NCMB 312 Rle or Performance Checklist PDF

OUR LADY OF FATIMA UNIVERSITY
QUEZON CITY
Name: Section & Group:
PERFORMANCE CHECKLIST
SURGICAL SCRUB
4 3 2 1
1. Gather materials to be used.
2. At the surgical sink, wet arms, hands and elbows.
3. Maintain hands in upright position.
4. Apply soap and rub hands and arms up to 3 inches above
elbows.
5. Rinse both hands and arms.
6. Get a brush. Rinse brush and apply soap.
7. Brush your non-dominant hand by your dominant hand,
starting from the fingertips and nails in circular motion.
8. Fingertips and nails, 30 strokes. All sides of each fingers, 20
strokes, palm 20 strokes, side of the hand 20 strokes, back of
the hand 20 strokes.
Arms: for each third of the arm 20 strokes, 3 inches above the
elbow 20 strokes, elbow 20 strokes.
9. Rinse brush thoroughly and reapply soap.
10. Brush your dominant hand by your non-dominant hand. Follow
step no. 8.
11. Rinse brush, hands and arms. Be careful not to touch any part
of the sink and faucet.
12. Drop the brush into the sink.
13. Keep arms flexed and proceed to the area with sterile field.
TOTAL: ______ /52
Scale:
4 – Exemplary (Competent and Independent)
3 – Proficient ( Requires minimum guidance)
2 – Satisfactory (Requires frequent guidance)
1 – Developing (Requires close guidance)
Grade:
Signature over Printed Name of Clinical Instructor
Date:
QUEZON CITY
DRYING HANDS AFTER SURGICAL SCRUBBING

4 3 2 1
1. When picking up the towel, do it with a swift, efficient motion.
2. Take the towel in the middle, being careful not to contaminate
the sterile gown under it.
3. Bend at the waist to help prevent the sterile towel from
touching the unsterile gown while drying your hands and arms.
4. Dry hand to mid-lower arm, then transfer dry end of towel to
other hand.
5. Do not dry hand then arm and return to same hand.
6. After the second hand and mid-lower have been dried, fold
towel in thirds and dry elbows.
7. Be sure hand is well covered. When transfer of towel is made
from hand to hand, do not allow hand to touch where elbow
has touched.
8. Discard towel in linen hamper.
TOTAL: ______ /32
Scale:
Grade:
Date:
QUEZON CITY
CLOSED GOWNING AND GLOVING

4 3 2 1
1. Maintain sterility of gown and gloves during the entire
procedure.
2. Grasp the gown and step backward.
3. Allow the bottom part of the gown to fall.
4. Dry handle and arm using the bottom part of the gown.
5. Open the gown and slip both arms in the gown simultaneously.
6. Keep your hands inside the sleeves of the gown. The circulating
nurse will secure the ties of the gown.
7. With hands still inside the sleeves, open the wrapper of the
sterile gloves already placed in the sterile field.
8. With your dominant sleeved hand, place the palm of the non-
dominant hand glove against the sleeved palm of the non-
dominant hand.
9. Grasp the cuff of the glove with your non-dominant hand. With
your dominant hand, turn the cuff over the end of the non-
dominant hand and gown’s cuff.
10. Slowly extend the fingers into the glove while holding the
glove and the gown cuffs.
11. With the gloved non-dominant hand, repeat steps 8 – 10.
12. Interlock your gloved fingers to fit the gloves.
TOTAL: ______ /48
Scale:
Grade:
Date:
QUEZON CITY
DRAPING THE MAYO STAND, COUNTING AND HANDLING OF SURGICAL INSTRUMENTS

4 3 2 1
1. Drape the Mayo stand; hands are protected in cuff of the
drape.
2. Folds of drapes are supported on arms, in bend of elbows to
prevent their falling below waist level.
3. Hold the drapes high until it is directly over the proper area.
4. Place foot on base of the stand to stabilize it.
5. Place and arrange the sterile instruments in proper order,
according to the specific surgery and surgeon’s requirement.
6. Insert the scalpel blade on a knife handle, holding it downward,
grasp and slip the blade into the groove of the handle.
7. Counting of sponges, surgical needles, blades and instruments
as the circulating nurse stands to counter check the counting.
8. Hands, instruments, sponges, sutures and other needed
materials according to surgeon’s preference.
TOTAL: ______ /32
Scale:
Grade:
Date:
QUEZON CITY
GOWNING AND GLOVING ANOTHER PERSON

4 3 2 1
1. Unfold the gown, holding it at the neckband.
2. Keep the hands on the outside part of the gown under the
protective cuff and shoulder area. Offer the inside of the gown
to the surgeon. The surgeon slips into the sleeves.
3. Release the gown. The surgeon holds arms outstretched while
the circulating nurse pulls the gown into the shoulders and
adjust the sleeves and cuffs.
4. Get the right glove, grasp it firmly with the fingers under the
everted cuff.
5. Hold the palm of glove toward the surgeon.
6. Stretch the cuff sufficiently for the surgeon to insert the hand.
Avoid touching the hand by holding your thumbs out.
7. Exert upward pressure as the surgeon plunges the hand into
the gloves. Unfold the everted glove cuff over the cuff of the
sleeve.
8. Repeat for the left hand.
TOTAL: ______ /32
Scale:
Grade:
Date:
QUEZON CITY
The gown is always removed before the gloves. It is pulled downward from the
shoulders turning the sleeves inside out as it is pulled of the arms.
REMOVING GOWN AND GLOVES AFTER OPERATION

4 3 2 1
1. With gloves on, loosen cuffs of gown and shake them down
over wrists.
2. Then grasp right shoulder of gown (untied) with left hand.
3. Pulling the gown, off arms, turn arm of gown away from body
with flexed elbow.
4. Then grasp the other shoulder with the other hand and remove
gown entirely, pulling it off inside out, thus arms are kept
clean.
5. Glove to glove technique – with the gloved right hand, remove
the left glove by holding it at its outer surface and pull-off.
6. Skin to skin technique – to remove the right glove, insert your
thumb or three fingers between the skin and the gloves.
TOTAL: ______ /24
Scale:
Grade:
Date:
QUEZON CITY
GLOVING
4 3 2 1
1. Be sure that fingernails are short. Remove jewelries.
2. Wash and dry hands.
3. Maintain the sterility of the gloves during the entire procedure.
4. Remove the package from the outer wrapper. Place the
package on a clean dry surface.
5. Open the package by pulling the corners of the wrapper.
6. Identify the right and left gloves. Glove dominant hand first.
7. Get the first glove by grasping the folded cuff with the thumb
and first two fingers of the non-dominant hand, touching only
the cuff.
8. Slip in your dominant hand on the glove. Hold hand above
waist level.
9. Using the gloved dominant hand, slip your fingers under the
cuff of the other glove.
10. Slip the glove onto non-dominant hand.
11. Interlock the fingers of your gloved hands to fit the gloves
onto each finger.
12. If gloves are soiled, remove as follows: Using the fingers of
your dominant hand, grasp the outer part of the glove at the
wrist.
13. Pull the glove down to the fingers (glove to glove).
14. Slip the ungloved fingers of your non-dominant hand under
the glove of your dominant hand (skin to skin).
15. Pull and remove the glove.
16. Dispose soiled gloves and wash hands.
TOTAL: ______ /64
Scale:
Grade:
Date:

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OUR LADY OF FATIMA UNIVERSITY

Name: Section & Group:

Name: Section & Group:

DRYING HANDS AFTER SURGICAL SCRUBBING

Name: Section & Group:

CLOSED GOWNING AND GLOVING

Name: Section & Group:

DRAPING THE MAYO STAND, COUNTING AND HANDLING OF SURGICAL INSTRUMENTS

Name: Section & Group:

GOWNING AND GLOVING ANOTHER PERSON

Name: Section & Group:

REMOVING GOWN AND GLOVES AFTER OPERATION

Name: Section & Group:

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