Major Scrub PRS For Simulation - VCP

Republic of the Philippines
Cebu Normal University

Osmeña Blvd., Cebu City, 6000, Philippines
College of Nursing
Telephone No.: (+63 32) 254 4837
Email: cn@cnu.edu.ph
Website: www.cnu.edu.ph
Performance Rating Scale

_____ INTRAOPERATIVE MAJOR SCRUB
Name of Student: _________________________ Level and Section: __________

Instructions: Please rate the student’s performance as PERFORMED or NOT PERFORMED in the
competency column and write down your comments for any additional remarks.
A. PRELIMINARY PREPARATIONS
Performed Not Performed
Criteria Remarks
(1) (0)
1. Reports to the assigned OR after endorsement.
2. Cleans and disinfects the assigned operating
room.
3. Prepares the following:
3.1. Linen Pack
3.2. Instrument Set
3.3. Sutures
3.4. Paraphernalia
3.5. Equipment
4. Observes/Assists the circulating staff
nurse/clinical instructor in opening the pack or
drapes on the back-up table.
B. SURGICAL HAND SCRUBBING
Criteria Remarks
(1) (0)
1. Keeps skin and nails clean and removes finger
jewelry
2. Makes sure hair is covered by headgear. Hair
studs should be covered.
3. Adjust disposable mask snugly and comfortably
over the nose and mouth.
4. Adjusts eyeglasses in relation to mask.
5. Adjusts faucet and flow of water. Performs
medical hand washing as a pre-scrub wash.
6. Applies antimicrobial solution on the palm and
produces lather.
Certification Date: 1 February 2021

Recertification due date: 24 January 2024
For verification of the certificate please
access www.gcl-intl.com (Certification Page 1 of 7
check and type the registration number)
Registration No. 52Q18778

College of Nursing
Telephone No.: (+63 32) 254 4837
7. Lathers finger tips with soap evenly then, rub

the spaces under the fingernails.
8. Lathers digits; in circular manner on all four
sides of each finger.
9. Lathers palm, back of hand, heel of hand, and
space between thumb and index finger.
10. Continues to lather in rotating motion down the
arm extending below the elbow.
11. Repeats the process on the opposite arm.
12. Adds solution anytime to ensure adequate
lather.
13. Rinses hands and arms without retracing and
or contaminating.
14. Slightly bend forward, keeps hands and arms
above the elbow, and arms away from the
body. *
15. Allow the water to drip from the elbows before
entering the operating room.
C. GOWNING
Criteria Remarks
(1) (0)
1. Slightly bends forward, picks up the surgical
gown from the top of the surgical packs. *
2. Steps back away from the sterile table to
provide a wide margin of safety and holds the
gown at the shoulder level.
3. Dry all sides of the fingers, the forearm, and the
arm thoroughly excluding the elbows.
4. Grasps the two (2) armholes of the gown with
one hand.
5. Carefully spread the gown keeping the inside
part of the gown towards the body. *
6. Inserts the hands and arms into the sleeves of
the gown without exposing the bare hands.
7. Avoids touching the front part of the gown with
bare hands.*
8. Prevents exposing the ungloved hand outside
the gown cuffs. *


College of Nursing
Telephone No.: (+63 32) 254 4837
9. Requests circulating nurse to fasten the gown

at the back.
10. Prevents the gown from touching the floor and
other non-sterile surfaces.
D. GLOVING
Criteria Remarks
(1) (0)
1. Gloves the dominant hand first. Picks up the
correct glove and places it on the palm.
2. Through the gown, grasps the folded cuff of the
gown with the thumb of the non-dominant
hand.
3. While gripping the glove, makes a fist and
stretches the cuff over the hand, aiming to
cover the knuckles and thumb just before
straightening the fingers of the dominant hand.
4. With the gloved dominant hand, picks the other
glove and places it on the wrist of the non-
dominant hand.
5. Through the gown grasp the folded cuff of the
gown with the thumb of the dominant hand.
6. While gripping the glove, make a fist and
stretch the upper cuff over the hand aiming to
cover the knuckles and thumb just before
straightening the fingers of the non-dominant
hand.
7. Pull the glove over the gown and adjust to give
a good fit ensuring the gown cuffs remains
above the wrist.
8. Prevents exposing the bare hands during the
entire process. *
9. Avoids touching the inside part of the gloves
that came in contact with bare hands. *
E. PREPARATION OF THE BACK-UP TABLE AND MAYO TABLE


College of Nursing
Telephone No.: (+63 32) 254 4837

Criteria Remarks
(1) (0)
1. Arranges the sterile linens and paraphernalia
on the back-up table:
1.1. Gowns and drapes *
1.2. Gloves
1.3. Operating sponges and visceral packs
1.4. Other paraphernalia
2. Places a sterile lining (as appropriate) on the
back table and creates a pillow for the
instruments.
3. Carefully transfers the sterile instruments from
the container to the back table following proper
placement.
4. Detaches the “locked instruments”
5. Arranges the instruments appropriately in the
back-up table:
5.1. Forceps *
5.2. Sharps *
5.3. Retractors *
5.4. Basins *
5.5. Additional instruments
6. Prepares/attaches the additional paraphernalia
as applicable:
6.1. Surgical scalpel *
6.2. Loaded suture (attached to needle
holder) *
6.3. Stick tie *
6.4. Sponge stick *
7. Covers the mayo table with a sterile
drape/cover.
8. Arranges the instruments appropriately in the
mayo table:
8.1. Sharps
8.2. Forceps


College of Nursing
Telephone No.: (+63 32) 254 4837
9. Proceeds with first official counting together

with the Circulating nurse. *
F. GOWNING THE SURGEON AND ASSISTANTS
Criteria Remarks
(1) (0)
1. Picks up sterile gown and serves the lower
hemline to the surgeon and/or assistants for
drying their hands. *
2. Unfolds the gown carefully and locates the
landmarks then offers the wrong side (inside) of
the gown to the surgeon and/or assistants. *
3. Releases the gown making sure that it is
properly served while maintaining appropriate
distance from the person being gowned.
4. Avoids touching the part used to dry the hands.
*
G. GLOVING THE SURGEON AND ASSISTANTS
Criteria Remarks
(1) (0)
1. Picks up the right glove (left if the surgeon is
left-handed), grasps firmly the glove with four
fingers under elevated cuff. Holds the palm of
the glove toward the surgeon.
2. Stretches the cuff sufficiently for the
surgeon to insert by pointing thumbs outward. *
3. Unfolds the inverted glove cuff over the cuff of
the sleeves.
4. Repeats the procedure for the other hand.
H. DRAPING THE CLIENT
Criteria Remarks
(1) (0)
1. Passes the two (2) draw sheets to the surgeon
or assistant.
2. Hands over 1 towel drape to the surgeon or
assistant.
3. Passes the towel clips immediately after the
towel drapes*


College of Nursing
Telephone No.: (+63 32) 254 4837
4. Passes the large sheet (Top sheet) to the

surgeon or assistant
5. Carefully assist the circulating nurse in
positioning the mayo table and back-up table.
6. Maintains appropriate distance from the
undraped patient and unsterile surfaces in
passing the drapes and instrument. *
I. ASSISTING THE SURGERY
Criteria Remarks
(1) (0)
1. Counts the operating sponges in front of the
surgical team prior to cutting. (If applicable)
2. Hands in 2 operating sponges to the surgeon.
3. Hands the surgical knife (placed in the kidney
basin) to the surgeon.
4. Anticipates the surgical team’s needs.
5. Conducts intraoperative counting of sponges,
sutures and instruments. *
6. Maintains sterility all throughout the procedure.
*
7. Keeps the back-up table and mayo table clean
and organized.
J. AFTER CARE
Criteria Remarks
(1) (0)
1. Without removing the gloves and gown,
gathers and sorts all the instruments.
2. Removes and disposes all sharp materials.
3. Washes all the instruments used.
4. Soaks / Oils the instrument as applicable
5. Thoroughly dries the instruments.
6. Arranges the instruments and places the
indicator.
7. Requests the circulating staff nurse to check
the instruments.
Legend: * Critical competencies must be accomplished/performed. Failure to do so would mean a repeat performance for the student. The
inability to successfully pass the procedures will prevent them from assisting in the actual clinical duty and OR simulations (PRC required case).


College of Nursing
Telephone No.: (+63 32) 254 4837
Competent Advanced Beginner Novice

(86-100%) (70 – 85%) (<70%)
Description reflecting Description reflecting
Description reflecting beginning
achievement of mastery level of movement toward mastery level
level of performance
performance of performance
(Score of 62 or less)
(Score of 77-90) (Score of 63-76)
Performance of Items in the
Performance of Items in the Performance of Items in the
Procedural Checklist
Procedural Checklist Procedural Checklist
Total Score: ________ Description of Student’s Skill Competency: __________________________
Note: Students are expected to attain at least the level of being an advanced beginner for the case to be
credited as part of the PRC requirements. For return demonstrations, rate only procedures A to G. However,
for OR simulations and actual clinical OR cases, kindly rate procedures A to J.
_____________________________________
Signature and Name of Clinical Instructor


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Republic of the Philippines

Cebu Normal University

Performance Rating Scale

Name of Student: _________________________ Level and Section: __________

Certification Date: 1 February 2021

Registration No. 52Q18778

7. Lathers finger tips with soap evenly then, rub

Certification Date: 1 February 2021

Registration No. 52Q18778

9. Requests circulating nurse to fasten the gown

Certification Date: 1 February 2021

Registration No. 52Q18778

Performed Not Performed

Certification Date: 1 February 2021

Registration No. 52Q18778

9. Proceeds with first official counting together

Certification Date: 1 February 2021

Registration No. 52Q18778

4. Passes the large sheet (Top sheet) to the

Certification Date: 1 February 2021

Registration No. 52Q18778

Competent Advanced Beginner Novice

Total Score: ________ Description of Student’s Skill Competency: __________________________

Certification Date: 1 February 2021

Registration No. 52Q18778

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Name of Student: _______________ Level and Section:

Total Score: Description of Student’s Skill Competency: __________________