheels of bed and stretcher. To stabilize and prevent falls.
14. Having one nurse stand close to client’s head. To assist and ensure safety of
client.
15. Logroll the client and place a lift sheet under To maintain correct body
the client’s, trunk, and upper legs. The lift sheet can alignment.
extend under the head if the client lacks head
control abilities.
 E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
16. Empty all drainage bags (e.g. T-tube, Hemovac, To prevent drainage spills and
Jackson-Pratt). Record amounts. Secure drainage ensure accuracy of amounts.
system to client’s gown prior to transfer.
17. Move client to edge of bed near stretcher. Lift For easy accessibility in
up over to avoid dragging. moving the client.
18. Because the client is now on the side of the bed, To ensure client’s safety.
without the side rail up, the nurse on nonstretcher
side of bed holds the stretcher side of the lift sheet
up (by reaching across the client’s chest to prevent
the client from falling or off the bed.
19. Place pillow or slider board overlapping the bed To promote comfort and safety.
and stretcher.
20. Have staff member grasp edges of lift sheet. Be For security and prevent falls.
sure to use good body mechanics.
21. On the count of three, have staff members pull For efficiency and safety.
lift sheet and the client onto the stretcher.
22. Position client on stretcher, place pillow under For proper positioning and
head, and cover with a sheet or bath blanket. provide comfort.
23. Secure safety belts and elevate side rails of To ensure client’s safety.
stretcher.
24. If IV pole is present, move it from bed IV pole For easy accessibility.
to stretcher IV pole client transfer.
POST-PROCEDURE ACTIVITY:
25. After care. To maintain cleanliness.
26. Wash hands. Prevent transmission of
microorganisms.
27. Documentation. For future reference.
ATTITUDE OF THE STUDENT
28. Accepts constructive suggestions and To develop positive attitude
criticisms. and learn from mistakes.
29. Assume accountability. To take responsibility with all
actions.

Source:
Daniel, Ricks, Nursing Fundamentals: Caring and Clinical Decision Making.
Thomson Asian Edition, united States: Delmar, 2004, pp. 1212-1214

COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PROCEDURE LIST

CRUTCH WALKING

Name: Year & Section: Grade:

LEGEND:
1 - Excellent
2 – Above
Aberage 3 –
Average
4 – Poor

PROCEDURE RATIONALE 1 2 3 4 REMARKS

I. PREPARATION
1. Identify patient. Proper
identification.
2. Explain the procedure to the patient. To promote client
cooperation.
3. Obtain a pair of crutches, robe and shoes and To avoid further
clear the litters and spills. injury.
II. BEGIN THE PROCEDURE
4. Stand with both crutches in one hand. To obtain
support.
4.1 Take the crutch stance, with crutch tips Proper crutching
approximately 6 inches to side and slightly ahead needs proper
of feet. height to be able
to use properly.
5. Begin Gait.
A. Three-Point Gait.
Teach patient to do the following:
1. Support weight on strong leg. To avoid injury
on the affected
leg.
2. Lift crutches and lift weak leg forward 6 to 12 To support
inches simultaneously. affected leg.
3. Shift weight to crutches. To gain support.
4. Step strong leg forward. To maintain
balance.
5. Shift weight to strong leg. To bear weight.
6. Repeat pattern. For
familiarization.
B. Three-Point-plus-Knee Gait.
(Partial Weight Bearing)
Teach the patient to do the following:
1. Take Crutch stance, with full weight on To bear weight
strong leg and partial weight on weak leg. and maintain
balance.
2. Shift weak leg to strong leg. To bear weight
and give support.
3. Move crutches and affected leg forward 6 to To provide broad
12 inches. base support of
client.
4. Shift weight to hands on crutches with some For weight
weight on affected leg. bearing support.
5. Step strong leg ahead with same size steps. To bear weight
6. Shift weight to strong leg. To obtain support
7. Repeat pattern. For
familiarization.
C. Four –Point Gait
Teach the patient the following:
 1. Take Crutch stance, with full weight on both To bear weight
leg and both crutches. and obtain
support and
balance.
2. Move left crutch forward. To obtain
support.
3. Move right leg forward. To obtain
support.
4. Move right crutch forward. To obtain support
5. Repeat pattern. For
familiarization.
D. Sitting down with Crutches.
Teach the patient to do the following:
1. Walk to the chair. To be ready in
sitting down.
2. Turn around so back is to the chair and back To ensure that
of legs touch the chair. patient will sit
properly on the
chair.
3. Grasp both crutches in one hand. To promote
control and
mobilizing.
 PROCEDURE RATIONALE 1 2 3 4 REMARKS
4. Reach back with free hand and grasp arm of To obtain
chair. support.
5. Lower self into chair using support of both To avoid further
crutches and hand. injury.
III. EVALUATION
1. Check fatigue level of patient. To promote rest.
2. Found out how patient feels. To provide
comfort.

COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PERFORMANCE CHECKLIST

SUCTIONING

Name: Year & Section: Grade:

PROCEDURE RATIONALE 1 2 3 4 REMARKS

PREPARATION:
1. Check the physician’s order and patient’s care plan. To provide
appropriate
intervention.
2. Gather the necessary equipment to the To save time and
bedside of the patient. energy.
a. Suction machine
b. Suction catheter
c. Containers
d. Sterile saline
e. Tongue depressor for oral suctioning
f. sterile gloves
3. Assess the patient’s respirations, skin and mucous Assessing before
membranes, difficulty in breathing, lung sounds, the procedure
ability to cough and procedure sputum and level of provides baseline
consciousness before and after procedure. data. Assessing
after the procedure
is for evaluation
purposes.

4. Wash your hands thoroughly before starting the Reduce

procedure. microorganisms
and prevent cross
contamination.
PROCEDURE: To reduce anxiety,
1. Explain the procedure and rationale to patient promote comfort,
regardless of the patient’s level of consciousness. and gain
cooperation.
2. Position the patient (unconscious or conscious) Provide comfort
appropriately. to the patient and
to have access on
the site.
3. Place the towel over the pillow under the chin. To protect patient
from getting wet.
4. Open the sterile suction package. To reduce
contamination
5. Don the sterile gloves and don a non-sterile glove Sterile to sterile
on the non-dominant hand and then the sterile gloves and unsterile to
on the dominant hand. unsterile. To
maintain sterility
throughout the
procedure.
6. With your sterile gloved hand, pick up the catheter, To prevent
and attach it to the suction unit. contamination of
the catheter.
7. Turn on the suction machine. To start
suctioning
procedure.
8. Make an approximate measure of the To remove
depth for catheter insertion. secretions
a. Oral and nasal suctioning – insert catheter only properly and
two to four inches into the nares or within oral cavity. thoroughly.
b. Pharyngeal suctioning – an approximate
measure is the distance between the tip of the client’s
nose and earlobe or about 13cm to 15cm for an adult.
c. Tracheal suctioning – insert catheter six to
eight inches.
9. Test the suction and the patency of the catheter by To check if the
applying your finger or thumb to the suction control suction is working
and create suction. to remove
secretions
properly.
11. The nurse performs the following steps in: -Ensures that
a. Nasopharyngeal suctioning catheter tip
a.1 Insert the catheter gently through a reaches pharynx
nostril with your thumb away from the suction for suctioning.
control.
a.2 Direct the catheter along the floor
of the nasal cavity. -To remove
a.3 If one nostril is obstructed, try the other. secretions.
a.4 Never force the catheter -To prevent injury.
against an obstruction. -May cause
b. Oropharyngeal suctioning trauma to mucus
b.1 Insert the catheter through the mouth membrane.
along one side into the oropharynx, without applying
suction.
 c. Orotracheal/Nasotracheal suctioning -Allows proper
c.1 Hold the proximal end of the catheter insertion.
close to one ear while the distal end is gently
advanced through the patient’s nose or mouth where - Deep breathing
an increase in breath sound is heard. exercises relieves
c.2 Advance the catheter as patient anxiety.
pants or deep breathes with coaching.
12. Apply your finger to the suction control part and It should not be
gently rotate the catheter 5-10 seconds, then remove more than 10s to
your finger from control and remove the catheter. prevent irritations
and not less than
3s to ensure
secretions are
properly removed.
13. Wipe off the catheter with sterile gauze if it is To rinse the
thickly coated with secretions, flush it with sterile catheter from
water or saline and repeat steps 9, 11, 12, until the air secretions.
passage is clear.
14. If a specimen is required, use sputum trap. For diagnostic
purposes.
15. Offer or assist the client with oral or nasal hygiene To reduce
and place patient in a comfortable position. microorganism
and prevents
contaminations.
16. Dispose the catheter glove, water and waste To prevent cross
container. The catheter can be rolled inside the glove contamination.
for disposal.
17. Ensure that the equipment is available for the next For easy access of
suctioning. materials and
saves time and
energy.
18. Assess the client’s breathing and general status. For evaluation
purposes.
19. Wash your hands. Prevent
contamination and
infections
20. Document all relevant information. For legal
purposes and
continuity of care.

COMMENTS:

Student’s Signature

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PERFORMANCE CHECKLIST

ROUTINE TRACHEOSOMY CARE

Name: Year & Section: Grade:

LEGEND:
EQUIPMENT: 1 - Excellent
Assemble the following equipment or obtain a pre-packed tracheostomy care kit: 2 – Very good
Sterile Towel Sterile gloves 3 – Good
Sterile gauze sponges (12) Hydrogen Peroxide 4 – Fair
Sterile cotton swabs cotton pledgets Antiseptic solution & ointment (optional) 5 –
Poor Sterile water Face shield/Face mask
Tracheostomy tie tapes or Kidney basin
commercially tracheostomy Pipe
cleaners securing devices

PROCEDURE RATIONALE 1 2 3 4 REMARKS

PREPARATORY PHASE
1. Assess the condition of stoma before a tracheostomy To assess if there
care (redness, swelling, character or secretions, and is any infection
presence or purulence of bleeding).
2. Examine neck for subcutaneous emphysema. To be reported to
the physician right
away
PERFORMANCE PHASE
1. Suction the trachea and pharynx thoroughly before Suctioning clears
tracheostomy care. mucus from the
tube and is
essential for
proper breathing
2. Explain the procedure to patient. To reduce anxiety
and involve
cooperation
3. Wash hands thoroughly. Prevents spread of
microorganisms
4. Assemble equipment: To save time and
a. Place sterile towel on patient’s chest under energy
tracheostomy site. To prevent
spillage
b. Open 4 gauze sponges and pour hydrogen peroxide For removal of
on them. mucus which
promotes bacterial
growth
c. Open 2 gauze sponges; keep dry. For final cleansing
d. Open 2 gauze sponges and pour sterile water on For final cleansing
them.
e. Place tracheostomy tube tapes on field. For easy access
f. Put on face shield and sterile gloves. To protect
self/prevent
contamination
5. Clean the external end of the tracheostomy tube with Preserve it from
hydrogen peroxide; discard sponges. handling sterility
6. Clean the stoma area with 2 peroxide soaked gauzed Hydrogen
sponges. Make only a single sweep with each gauze peroxide may help
sponge before discarding. loosen dry
secretions
7. Loose and remove crust with sterile cotton swabs. Ensure hydrogen
peroxide is
removed
8. Repeat step 6 using the sterile water soaked gauzed Ensure that
sponges. hydrogen is
removed
9. Repeat step 6 using dry gauze. Ensure dryness in
the area
10. (Optional) an infected wound may be cleansed with May help clean
gauze saturated with antiseptic solution, then dried. A hard secretions
thin layer or antibiotic ointment may be applied to
stoma with a cotton swabs.
11. With the non-dominant hand, unlock about 90 To remove tangle
degrees counter-clockwise. of
cannula which is
sterile
a. With the non-dominant hand, remove the inner Moistens/loosens
cannula by gently pulling it out towards you. dried secretion
b. Remove the cannula from the soaking solution. Removes
accumulated
secretions
c. Suction the outer cannula. Removes
accumulated
secretions
12. Remove the gloves, and clean the cannula. Prevent
contamination
a. Remove the gloves, and replace them with sterile Maintain sterile
gloves on both hands. technique
 PROCEDURE RATIONALE 1 2 3 4 5 REMARKS
b. Remove the cannula from the soaking Prevent
solution. accidental
dislodgement
c. Clean the lumen and entire inner cannula Rinses the
thoroughly, using the pipe cleaners of brush cannula
moistened with sterile saline.
d. Agitate the cannula for several seconds in Rinses the
the sterile saline. peroxide off the
cannula
e. Inspect the cannula for cleanliness by Rinses the
holding it at eye level and looking through peroxide off the
it into the light. If encrustation are evident, cannula
repeat step 12.
f. After cleansing the cannula, gently tap it Maintain sterility
against the inside of sterile solutions bowl.
13. Dry the inside of the cannula. Completely
remove
secretions
a. Use two or three pipe cleaners twisted Acts as lubricants
together to dry the inside of the cannula. Do
not dry the outer surface.
14. Suction the outer cannula if secretions are Prevents
excessive. adherence in the
tubes
15. Insert the inner cannula, and secure it. To maintain
position securely
a. Grasp the outer flange of the inner cannula To promote easy
and insert the cannula in the direction of insertion
its curvature.
b. Lock the inner cannula in place by turning To maintain
the lock clockwise about 90% to an upright position of the
position. cannula
16. Clean the flange with cotton tripped Prevents
applicators. infection
17. Change the tracheostomy tie tapes. Prevents
contamination
a. Cut soiled tape while holding tube securely Secures position
with the other hand. Use care not only to but of the tube
the pilot balloon tubing.
b. Remove old tapes carefully To promote
sterility
c. Grasp slit end of clean tape and pull through Secure position
the opening on side of the tracheostomy of the tube
tube.
d. Pull other side of the tape securely through Secure position
the slit end of the tape. of the tube
e. Repeat on the other side. Secure position
of the tube
f. Tie the tapes at the side of the neck in a To prevent
square knot. Alternate knot from side irritation and
each rotate pressure
time tapes are changed. site
g. Tights should be fit enough to keep the tube Excessive
securely in the stoma, but loose enough to tightness of the
permit two fingers to fit between the tapes of tapes will
the neck. compress jugular
veins
18. Place a gauze pad between the stoma site and Prevents
the tracheostomy tube to absorb secretions and irritation
prevent irritation of the stoma according to of the mucous
institution policy. membrane
NOTE: If only one clinician is available, the stoma
is new (2 weeks), or the patient’s condition is
unstable, follow steps c through f before removing
tapes. After completing step f, cut and remove the
old tapes.
Also, a tracheostomy-securing device can be used
instead of tracheostomy ties.
FOLLOW-UP PHASE
1. Document procedure, observations of the Provides baseline
stoma (irritations, redness, edema, data and to note
subcutaneous air), and character of any problems that
secretions (color, purulence). Report occur
changes in stoma appearance or secretions.
 PROCEDURE RATIONALE 1 2 3 4 5 REMARKS
2. Cleaning of fresh stoma should be performed Prevent
every 8 hours or more frequently if indicated by contamination
accumulation of secretions. Tie should be changed
every 24 hours or more frequently if soiled or wet.

COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PERFORMANCE CHECKLIST

CHANGING A BOWEL DIVERSION OSTOMY APPLIANCE: Pouching a Stoma

Name: Year & Section: Grade:

INDIVIDUAL REQUIREMENTS:
1. Clinical Learning Experience Manual
2. Student manual
3. Bandage scissors
4. Health kit
5. Waste receptacle
6. Pen/pencil
GROUP REQUIREMENTS:
1. 2 pairs of clean gloves
2. 2 wash cloths
3. 2 pcs. 4x4 gauze pad
4. Hypoallergenic tape
TO BE BORROWED FROM THE LABORATORY:
1. 2 colostomy bags
2. 1 measuring guide
3. 1 wafer
4. 2 small
basins LEGEND:
1 – Excellent
2 – Above
average 3 –
Average
4 - Poor

PROCEDURE RATIONALE 1 2 3 4 REMARKS

1. Determine the need for appliance change. -Remove old
a. Assess the used appliance for leakage pouching to
of effluent. avoid infection.
b. Ask the client about any discomfort at or -if the pouch is
around the stoma. full and is heavy,
c. Assess the fullness of the pouch. Pouches it may cause
need to be emptied when they are one-third to leakage and
one-half full. tension.
*If there is pouch leakage or discomfort at or
around the stoma, change the appliance.
2. Select an appropriate time Change when
bowel is less
✔ Avoid times close to meal or visiting hours. active to prevent
spillage of
contents.
✔ Avoid times immediately after the
administration of any medications that may
stimulate bowel evacuation.
3. Prepare the client and support persons. -Promotes client
a. Explain the procedure to the client and support independence.
persons. Changing an ostomy appliance should not -Educate them to
cause discomfort, but it may be distasteful to the always check
client. appliance and
b. Communicate acceptance and support to the change it with
client. It is important to change the appliance respect to client.
completely and quickly and not to convey disgust. -To promote
c. Provide privacy, preferably in the bathroom, comfort on client
where clients can learn to deal with the ostomy as and respect to
dignity.
they would at home.
 PROCEDURE RATIONALE 1 2 3 4 REMA
RKS
d. Assist the client in a comfortable sitting or lying -Promotes better
position in bed or preferably a sitting or standing evacuation of stools,
position in the bathroom. avoid wrinkles on
e. Don gloves, and unfasten the belt if the client is colostomy.
-Protect self from body
wearing one. fluids; stool.
4. Empty and remove the ostomy appliance. -To avoid spillage of
a. Empty the contents of the pouch through contents.
the bottom opening into a bedpan. -Always check for
b. Assess the consistency and amount of signs of
the effluent. abnormalities.
c. Peel the bag off slowly while holding the -To seal and avoid
client’s skin taut. If the appliance is disposable, bad odor.
discard it in
a moisture proof bag.
5. Clean and dry the peristomal skin. -Promotes hygiene &
a. Use toilet tissue to remove excess stool. comfort.
b. Use warm water, mild soap (optional), and -Avoid using soaps
cotton balls or a washcloth and towel to clean the that are drying to
skin and stoma. Check agency practice on the use prevent irritation to
of soap. the stoma.
c. Use a special skin cleanser to remove dried, -Avoid rubbing as it
hard stool. may cause pain or
d. Dry the area thoroughly by patting with towel or tension.
cotton swabs. - By patting the skin
to dry, it removes
moisture that makes it
difficult
6. Assess the stoma and peristomal skin. -Assess for signs of
a. Inspect the stoma for color, size, shape, infection.
and bleeding. -Check skin for any
b. Inspect the peristomal skin for any abnormalities.
redness, ulceration, or irritation. -Tissue & pads
c. Place a piece of tissue or gauze pad over absorbs spillage.
the stoma, and change it as needed.
7. Prepare and apply the skin barrier (peristomal a. To get
seal). For a solid wafer or disc skin barrier: accurate
a. Use the guide to measure the size of the stoma. measure of the
b. On the backing of the skin barrier, trace a size.
circle the same size as the stomal opening. b. Ensures
c. Cut the traced stoma pattern to make an accurate size
opening in the wafer skin barrier. c. This allows
d. Attach clean pouch to wafer. space for the
e. Remove the tissue over the stoma. stoma to
f. Remove the backing to expose the expand
slightly when
sticky adhesive side.
functioning
g. Center the skin barrier over the stoma, and
and minimizes
gently press it onto the client’s skin, smoothing out the risk of tool
any wrinkles or bubbles. Tape the edges as needed. contacting
peristomal
skin.
d. Necessary that
the pouch is
clean to avoid
transmission
of bacteria.
e. Helps protect
your skin from
stoma output.
f. This allows
the sticky
adhesive side
to expose.
g. Ensures the
 proper way of
placement.

8. Dispose of equipment, or clean reusable equipment. a. To minimize

a. Discard disposable bags in plastic bags the spread of
before placing in the waste container. infection.
b. If feces is liquid, measure its volume b. For future
before emptying the feces into the toilet. reference.
c. Wash reusable bags with cool water and c. To have a
mild soap, rinse, and dry. clean reusable
d. Remove and discard gloves. bag and
prevents the
spread of
infection.
d. To maintain
cleanliness
and prevents
cross
contamination.
9. Report and record pertinent a. To ensure
assessment and interventions. quick response
a. Report to the nurse in charge any increase in or intervention
stoma size, change in color indicative of circulatory needed.
impairment, and presence of skin irritation or b. For future
erosion. references that
b. Record on the patient’s chart discoloration of will help in
the stoma, the appearance of the peristomal skin, ascertaining
the amount and type of drainage, the client’s accurate
fatigue, discomfort, and significant behavior about interventions.
the ostomy, and skills learned. c. Client learning
c. Adjust the teaching plan and nursing care plan as is facilitated
needed. Include on the teaching plan the equipment by consistent
and procedure used. nursing
intervention.
COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PROCEDURE LIST

ASSISTING IN INSERTING NASOGASTRIC TUBE

Name: Year & Section: Grade:

LEGEND:
1 - Excellent
2 – Very
Satisfactory 3 –
Satisfactory
4 – Needs Improvement
5 – Poor
PROCEDURE RATIONALE 1 2 3 4 5
A. ASSESSMENT
1. Check patency of nares and intactness of nasal To ensures accurate placement of
tissues. the nasogastric tube.
2. Check of history of nasal surgery. To assess for any nostril surgery and
abnormal bleeding.
3. Determine mental status or ability to Coughing, Checking and
cooperate with the procedure. displacement may risk and from
pulmonary indicate placement of the
airway.
4. Assess mental status or ability to cooperate To require much cooperation and to
with the procedure. establish rapport to patient.
B. PLANNING
1. Determine the size of the tube. Provide and promote client’s
cooperation.
2. Determine whether or not the tube is to be To reduce transmission of
attached to suction. microorganisms.

C. IMPLEMENTATION
1. Explain to the patient the procedure and To elicit patient’s cooperation.
describe each item.
2. Wash hands and observe other appropriate To reduce the transfer of
infection control procedures. microorganisms.

3. Provide privacy To provide comfort to the patient.

4. Assess the client’s nares.

o Ask the client to hyperextend head To decrease discomfort and
and using a penlight, observe unnecessary trauma.
intactness of nostrils.
o Examine the nares for any
obstructions and deformities.
o Select the nostrils with the greater
airflow.
o Place a towel or disposable pad
across the chest.
5. Prepare the tube.
Rubber tube: Place on ice 5-10 min. Facilitate insertion thus allowing the
Plastic tube: Place in warm water until tube is tube to be stiffened.
softer and more flexible.
6. Determine how far to insert the tube Determine the efficient amount of
o Put on gloves tube needed to reach the stomach.
o Measure starting from the tip of
the earlobe to the tip of the
xiphoid.
o Mark length with adhesive tape if
the tube does not have markings.
7. Insert the tube.
o Lubricate tip of the tube well with water- Approximate length of tube needed
soluble lubricant about 4 inches. to reach the stomach.
o Insert the tube with its natural
curve towards the ear on that side.
o In cooperation with the client, pass tube
5-10 cm (2.4 inches) with each swallow
until the indicated length is reached.
 NURSING
PROCEDURE RESPONSIBILITY RATIONALE 1 2 3 4 REMARKS
8. Check tube placement The small
A. Aspirate 20-30 ml of stomach diameter of some To make sure that
contents. NG tubes may the tube is in the
B. Auscultate the air insufflation by make it difficult line with the
placing a stethoscope over the to hear air stomach
client’s epigastrum or upper left entering the
quadrant and injecting 10-30 ml of stomach
air into the tube listening for:
Whooshing, bubbling and gurgling
sound.
C. Radiographic Verification
9. Secure tube by taping it to the It is very To prevent
bridge of the nose. important to peristaltic
o Cut 7.5 cm (3 inches) of the tape ensure that the movement from
and split it lengthwise at one NG tube is in its advancing the tube
side end, leaving a 2.5 (1 inch) correct place or from the tube
tab at the end. within the unintentionally
o Place tape over bridge of nose stomach because, being pulled out.
and ring split ends either under if by accident the
and around the tubing or under NG is within the
the tubing and back up under trachea, serious
the complications in
nose. relation to the
lungs would
appear.
10. Attach tube to suction machine or Clamp suction For the patient to
feeding apparatus as ordered or clump tubing near site. be comforted
the end of the tubing. Disconnect NG
tube from suction
apparatus and lay
on disposable
pad or towel.
11. Secure tube to client’s gown. NG tube that is Enhance the level
secured to of comfort/allows
client’s nose with easier movement.
tape and pinned
to gown
12. Document relevant information. Drainage from Documentation
o Date and time of insertion of the NG tube is provides accurate
tube, means by which correct measured as record of client’s
placement was determined and output every 8 response to NG
client’s response. hour. If drainage drainage.
is copious,
necessary
emptying of
container is
necessary.
13. Establish a plan for providing Nostrils need Promotes
daily nursing care. cleansing & continuity of care
o Inspect the nostril for lubrication with and shows
discharge and irritation. water-soluble implementation of
o Change the adhesive tape lubricant. Tape intervention
as required. must be changed promotes comfort.
o Give frequent mouth care. when necessary.
Frequent mouth .
care (at 2-hr
intervals)
COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PERFORMANCE CHECKLIST

POST MORTEM CARE

Name: Year & Section: Grade:

Things to bring Things to prepare

1. Set of clean gloves 1. 1 bed sheet
2. Tags with proper label 2. 2 ties
3. 1 face towel
4. 1 top sheet
5. 1 cravat
cotton balls
6. 1 bed
7. 1 pillow

LEGEND:
1 – Excellent
2 – Above
average 3 –
Average
4 - Poor

PROCEDURE RATIONALE 1 2 3 4 REMARKS

1. Wash your hands and wear gloves. To prevent the
spread of
infection.
2. Assemble all equipment and supplies needed in the To save time and
patient’s room/cubicle. effort.
3. Straighten the body, and place a pillow under the To maintain body
head. alignment before
rigor mortis sets
in.
4. Remove all IV lines, monitors, and other To prepare for
equipment, unless ordered otherwise. the procedure.
5. Remove jewelry. If there is a specific order, you Institutional
may tape a wedding ring in place. Carefully document policy will
this. determine the
appropriate
actions to be
done.
6. Close the client’s mouth by placing a rolled towel Placed a rolled
under the chin. towel under the
chin helps the
jaw closed.
7. Bathe any part of the body that has been soiled with To clean patient’s
discharges. body.
8. Remove soiled dressings and replace them with Keep client’s
clean ones. Pad the wrists and ankles and tie them body presentable
loosely together. and clean and
prevent leaving
trauma marks.
9. List all personal belongings and have the family Inventory of
sign for them and take them. Make sure to check the client’s
closet and dresser. belonging is
preliminary prior
to disposition.
10. Send all flowers and cards home with the family. To prevent loss
 when
transporting.
11. If the person’s eyes are to be donated, close them, Maintain body
and place a small ice pack on each eye. A glove with a alignment before
few ice chips works well. rigor mortis sets
in.
12. Give the client’s dentures and glasses to the family Funeral directors
as well. are assigned to
beautify the
client.
13. Remove all extra equipment from the room; Providing
remove all top bed linens but the sheet that covers the environment for
client. the
family/friends to
view.
14. Wrap the body before it is taken to the morgue. Follow policy
and ensure
patient is
properly placed.
a. Attach two tags to the body. One tied toe The policy will
(usually the big toe) and the other to the hand determine how
or wrist. Another may be attached to the the body should
covering sheet. Tags should include patient’s be identified.
name, address, diagnosis, date and time of
death.
b. If a client had a known communicable disease, To provide safety
note this on the cover area. for other
individuals.
 PROCEDURE RATIONALE 1 2 3 4 REMARKS
c. Wash your hands. To prevent the
spread of
infection.
d. Complete the client’s chart, documenting the For
exact time of death and any pertinent observations. documentation
purposes and
reference.
ATTITUDES:
1. Accepts constructive suggestions/criticisms. To encourage
positive attitude
and learn from
mistakes.
2. Assume responsibility of his/her actions. Assumes
accountability.

COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PERFORMANCE CHECKLIST

INSULIN INJECTION

Name: Year & Section: Grade:

LEGEND:
EQUIPMENT: 1 - Excellent
Medication tray containing: 2 – Very Satisfactory
● Alcohol wipes 3 – Satisfactory
● Insulin syringe 4 –Needs Improvement
● Dry cotton balls 5 – Poor
● Medicine ticket
PROCEDURE FOR ONE INSULIN SOLUTION
NURSING E VS S NI P
PROCEDURE RATIONALE
RESPONSIBILITY 1
2 3 4 5
1. Check the medication ticket. Verify from the Ensures accuracy and
doctor’s order. less error
2. Explain the procedure to the patient. Emphasize the To enhance patient’s
importance of the knowledge and promote
therapy. compliance
3. Wash hands. To inhibit the spread of
microorganisms
4. Gather equipment: Obtain specific Recheck for the To obtain correct
insulin syringe for strength of insulin strength of insulin and number of units of
being administered. (U40, U80, U100) specific insulin insulins
syringe.
5. Rotate insulin bottle between hands. Place the insulin bottle To ensure uniform
securely between suspension of insulin
hands.
6. Wipe top of insulin bottle with Remove protective The antiseptic cleanses
alcohol. metal cap, and clean the cap so that the
the rubber cap with needle will remain
alcohol by rubbing in sterile when it is
a rotary motion. inserted
7. Pull plunger of syringe down to a Carefully insert the Air is injected into the
desired amount of medicine and inject needle into that vial vial to keep its content
that amount of air into the insulin through the center of under slight positive
bottle, keeping the level, of the needle the cap, pressure and to make it
above surface of the medication. maintaining sterility easier to withdraw the
insulin
of needle.
8. Draw up ordered amount of insulin Invert the vial and To ensure accuracy of
into syringe and remove needle from hold it at the eye level the correct dosage
vial. while withdrawing the
correct dosage of the
drug into the syringe.
9. Expel air from the syringe. Invert the syringe and To avoid entry of air
gently pushing on the into the site
plunger until a drop of
solution can be seen in
the needle level.
10. Replace needle cap. Pull the cap straight The needle will
off to avoid become contaminated
contaminating the
needle by the outside
edge of the cap.
11. Check medication card, bottle and Coordinate with a fellow To prevent medication
syringe with another nurse for nurse to serve as a witness error
when administering the
accuracy. medication.
12. Double-check site of last injection. Check the previous To make sure that the
last injection site was
 site with the patient. not hit again
13. Wash your hands. To inhibit spread of
microorganisms
 NURSING E VS S NI P
PROCEDURE RATIONALE
2 3 4 5
RESPONSIBILITY 1

14. Document your action. Include time of Produces evidence of

administration, drug nursing care
name, dose, route and
any complaints of the
clients.

PROCEDURE FOR TWO-INSULIN SOLUTION

NURSING E VS S NI P
PROCEDURE RATIONALE
RESPONSIBILITY 1
2 3 4 5
1. Follow steps 1-3 for one insulin Remove the insulin bottle To obtain correct
solution procedure. from the refrigerator, wash procedure
your hands and gather the
materials.
2. Gather equipment: 2 vials of insulin, Recheck for the To obtain the covered
obtain specific insulin syringe for strength of insulin and unit of oxygen
strength of insulin being administered. specific insulin
(U40, U80, U100) syringe.
3. Inspect the appearance of the Also check the expiration Preparation that have
medication for clarity. Some meds are date. Do not use expired changed the appearance
insulin. The solution should be discarded
normally cloudy. should be clear with no
particles. Do not use the
insulin if there are clumps
or particles in it.
4. Rotate insulin bottle between hands. Place the insulin bottle To ensure an adequate
securely between concentration
hands.
5. Wipe top of insulin bottle with Remove protective To maintain sterility
alcohol. metal cap, and clean
the rubber cap with
alcohol by rubbing in
a rotary motion.
6. Insert needle and inject prescribed Carefully insert the Air is injected into the
amount of air into intermediate acting needle into that vial vial to keep the content
or long acting bottle. through the center of under slight pressure
the rubber cap,
maintaining sterility
of the needle.
7. Pull needle out of insulin bottle and Slowly pull on the plunger To ensure accurate
withdraw prescribed regular insulin to draw insulin into the amount of insulin
syringe, pull the plunger to
dosage. the total units of insulin
you need.
8. Inject air into regular bottle and Carefully insert the To keep its content
withdraw medication. Check dose with needle into that vial under slight pressure
another nurse. through the center of and to make it easier to
the rubber cap, withdraw the insulin
maintaining sterility
of the needle.
9. Expel all air bubbles by tapping the As soon as air bubbles To prevent injecting air
barrel. are at the center, push and obtain correct
the plunger a little. dosage of insulin
10. Insert needle into second insulin Turn the bottle and the To prevent the insulin
bottle taking care not to push any syringe upside down. Pull from being injected into
the plunger to fill the the second bottle with
regular insulin into bottle. syringe with just a little contaminated insulin
more of the insulin dose
needed
11. Invert bottle and pull back on Remember the total To obtain correct
plunger to obtain prescribed amount of insulin dose will amount of insulin
insulin. include the amount of
regular insulin already
drawn up into the
syringe.
12. Check the medication ticket, bottle Be certain to give the To verify and avoid
and syringe with patient. correct type of insulin errors
13. Double-check site of last injection Ask the patient as to To avoid insulin site
with patient. the last site of complication
injection.
14. Wash your hands. Lather the hands and To inhibit spread of
vigorously rub them microorganisms
together and rinse with
water.
15. Document your action. Include time of Provides evidence of
administration, drug nursing care
name, dose, route and
any complaints of the
clients.
COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PERFORMANCE CHECKLIST

DIABETIC FOOT CARE

Name: Year & Section: Grade:

EQUIPMENT:
Washbasin Moisture resistant disposable pad
Thermometer to test the water temperature Lotion or foot
powder Soap Toe nail clipper
Washcloth Nail file
2 towels Orange stick

PREPARATION:
1. Determine foot care needs based on the patient’s condition and assessment data.
2. Check the physician’s orders and patient’s care plan. LEGEND:
3. Discuss the procedure with the patient. 1 – Excellent
4. Wash your hands. 2 – Very Satisfactory
5. Collect all the necessary equipment. 3 – Satisfactory
6. Help the patient into a chair in a comfortable resting position if possible. 4 –Needs Improvement
5 – Poor
ASSESSMENT:
1. Inspect for each foot for cleanliness, odor, dryness, inflammation, swelling, abrasions or other
lesions. Carefully check all skin surfaces paying particular attention to the area between the
toes.
2. Assess the status of toenails and surrounding skin.
3. Palpate the bony and muscular structures of the feet and planar surfaces to locate the points
of tenderness.
4. Palpate the anterior and posterior surfaces of the ankles for edema.
5. Palpate the dorsalis pedis pulse on the dorsal surface of the foot just above the longitudinal arch
and compare skin temperature of 2 feet to assess circulatory status.
6. Assess the client’s ability to stand, walk and perform ROM exercises with each ankle and set of toes.

NURSING E VS S NI P
PROCEDURE RATIONALE
2 3 4 5
RESPONSIBILITY 1

1. Assess the feet. To follow assessment Check for any skin

guide. breakdown
2. Fill the washbasin with 40.5*C Do not use water over Warm water provides
150*F, follow better circulation
recommendation
temperature.
3. Assist the ambulatory client to a Explain the procedure Sitting in chair
sitting position in a chair, assist the to the patient to facilitates immersing
person considered to bed to a supine or lessen anxiety. feet in the basin.
semi-fowler’s position as health
permits.
4. Place a pillow under the knees of the Inform the patient Provide foot support
person in bed. before doing this step.
5. Place the washbasin on the moisture Spread the moisture To avoid spillage on
resistant pad at the foot of the bed or for resistant pad evenly. the floor
an ambulatory client on the floor in
front of the chairs.
6. Pad the rim of the washbasin with a Warm the rim of the Prevents undue
towel for the person in bed. washbasin pressure on the skin
7. Place one of the client’s feet in the Pay particular To soften the callouses
basin and soak for at least 10 minutes. attention to the of the foot.
Re-warm the water as needed. interdigital areas.
8. Using a washcloth, gently wash Pay particular Friction removes dead
patient’s feet with soap and water. Rub attention to the skin layer of the body.
calloused areas or the foot with the interdigital areas.
washcloth.
9. Rinse the footwall to remove soap. Remove the soap Soap irritates the
completely skin
10. Remove the foot from the basin and Keep the skin dry and To pat dry and avoid
place it in the towel. moisture free. moisture.
 NURSING E VS S NI P
PROCEDURE RATIONALE
RESPONSIBILITY 1
2 3 4 5
11. Dry each foot gently and Always pat skin dry Harsh rubbing damage
thoroughly, particularly between the to the skin.
toes.
12. Apply lotion or lanolin cream or Apply noncaking body This lubricates dry
foot powder containing a non-irritating powder to areas of the skin and keeps area
deodorant if the foot tends to perspire skin touching each other between the toes dry
excessively.
13. Observes the foot for any problems. Inspect for areas of For assessment
redness and warmth purposes
14. Empty the washbasin and refill it Dispose the water Soaking softens the
with water. Then, soak and then clean properly skin
the other foot.
15. While the second foot is soaking, Cut the toenails straight Soaking softens the
clean and trim the toenails of the first across nails and loosens
foot, if permitted. debris under them
CLINICAL ALERT: Be informed of the
Check policy of the hospital hospital policy To avoid further injury
Re: cutting of nails for clients with toe or complications to the
infections or peripheral vascular patient.
disease. Some health care facilities
require that only a podiatrist can cut
nails.
1. Starting with the large toe out or file Filing the thicken nail is Trimming should be
straight across the nail beyond the end easier than cut it done to avoid injury to
of the toe. If the client has diabetes or the surrounding skin
circulatory problems, file the
nails rather than cut them.
2. Shape the fingernail with a file, Make sure to file the So that there are no
rounding the corners. sharp edges sharp edges that
compromise skin
integrity.
3. Clean under the nail, working from Don’t wound the nail To remove the
one side to the others using the pointed unwanted dirt under
end of the nail file or orange stick. the nail.
4. Proceed to the next toe and repeat Apply accurate To clean the other nails
steps for all toenails. procedure
5. Massage lotion onto the feet, giving Pay attention to the To soften the skin
particular attention to the cuticles cuticles
ordered the nails.
6. Gently push the cuticle back around Remove the dead cells To prevent break of the
the base of the nail using the orange skin
stick.
7. Repeat trimming for the second foot. Apply accurate To clean the other foot
procedure
8. Document any foot problems Important to patients To assess interventions
observed. with diabetes

COMMENTS:

Clinical Instructor’s Signature

Date
 University of Cebu – Banilad
College of Nursing
Cebu City

SKILLS LABORATORY PROCEDURE LIST

Name: Year & Section: Grade:

ISOLATION TECHNIQUE
LEGEND:
1 - Excellent
2 – Very
Satisfactory 3 –
Satisfactory
4 – Needs Improvement
5 – Poor

PROCEDURE RATIONALE 1 2 3 4 REMARKS

I. PREPARATION:
1. Hand washing equipment: To save time and effort.
2. PPE (Personal Protective Equipment) To protect the nurse and
-Bonnet/Disposable cap ensures smooth flow of
- Eyewear/Googles procedure.
- Disposable mask
- Gown
- Clean gloves (3)
- Footwear/Shoecover
II. PROCEDURES:
1. Do medical hand washing. Towel dry. To reduce
microorganisms.
2. Wear personal protective equipment. Wearing PPE protects
Follow the following sequence: the nurse from
--Bonnet/Disposable cap contamination and
- Eyewear/Googles protects the client as
- Disposable mask well.
- Gown
- 1st Clean gloves
- Footwear/Shoecover
FEEDING ISOLATION PATIENT
1. Take a regular tray of food from the food To be used when
service area or to the kitchen to the table outside transferring food.
the entrance door to the patient’s room.
2. Set it next to the patient’s isolation food tray. For easy transfer of
food.
3. Remove the cover from the patient’s tray and Prevent transmission of
drop in hamper. microorganisms.
4. Transfer the food from service tray to the Prevent
patent’s plate without touching the patient’s cross-contamination.
isolating tray.
5. Serve food to the patient inside the isolation To let the patient, eat
room. his/her meal.
6. After the patient is done eating, wash the To maintain cleanliness
dishes at the patient’s sink dry them and put the and prevent
plate back on the isolation tray. contamination.
7. Return the isolation tray to the table outside Ready for next use.
the patient’s room.
8. Remove the clean gloves and discard. Prevent
cross-contamination.
9. Get the clean/new tray lining from the service To prevent
tray and cover the patient’s tray. contamination.
10. Remove the PPE. Reduce spread of
infection.
11. Return the service tray to the kitchen or Adherence to
service area. institutional policy.
12. Do medical hand washing. Reduce spread of
microorganisms.
13. Documentation For future reference.
CARE FOR ISOLATION ROOM WASTE BY
DOUBLE BAGGING:
1. Do medical hand washing. To reduce transmission
of microorganisms.
2. Wear PPE, 2nd set of gloves. Prevent spread of
infection.
 E VS S NI P
PROCEDURE RATIONALE
1 2 3 4 5
3. Remove the contaminated bag by touching the Reduce the possibility of
outer portion of the bag, roll and tie. transmission.
4. Bring the contaminated bag and throw it on the To avoid spread of infection.
trash bag outside the patient’s unit.
5. Touch the inner portion of the trash bag leaving Prevent contamination.
it widely open.
6. Remove PPE (clean gloves, bonnet, eyewear, Prevent the spread of infection.
mask, shoe cover, gown) and throw it on the trash
bag.
7. Touch the outer portion of the trash bag, roll and To prevent spills and drainages.
tie.
8. Put isolation tag/sign on the trash bag and place For correct identification.
in proper disposal container for contaminated
items.
9. Do medical hand washing. Reduce transmission of
microorganisms.
10. Documentation. For future reference.
CARING FOR ROOM WHEN ISOLATION
ENDS
1. Do medical hand washing. Reduces transmission of
bacteria.
2. Wear PPE, 3rd set of gloves. Prevent the spread of infection.
3. String all washable articles (rubber sheet, Kelly For disinfection purposes.
pad etc.) soak in germicide, wash and hang. Air dry
and expose to sunlight if possible.
4. Throw away all articles used by the patient such To avoid contamination and
as toothbrush, soap, toilet paper, toothpaste, transmission of infection.
newspaper, etc. Valuable items left behind like
jewelries, gadgets, etc. place in plastic bag and
endorsed to the nurses’ station.
5. Disinfect the bed by spraying or wiping with a To prevent spread of infection.
disinfectant solution and air out to dry.
6. Disinfect the whole unit from ceiling, walls and To prevent transfer of infection.
floor with a disinfectant solution and air dry.
7. In some institutions, disinfectant bombs Fumigation aids in the
(available in drugstores) are being used. After decontamination of the whole
thorough cleaning close the windows, throw the unit.
disinfectant bomb, close the door then seal the door
with a tape. This process is called FUMIGATION.
The fumes stays inside the room and
decontaminates the room and its furnishings.
8. Close the door for 24 hours and open the To lessen odor.
windows to air the room for another 24 hours.
9. Remove PPE. Prevent the spread of infection.
10. Do after care. To maintain cleanliness.
11. Do medical hand washing. Reduce transfer of
microorganisms.
12. Documentation. For future reference.
TAKING OF ISOLATION GOWN
Note: If the gown is soiled drop in isolation Prevent the spread of infection.
hamper.
If gown is dry and clean hang it back on the hook / To be ready for the next
hanger. Do the following steps: procedure.
1. Untie the waist tie and let it drop on the side. Prevents contamination and
contact with unsterile filed.
2. Untie the neckline and remove the gown by To avoid contamination from
touching only the inside portion. unsterile surfaces.
3. With your dominant hand reach for the inner Prevent contamination of the
portion of the sleeves of the gown and remove, do gown.
the same on the other side.
4. Hang the gown on the hook (inside out). Preparation for next use.
5. Do medical hand washing. Prevent transfer of infection.
6. Documentation. For future reference.
ATTITUDE
1. Accept constructive suggestions/criticisms. Develop positive attitude.
2. Assume responsibility of his/her actions. To be accountable with all
actions.
COMMENTS:

Clinical Instructor’s Signature

Date
 College of Nursing

NAME: DATE:
AGE: SEX:

CONSENT

Permission is hereby granted to , my practicum partner to perform

VENIPUNCTURE as part of the practicum on my on-going IV THERAPY TRAINING being
conducted by the University Of Cebu College Of Nursing.

It is understood that I will not hold my practicum partner liable nor University Of Cebu faculty and
staff for the pain, discomfort or any adverse effects accompanying the procedure.

The undersigned certifies that I have read the foregoing agreement and is voluntarily giving my
consent.

Signature over printed name

 College of Nursing

PRACTICUM

PROCEDURE

Name of Student: Level & Section: _

Direction:
The checklist aims to evaluate the student nurses performance in cannulation. Check the appropriate score
in the proper column denoting the extent to which student nurses demonstrated or observed the procedures.

Use the following scoring guide:

1 – Excellent 3 – Average
2 – Above Average 4 – Poor

Things to prepare:
1. IV Cannulation gauge 22
2. Q-style (heparin lock or needleless port – BD Q-style, 3ml)
3. IV Starter Pack
- Alcohol Swab
- Tourniquet
- TSM dressing (Transparent)
- Sterile Gauze
- Pre-filled NSS (Posiflush)
- 1 inch plaster (hypoallergenic)
4. Non-sterile Gloves
\
I. ONE – ON – ONE IV INSERTION
STEPS 1 2 3 4 REMARKS
1. Verify the written prescription for IV therapy;
check prepared IVF and other things needed.
2. Explain the procedure to reassure the patient and
significant others and observe the ten (10) rights.
3. Obtain patients consent.
4. Do hand hygiene before and after procedure.
5. Do non-sterile gloves.
6. Choose site for IV.
7. Apply tourniquet 2-6 inches above injection site
depending on condition of the patient.
8. Check for radial pulse below tourniquet.
9. Disinfect the insertion site with alcohol swab.
10. Using the appropriate cannula. Pierce skin with the
correct technique.
11. Upon backflow visualization, continue inserting
the catheter into the vein.
12. Position the IV catheter parallel to the skin.
13. Hold stylet stationary and slowly advance the
catheter until the hub meets the site.
14. Do the H-Taping Method.
15. Slip sterile gauze under the hub. Release the
tourniquet; remove the stylet while applying digital
pressure over the catheter with one finger about 1-2
inches from the tip of the inserted catheter.
16. Connect the needleless port (Qsyte) aseptically to
the IV catheter.
17. Dress the Site with TSM, anchor properly.
18. Disinfect injection port.
19. Flush and LOCK using pre-filled NSS (Posiflush)
20. Discard sharps and waste according to Health Care
Waste Management (DOH/DENR)
COMMENTS:

Preceptor’s Name and Signature Date:

 POVIDONE IODINE TSM DRESSING
SWAB STICK (TRANSPARENT)

STERILE
GAUZE

ALCOH 1 INCH PLASTER

OL TOURNIQUET (HYPOALLERGENIC)
SWAB
 IV
CANNULATION
GAUGE 22