Rubrics All

Name: __________________________________ Yr.& Sec. __________Date: _________ C.I.
_____________
HANDWASHING RUBRICS
CRITERIA
4 3 2 1
Proficient Approaching Developing Beginning Rating
proficiency
PROCEDURE Independently Performs skills Performs Performs
performs all with skills with skills with
skills fluently assistance of assistance of assistance of
and without faculty 1 - 2 faculty 3 - 4 faculty
difficulty. times during times during greater than
simulation. simulation 4 times
during
simulation
PREPARATION
ASSESSMENT:
1. Check that nails are filed short.
2. Check hands for breaks in the

skin, such as hangnails or cuts.
3. Remove all jewelry.
PLANNING
4. Assemble equipment needed.
IMPLEMENTATION:
5. Stand in front of the sink,
keeping hands and uniform away
from sink surface.
6. Turn on the water and adjust

the flow.
7. Hold the hands lower than the

elbows.
8. If soap is liquid; apply 2-4 ml

(1 tsp.). If it is bar soap, rub it
firmly between the hands to
remove its outer layer.
9. Lather hands well then drop bar

soap without touching the sink or
the soap dish.
10.Thoroughly wash and rinse the
hands. Use firm, rubbing and
circular movements.
a. Rub hands palm to palm;
b. Right palm over the left
dorsum with interlaced
fingers and vice versa
c. Palm to palm with fingers
interlaced
d. Back of fingers to opposing
palms with fingers
interlocked;
e. Rotational rubbing of left
thumb clasped in right palm
and vice versa
f. Rotational rubbing,
backwards and forwards
with clasped fingers of right
hand in left palm and vice
versa.
11.Rinse hands thoroughly.

Duration of the hand wash 15-20
seconds. (Steps a-f)
12.Turn off water flow using foot

or knee pedals. Use clean, dry
paper towel to turn off hand
faucet. Avoid touching with hands.
13.Thoroughly dry the hands from

fingers to forearm by blotting
paper towel on the skin.
14.Discard the paper towel in the

appropriate container
EVALUATION:
15.Hand washing procedure
performed at recommended time
duration. Duration of the entire
procedure 40-60 seconds.
TOTAL POINTS: 60
____________________________________________
Signature over Printed name of the Student
____________________________________________
Signature over Printed name of the Clinical Instructor
Prepared:
Marie Christine N. Mercado, RN, MAN, Ed.D
Level II – RLE Coordinator
Noted:
Jill Marie C. Hermogenes, RN, MAN, Ed.D
Assistant Dean
Approved:
Michelle B. Yu, RN, MAN, DM
Dean
Name: __________________________________ Yr.& Sec. __________Date: _________ C.I. _____________
STERILE OPEN GLOVING RUBRICSSkills
CRITERIA
4 3 2 1
Proficient Approachin Developing Beginning Rating
g
proficiency
PROCEDURE Independently Performs Performs Performs
performs all skills with skills with skills with
skills fluently assistance of assistance of assistance
and without faculty 1 - 2 faculty 3 - 4 of faculty
during
simulation
Initial Steps
1. Performs hand hygiene .
2. Checks that the sterile glove

package is dry and unopened.
3. Notes package expiration date,
making sure that the date is still
valid.
Procedure Preparation
1. Places the sterile glove package
on a clean, dry surface at or above
your waist.*
2. Opens the outside wrapper by

carefully peeling the top layer back.
3. Removes the inner package,
handling only the outside of it.
4. Places the inner package on the
work surface with the side labeled
“cuff end” closest to the body.
5. Carefully opens inner package
Open Packaging & Prep

Application
1. Folds open top flap, then bottom
and sides.
2. Is careful not to touch inner

surface of the package or the
gloves.
3. Using the thumb and forefinger of
the non-dominant hand, grasps the
folded cuff of the glove for the
dominant hand, touches only the
exposed inside of the glove.
4. Keeps the hands above the
waistline, lifts and holds the glove up
and off the inner package with
fingers down and steps back away
from the sterile field.
5. Glove does not touch any
unsterile objects.
Don Sterile Gloves
1.Carefully inserts dominant hand

palm up into glove, pulling glove on.
2. Holds thumb of gloved hand

outward. Places fingers of gloved
hand inside cuff of the remaining
glove, lifting it up and back from
sterile field, taking care not to touch
anything with the gloves or hands.
3. Carefully inserts non-dominant
hand into glove, pulling glove on and
ensuring the skin does not touch
any outer glove surfaces.
4. Adjusts gloves if necessary,
touching only sterile areas with
other.
Remove Sterile Gloves
1. Grasps the palm of the first glove
without touching contaminated
surfaces with clean surfaces
2. Gently pulls glove off, holds it in
the palm of the remaining gloved
hand.
3. Slides bare fingers inside the cuff
of the remaining glove without
touching the glove exterior.
4. Peels the glove off from the
inside, using it to envelope the other
glove.
5.Discard gloves in appropriate
container and wash hands.
TOTAL POINTS: 88
____________________________________________
____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean
ASSESSING VITAL SIGNS RUBRICS
CRITERIA
4 3 2 1
g
proficiency
during
simulation
INITIAL STEPS
1. Identify the patient. Discuss

procedure with patient and assess
patient’s ability to assist with the
procedure.
2. Prepare all the equipment needed
and ensure they are all in good
condition.
3. Provide privacy.
4. Perform hand hygiene.
BODY TEMPERATURE
1. Helps the client to assume a

position of comfort for axillary
temperature.
2. Takes the thermometer out of its

holder.
3. Turns on the thermometer and

places it in the armpit.
4. Removes the thermometer when

it beeps and reads at the digital
display.
5. Cleans the thermometer using

alcohol swabs before placing it
back.
6. Places the thermometer back in

its holder.
PULSE
1. Positions the client so that his

arms are relaxed and supported
2. Places fingertips index and
middle finger on the inner surface of
the wrist. (radial artery)
3. Compresses the artery gently on
the thumb side of the wrist against
the adjacent bone so that the client’s
pulsating artery can be felt distinctly.
4. Using a watch with a second

hand count the number of pulsation
for one full minute.
RESPIRATION
1. Assumes the same position in

taking pulse rate.
2. Keeps fingertips in place after
counting the pulse, but note the rise
and fall of the client’s chest with
each inspiration and expiration
without patient’s awareness
3. Counts the number of respirations
for one full minute.
BLOOD PRESSURE
1. Assists patient assume a correct

position
2. Removes or rearranged clothing
to expose the area where the cuff
will be applied
3. Extends the arm with the palm

facing upward
4. Places the cuff approximately 1-2

inches above the inner aspects of
the elbow with bladder over the
brachial artery.
5. Arranges the manometer gauge

at eye level
6. Palpates the brachial artery or

radial pulse by pressing gently with
the fingertips. Tighten the screw
valve on the air pump and Inflate the
cuff while continuing to palpate the
artery. Note the point on the gauge
where the pulse disappears. Deflate
the cuff and wait for 15 seconds.
7. Place the stethoscope earpieces

in the ears properly. Then position
the diaphragm of the stethoscope
firmly but with as little pressure as
possible over the artery where the
pulse is felt. Do not allow the
stethoscope to touch clothing or the
cuff.
8. Pump the pressure 30 mm Hg

above the point at which the pulse
disappeared.
9. Note the point on the gauge at

which there is an appearance of the
first faint, but clear, sound, which
slowly increases in intensity. Note
this number as the systolic pressure.
Read the pressure to the closest
even number.
10. Releases air entirely from the
cuff and remove the cuff from
patient arm
AFTER PROCEDURE
2. Records the temperature,

respiratory rate, pulse rate and
Blood Pressure reading on a flow
sheet and indicate the time. Report
any abnormal findings to the
appropriate person.
TOTAL POINTS: 116
____________________________________________
____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean
TEMPERATURE PULSE AND RESPIRATION RATE CHART
Patient Name: __________________________________________ Attending Physician: ________________________________________
Age: _______ Sex: _______ Room No. /Bed No. ___________ Hospital Unit No. ____________________________________________
Day of
Hospitalization
Post-Operative
Day No.
Date
RR PR Temp 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12
150 41
140 40
130
39
120
38
110
37
100 36
90 35
80
70 70
60 60
50 50
40 40
30 30
20
10
BLOOD PRESSEURE
6-2
2-10
STOOL 10-6
TOTAL
6-2
URINE 2-10
10-6
TOTAL
DOH-SWUMeD-NSD-F-007 Rev.
FLUID INTAKE & OUTPUT MONITORING RECORD
Name: _________________________________ Age: _______________________________________ Attending Physician: ____________________________________
Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No. ___________________
DATE TIME INTAKE TOTAL OUTPUT TOTAL

PARENTERAL ORAL OTHERS URINE DRAINAGE OTHERS
7-3 = 7-3 =
3-11 = 3-11 =
11-7_ __=______________ 11-7 =_________________
24H Total = 24H Total =
Fluid Balance = _____________________________
DOH-SWUMed-NSD-F-012 Rev.1
INTRADERMAL (ID) RUBRICS
CRITERIA
4 3 2 1
g
proficiency
during
simulation
STEPS
1.Check accuracy and
completeness of each medication
administration record (MAR) with
prescriber’s medication order.
Check patient’s name and
medication name, dosage, and route
and time for administration.
2. Check date of expiration for
medication.
Aseptically prepare correct
medication dose from ampule or
vial. Check label of medication with
MAR two times while preparing
medication.
4. Close room curtain or door.
5. Introduce self and Identify patient
using two identifiers (e.g., name and
birth date or name and account
number) according to facility policy.
Compare identifiers with information
on patient’s MAR or medical record.
6. Compare name of medication on
label with MAR one more time at
patient’s bedside
7. Explain steps of procedure and
tell patient that injection will cause a
slight burning or sting.
8. Apply clean gloves. NOTE: If
patient has latex allergy, use latex-
free gloves.
9. Select appropriate injection site.
Inspect skin surface over sites for
bruises, inflammation, or edema.
*Note lesions or discolorations of
skin. If possible, select site three to
four finger widths below antecubital
space and a hand width above wrist.
10. Help patient to comfortable
position:
*Have patient extend elbow and
support it and forearm on flat
surface.
11. Clean site with an antiseptic
swab. *Apply swab at center of site
and rotate outward in circular
direction for approximately 5 cm (2
inches).
12. Hold swab or gauze between

third and fourth fingers of non-
dominant hand.
13. Remove needle cap or sheath
from needle by pulling it straight off.
14. Hold syringe between thumb
and forefinger of dominant hand
*Hold bevel of needle pointing up.
15. With non-dominant hand stretch
skin over site with forefinger or
thumb.
16. With needle almost against
patient’s skin, insert it slowly with
bevel up at a 5- to 15-degree angle
until resistance is felt. Advance it
through epidermis to approximately
3 mm (1 8 inch) below skin surface.
You will see needle tip through skin.
17. Inject medication slowly.
Normally you feel resistance. If not,
needle is too deep; remove and
begin again. Non-dominant hand
can stabilize needle during the
injection.
18. While injecting medication,
notice that small bleb approximately
6 mm (1 4 inch) in diameter
(resembling mosquito bite) appears
on surface of skin. Instruct patient
that this is a normal finding.
19. Withdraw the needle quickly at
the same angle at which it was
inserted.
• Do not massage the area.
position
21. Discard uncapped needle or
needle enclosed in safety shield and
attached syringe into puncture-proof
and leak-proof receptacle.
22. Remove gloves and perform
hand hygiene
23.Observe patient’s response to
medication at times that correlate
with onset, peak, and duration of
medication.
24.Use skin pencil and draw circle
around perimeter of injection site.
Read site within appropriate amount
of time, designated by type of
medication or skin test administered.
25. Chart medication dose, route,
site, time, and date given on MAR
immediately after giving medication .
TOTAL POINTS: 100
____________________________________________ ____________________________________________
Signature over Printed name of the Student Signature over Printed name of the Clinical Instructor
Prepared:
Noted: Approved:
Jill Marie C. Hermogenes, RN, MAN, Ed.D Michelle B. Yu, RN, MAN, DM
Assistant Dean Dean
INTRAMUSCULAR (IM) RUBRICS
CRITERIA
4 3 2 1
g
proficiency
during
simulation
STEPS
1.Check accuracy and
completeness of each medication
administration record (MAR) with
prescriber’s medication order.
Check patient’s name and
medication name, dosage, and route
and time for administration.
2. Check date of expiration for
medication.
Aseptically prepare correct
medication dose from ampule or
vial. Check label of medication with
MAR two times while preparing
medication.
4. Close room curtain or door.
5. Introduce self and Identify patient

using two identifiers (e.g., name and
birth date or name and account
number) according to facility policy.
Compare identifiers with information
on patient’s MAR or medical record.
6. Compare name of medication on
label with MAR one more time at
patient’s bedside
7. Explain steps of procedure and
tell patient that injection will cause a
slight burning or sting.
8. Apply clean gloves. NOTE: If
patient has latex allergy, use latex-
free gloves.
9. Select appropriate injection site.
Inspect skin surface over sites for
bruises, inflammation, or edema.
position:
* Position patient depending on site
chosen (e.g., sit or lie flat, on side,
or prone).
11. Clean site with an antiseptic
swab. *Apply swab at center of site
and rotate outward in circular
direction for approximately 5 cm (2
inches) .
12. Hold swab or gauze between
third and fourth fingers of non-
dominant hand.
13. Remove needle cap or sheath

from needle by pulling it straight off.
14. Hold syringe between thumb
and forefinger of dominant hand
* Hold as dart, palm down.
15. With dominant hand inject
needle quickly at 90-degree angle
into muscle. Insert needle into the
muscle using a smooth, steady
motion. After needle pierces skin,
grasp lower end of syringe barrel
with non-dominant hand to stabilize
syringe. Continue to hold skin tightly
with non-dominant hand. Move
dominant hand to end of plunger. Do
not move syringe.
16. Pull back on plunger 5 to 10
seconds. If no blood appears, inject
medicine slowly, at a rate of 1 mL/10
seconds.
17. Withdraw needle while applying
alcohol swab or gauze gently over
site.
18. Apply gentle pressure. Do not
massage site. Apply bandage if
needed.
position
20. Discard uncapped needle or
needle enclosed in safety shield and
attached syringe into puncture-proof
and leak-proof receptacle.
21. Remove gloves and perform
hand hygiene
22. Stay with patient and observe for
allergic reactions
23.Observe patient’s response to
medication at times that correlate
with onset, peak, and duration of
medication.
24. Inspect site, noting any bruising
or induration. Document bruising or
induration
25. Chart medication dose, route,
site, time, and date given on MAR
immediately after giving medication .
TOTAL POINTS: 100
____________________________________________ ____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean
Name: ______________________________Yr.& Sec. __________Date: _________ C.I.______________
ADMINISTERING ORAL MEDICATION RUBRICS
CRITERIA
4 3 2 1

proficiency
PROCEDURE Independentl Performs skills Performs Performs

y performs all with skills with skills with
during
simulation
STEPS
2. Prepare medication,
adhering to the ten rights of
drug administration.
3.Identify client by reading
identification bracelet and by
addressing client by name.
4. Explain procedure and
purpose of drug.
5. Prepare equipment’s
needed.
6. Verify any allergies listed
on medication record or
electronic medication record.
7. Obtain preassessment
data.
8. Separate drugs that might
be withheld on
preassessment data.
9. Assist client in semi-
Fowler’s or sitting position.
10. Don gloves if there is
possibility of exposure to oral
secretions.
11. Open unit-dose packages
and place one drug in client’s
hand or pour in medication
cup and give to client;
provide assistance if needed.
12. Instruct client to place
tablets or capsules into
mouth and to follow with
enough liquid to ensure.
13. Administer liquid
medications after pills,
instructing client to drink all of
the solution; provide
assistance if needed.
14. Remain with client until all
medications are taken; check
mouth if there is any question
of whether drug has been
swallowed.
15. Reposition client and
place call light within reach.
16. Lift side rails.
17. Discard or restore
equipment properly.
- If client refuses drug or
drug has not been given for
any reason, DO NOT leave
drug at the bedside.
- Remove drug from room
and restore in medication
drawer or cabinet only if in
unopened unit-dose package.
- If unit-dose package has
been opened, discard in sink
or flush down toilet, with
witness present, if necessary.
18. Remove gloves and
perform hand hygiene.
19. Document administration
on medication record.
20. Assess client 30 to 60
minutes after administration
and document client
response to medication.
TOTAL POINTS: 80
_______________________________________ _______________________________________
Signature over Printed name of the Student Signature over Printed name of the Clinical
Instructor
Prepared:
Noted:
Assistant Dean
Approved:
Dean
PREPARING MEDICATION FROM A VIAL RUBRICS
CRITERIA
4 3 2 1

g
proficiency

skills fluently assistance of assistance
and without assistance of faculty 3 - 4 of faculty
difficulty. faculty 1 - 2 times during greater than
times during simulation 4 times
simulation. during
simulation
STEPS
2. Organize equipment.
3. Check label of medication vial

with medication record or electronic
medication record using ten rights of
drug administration.
4. Perform dosage calculations if

vial contains more medication than
client requires.
5. Remove thin seal cap from top of

vial without touching rubber stopper.
6. Firmly wipe rubber stopper on top

of vial with alcohol swab.
6.1. Read the instruction at vial

label as to the amount of diluent
you are going to use.
6.2. Dilute/reconstitute the

powder drug in the vial.
7. Pull end of plunger back to fill

syringe with a volume of air equal to
the amount of solution to be drawn
up, do not touch inside of plunger.
8. Remove needle cap and needle if

necessary.
9. Using a slightly slanted angle

firmly insert needle into center of
rubber top of vial, with the sharpest
point of needle (tip of bevel) entering
first.
10. Continue insertion until needle is

securely in vial yet above the level
of fluid.
11. Press end of plunger down to

instill air to vial.
12. Hold vial with non-dominant

hand and turn it up, keeping
needle/spike inserted; control
syringe with dominant hand and
keep plunger down with thumb.
13. Pull needle/spike back to point

at which bevel is beneath fluid level;
keep needle/spike beneath fluid as
long as fluid is being withdrawn.
14. Slowly pull end of plunger back

until appropriate amount of solution
is aspirated into syringe.
15. If air bubbles enter syringe,

gently flick syringe barrel with
fingers of dominant hand; keep a
finger on end of plunger; continue
holding vial with non-dominant hand.
16. Push plunger in until air is out of

syringe.
17. Withdraw additional solution if

needed.
18. Pull needle out of bottle while

keeping a finger on end of plunger.
Apply sterile needle to syringe if
IM/SQ or ID injections will be given.
19. If bubble remain in syringe:
- Hold syringe vertically (with

needle pointing up if attached).
- Pull back slightly on plunger

and flick syringe with fingers.
- Slowly push plunger up to

release air, but not to the point of
expelling the solution.
20. Recheck amount of solution in

syringe comparing with drug volume
required.
21. Compare drug label with

medication record or electronic
record.
22. Change needle, if used to

withdraw the solution from the vial
and drug is known to be irritating to
tissue; replace cap.
23.Label syringe with drug name
and amount of drug.
24.Place syringe, medication record,

and additional alcohol swabs on
medication tray.
25. Discard or restore all equipment

appropriately.
TOTAL POINTS: 104
____________________________________________
____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean
CHANGING INTRAVENOUS SOLUTION CONTAINER RUBRICS
CRITERIA
4 3 2 1
proficiency
during
simulation
1. Wash hands.
2. Compare solution with

physician’s order. Adhere to
rights of medication
administration.
3. Remove IV bag from outer
wrapper. Look for leaks or
impurities in the bag.
4. Label solution container with

client’s name, solution type,
date and time hung. If not
already done, check prelabeled
container with physician’s order.
Line up time strip with volume
amount on bag or bottle. Record
solution change in the client’s
record.
5. Prepare container for spiking:
a. If solution is in a plastic bag,

remove plastic cover from entry
nipple. Maintain sterility of nipple
end.
b. If solution is in a bottle,
remove metal cap, metal disk
and rubber disk. Maintain
sterility of bottle top.
6. Close the clamp on the
existing tubing.
7. Take old solution from pole

and invert it
8. Remove spike from used

container, maintaining its
sterility. Spike new IV container
with firm/twist motion.
9. Hang new container on IV
pole.
10. Inspect tubing for air
bubbles and assess that drip
chamber is one-half full of
solution.
11. Adjust clamp to regulate flow
rate or program according to
orders.
12. Record to the IVF monitoring

sheet: time and date, flow rate,
IV site, bottle number, solution
type, additives/infusion.
TOTAL POINTS: 48
____________________________________________
____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean
POST MORTEM CARE RUBRICS
CRITERIA
4 3 2 1
proficiency
during
simulation
STEPS
1. Checks the chart for the
physician’s
certification of the death of
the patient
2. Prepares the necessary
materials.
3. Asks permission and explain
to the significant others that
you are going to perform
postmortem care
4. Asks the family if they wish to
remain inside the room
during the procedure
5. Draws curtains to provide
privacy.
6. Pours lukewarm water into
the basin
7. Washes hand and puts on
clean gloves.
8. Removes jewelry or any
personal items of the patient
and give them to the
significant others
9. Closes the patient’s eyes.
Puts on dentures, if any.
Then closes the patient’s
mouth
10. Removes all equipment,
tubes, supplies, and dirty
linens according to hospital
protocol.
11. Removes patient’s clothes
carefully as to not expose
any body part
12. Performs bed bath on the
patient.
13. Puts cotton balls on patient’s
closed eyes, in the nares,
and in the outer ear. Then
secures each with a tape
lengthwise
14. Secures the patient’s jaw
with a cravat.
15. Puts on the diaper,
underwear, and patient’s
new clothes.
16. Gives the family option to
view or not to view patient
and accompany them as they
do so.
17. Encourages the family to say
goodbye.
18. Asks if they would like to be
left alone
19. Applies nametags on the
hand and foot.
20. Covers and secures the
patient with the shroud.
Secure the shroud with
safety pins.
21. Secures another nametag on
the shroud.
22. Transports patient to the
morgue.
23. Documents the procedure
and wash hands.
TOTAL POINTS: 92
____________________________________________
____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean
Name: _________________________________ Year & Section: ____________ Score: _________
Subject: _______________________________ Date: __________________
PERINEAL CARE RUBRICS
PROCEDURE CRITERIA
PROFICIENT APPROACHING DEVELOPING BEGINNING

Independently PROFICIENCY Performs skills Performs skills
performs all skills Performs skills with assistance of with assistance
fluently and with assistance of faculty 3 - 4 of faculty greater
without difficulty. faculty 1 - 2 times during than 4 times
times during simulation. during
simulation. simulation.
4 3 2 1
STEPS
1. Position client in lithotomy
position
2. Wash hands.
3. Prepare six (6) sterile sponges

soaked with antiseptic solution
(iodine).
(Use picking forceps).
4. Identify the patient, introduce self,
and explain the procedure.
5. Apply sterile gloves for the prep
procedure.
6. Take a fresh sponge to begin
each new area and do not return
to a clean with a used sponge.
Six sponges are needed.
7. Use a zigzag motion from the
clitoris to lower abdomen just
above the pubic hairline.
8. Use a zigzag motion on the inner

thigh from the labia majora to
about halfway between the hip
and the knee.
9. Repeat on the other inner thigh.

10. Apply a single stroke on one side
from clitoris over labia, perineum
and anus.
11. Repeat for the other side.
12. Use a single stroke in the middle
from the clitoris over the vulva
and the perineum
13. Remove gloves.
14. Wash hands.
TOTAL POINTS: 56
____________________________________________
____________________________________________
Prepared:
Noted:
Approved:
Dean
Assistant Dean
PERINEAL SHAVING RUBRICS
CRITERIA
4 3 2 1

g
proficiency

simulation. during
simulation
STEPS
1. Check doctor’s order.
2. Introduce yourself and explain the

procedure to the patient.
3. Provide privacy.
4. Bring equipment and supplies to

the bedside.
4.1 Tray with lining containing

the following:
a. Razor
b. Pitcher with warm water
c. Cherry balls soaked in
betadine
d. Clean gloves
e. Dry cherry balls in a
container
f. 1 picking forcep soaked in
Cidex
g. 1 dressing forcep in Cidex
h. Kidney basin
i. Wastes receptacle
4.2 Absorbent Pad
4.3 Bedpan
5. Protect the bed with absorbent

pad.
6. Place the patient on bedpan in a

dorsal recumbent position.
7. Drape the client with a bath
blanket to permit exposing just the
perineal area.
8. Wash your hands.
9. Do gloves with your non-dominant

hand.
10. Pour water on the perineal area.
11. With the use of the dressing

forcep, apply the betadine cleanser
using the anterior-posterior stroke.
Discard the cherry ball after each
use and place into the waste
Receptacle.
12. Using the sharp, clean safety

razor, shave with one hand while the
other hand stretches the skin. For …
a. Complete shaving – shave

the entire pubic hair from the
mons pubis down the
perineum.
b. Partial shaving – shave the
pubic hair located half of the
vulva down to the perineum
c. Mini-prep-shave the pubic
hair located 1/3 below the
vulva down the perineum.
Note: Coarse Hair – shave

hair in the direction of hair
growth. Fine Hair – shave
hair by stroking against the
direction of hair growth.
13. Rinse the perineal area with

warm water. Pat dry using the
cherry balls.
14. Do after care and perform hand

wash.
TOTAL POINTS: 56
____________________________________________ ____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean
LEOPOLD’S MANEUVER RUBRICS
CRITERIA
4 3 2 1
g
proficiency
during
simulation
PREPARATION:
1. Wash Hands.
2. Encourage the patient to

empty the bladder.
3. Compute the following:

a. E D C =
b. A O G =
c. Fundal height =
4. Measure the fundal height of
the abdomen
First Maneuver:
1. Position the patient
2. Stand at the side of the bed,

facing the mother.
3. Palpate the uterine fundus

with warm hands
4. Determine which part of the

baby’s body lies on the
upper fundus according to
its;
a. Relative consistency
b. Shape
c. Mobility
Second Maneuver:
1. Place the palmar surface of
both hands on either sides of
the abdomen.
2. Apply gently but deep

pressure in one side of the
abdomen.
3. Palpate the opposite side

from the top to the lower
segment of the uterus in a
slightly circular motion.
4. Determine which side of the

uterus is the long axis of the
fetus located.
5. Check the fetal heartbeat.
Third Maneuver:
1. Grasp the lower uterine
segment with thumb and
fingers.
2. Identify the presenting part.
3. Determine the mobility of the

presenting part.
Fourth Maneuver:
1. Stand to the side facing the
patient’s feet.
2. Place the tips of the first

three fingers on both sides of
the midline about two inches
from the inguinal ligament
3. Apply pressure downward
and in the direction of the
birth canal.
4. Confirm the presenting part.
5. Record the findings and

hand wash.
TOTAL POINTS: 84
____________________________________________
____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean
ASSISTING DELIVERY RUBRICS
CRITERIA
4 3 2 1
g
proficiency
during
simulation
STEPS
1. Perform hand washing and don
open gloving.
2. Prepare the instruments:
DOCTOR
STUDENT
In order (from right to left):
TOP:
1. Surgical scissors – used for
episiotomy (no longer be used after
episiotomy)
2. Curve forceps
3. Straight forceps
4. Surgical scissors – used for cord
cutting and during episiorrhaphy
5. Needle holder
6. Tissue forceps
7. Syringe – used for anesthesia
8. Suture
9. Operating sponges (OS)
BOTTOM:
10. Basin – for the placenta
11. Ovum forceps
12. 2 allis
13. Suction bulb
3. Assist in fetal and placental
delivery.
4. Take note of the time of fetal and

placental delivery. Identify the
type of placenta.
5. Assist during episiorrhaphy.
6. Do perineal cleaning.
7. Discard sharps into the sharps
bin.
8. Wash used instruments including

the Kelly pad.
9. Monitor the patient every 15

minutes for 1-2 hours: vital signs,
fundus, lochia, bladder
10. Report for

abnormalities/unusualities.
TOTAL POINTS: 40
____________________________________________
____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean
HANDLING DELIVERY RUBRICS
CRITERIA
4 3 2 1
g
proficiency
during
simulation
STEPS
1. Transport the patient per hospital
bed from the labor to the delivery
room.
2. Transfer the patient from the bed
to the delivery table.
3. Place the patient in lithotomy

position.

open gloving.
5. Support the perineum using a

sterile white sheet.
6. Take note of the time of fetal

delivery and the gender of the baby.
7. Assist doctor in clamping and

cutting the umbilical cord.
8. Remove gloves.
9. Stay at the side of the patient and

prepare for blood pressure taking
after placental delivery. Report the
blood pressure reading to the
doctor.
10. Prepare the stretcher.
11. Transfer the patient from

delivery table to the stretcher. (After
episiorrhaphy and perineal
cleaning).
12. Transport the patient from
delivery to recovery room.
13. Monitor the patient every 15

minutes for 1-2 hours: vital signs,
fundus, lochia, bladder
14. Report for abnormalities/

unusualities.
TOTAL POINTS: 56
____________________________________________
____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean
IMMEDIATE NEWBORN CARE RUBRICS
CRITERIA
4 3 2 1
g
proficiency
during
simulation
STEPS
open gloving.
2. Dress the umbilical cord:
a. Fold one (1) OS into lengthwise,

soak it with sterile water for
injection, and wrap it around the
base of the umbilical cord.
b. Wipe the cord with the soaked OS

upward. Discard the used OS.
3. Clamp the umbilical cord 1 inch

(2.54 cm) from the base of the cord.
Ensure that the clamp is locked.
Note: Position the umbilical cord at
the center of the umbilical clamp.
4. Wrap the base of the umbilical

cord with OS (below the umbilical
clamp).
5. Cut the umbilical cord
immediately right on top of the
umbilical clamp. Use the surgical
scissors provided.
6. Wipe the umbilical cord and
clamp using the OS wrapped at the
base of the cord to remove blood.
7. Check for the umbilical blood

vessels.
8. Remove gloves.
9. Take note of the anthropometric

measurements, weight, Apgar, and
Ballard score.
10. Attach identification band.
11. Administer vitamin K at right

thigh and hepatitis B vaccine at left
thigh.
12. Wrap the baby snuggly.
13. Initiate early breastfeeding.
14. Monitor newborn’s vital signs

every 15 minutes.
15. Report for any

abnormalities/unusualities.
TOTAL POINTS: 60
____________________________________________
____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean
BATHING AN INFANT RUBRICS
CRITERIA
4 3 2 1
proficiency
during
simulation
STEPS
1. Fill the sink or baby tub with
no more than 3 inches of
warm water. Test temperature
of the water.
2. Undress your baby. Place

them on the pad, if giving a
sponge bath, or in a basin of
water.
3. Before putting soap on a

washcloth, gently clean your
baby’s eyelids. Using a clean
spot on the cloth, start at the
inner corner of the eye and
wash toward the ears.
4. Then, wash your baby’s face

with only water. Do not use
soap on their face.
5. Use clean water to wash the

outer part of the ear. Do not
use cotton swabs, like Q-tips®,
inside your baby’s ears
6. Wet your baby’s head with
water. Put mild soap or
shampoo on the washcloth.
Gently rub the washcloth over
their head from front to back.
Keep soap out of their eyes.
Rinse their head with clean
water and gently pat dry with
the towel.
7. While your baby is lying on the
pad or in the basin, reach
under them to lift their back
and head up with your arm
8. Make a soapy lather on the
washcloth or with your hands.
Start at the neck and lather
your baby’s entire body. Be
sure to clean between fingers,
toes, and skin folds.
9. Use the soapy washcloth or
your hands to clean the diaper
area.
o Start at the front and
move back to the
buttocks.
o If your baby is not
circumcised, do
not pull back the
foreskin to clean the
penis.
10. Rinse the soap off your baby

with a clean, wet washcloth.
After the Bath

1. Pat your baby dry with a
clean towel.
2. If you want, use lotion. Do
not put lotion on your
baby’s face.
3. Brush and comb your

baby’s hair.
4. Clean their fingernails and
toenails. Carefully clip the
nails with baby scissors or
clippers when needed. Do
this by making short, little
clips above the white nail
line. This will help avoid
cutting the nail too close.
Or you may file the nails
with a nail file. Keep your
baby’s fingernails short so
they do not scratch their
face.
Scalp Care
1. Put a small amount of
baby oil on their hair after
shampooing. Leave it on
until the next day.
2. Brush your baby’s hair and
scalp the next day to
remove old skin, then
shampoo your baby’s hair.
3. Wash the brush and comb
with soapy water, then
rinse and dry.
EVALUATION:
1. Do after care
2. Perform handwashing
TOTAL POINTS: 76
____________________________________________
____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean
HOW TO PREPARE HOME-MADE ORESOL RUBRICS
CRITERIA
4 3 2 1
g
proficiency
during
simulation
STEPS
1. Prepare a clean regular glass
of Nescafe
2. Grind some salt until it is very
fine.
3. Put a pinch of salt into the
water.
4. Add one heaping of teaspoon
of sugar.
5. Give to the patient to drink.
TOTAL POINTS: 20
____________________________________________
____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean
APPLYING A DRY DRESSING RUBRICS
CRITERIA
4 3 2 1

g
proficiency

simulation. during
simulation
1. Wash hands.
2. Prepare materials.
3. Provide privacy; draw curtains;

close doors.
4. Explain procedure to the client.
5. Wash hands.
6. Apply clean gloves.
7. Remove dressing and place in

appropriate receptacle. Remove
soiled gloves with contaminated
surfaces inward and discard in
appropriate receptacle and apply
clear gloves.
8. Assess the appearance of the

undressed wound bed for healing.
9. Cleanse the skin around the

incision if necessary with a clean,
warm, wet washcloth. If the suture
line requires cleansing. It should be
done gently. Use normal saline, half
strength hydrogen peroxide, or
Betadine swab (consult orders of
physician or qualified practitioners
and/or hospital policy regarding
antiseptic agents) and cotton-tip
applicators using a rolling motion.
Used applicators should not be
reintroduced into the sterile solution.
10. Removed used gloves.
11. Wash hands.
12. Set up supplies.
13. Apply a new pair of gloves.
14. Grasping the edges, apply a

new dressing using 4 x 4 gauze
pads folded in half to the 2 x 4 size.
Place the folded gauze pad
lengthwise on wound and tape
lightly or apply tubular mesh for
those with sensitive skin. Initial the
dressing, date and time it was
changed. Optional: an ABD pad may
be applied on top of the dressing for
added protection over sutures or for
client comfort.
15. Remove gloves and dispose

appropriately, then wash hands.
16. Conduct client and family

education about the dressing, which
may include teaching the dressing
technique to the client and family.
17. After care.
18.Wash hands.
19. Document.
TOTAL POINTS: 76
____________________________________________
____________________________________________
Prepared:
Noted:
Assistant Dean
Approved:
Dean

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Name: __________________________________ Yr.& Sec. __________Date: _________ C.I.

2. Check hands for breaks in the

3. Remove all jewelry.

6. Turn on the water and adjust

7. Hold the hands lower than the

8. If soap is liquid; apply 2-4 ml

9. Lather hands well then drop bar

11.Rinse hands thoroughly.

12.Turn off water flow using foot

13.Thoroughly dry the hands from

14.Discard the paper towel in the

STERILE OPEN GLOVING RUBRICSSkills

2. Checks that the sterile glove

2. Opens the outside wrapper by

Open Packaging & Prep

2. Is careful not to touch inner

Don Sterile Gloves

1.Carefully inserts dominant hand

2. Holds thumb of gloved hand

ASSESSING VITAL SIGNS RUBRICS

1. Identify the patient. Discuss

4. Perform hand hygiene.

1. Helps the client to assume a

2. Takes the thermometer out of its

3. Turns on the thermometer and

4. Removes the thermometer when

5. Cleans the thermometer using

6. Places the thermometer back in

1. Positions the client so that his

4. Using a watch with a second

1. Assumes the same position in

1. Assists patient assume a correct

3. Extends the arm with the palm

4. Places the cuff approximately 1-2

5. Arranges the manometer gauge

6. Palpates the brachial artery or

7. Place the stethoscope earpieces

8. Pump the pressure 30 mm Hg

9. Note the point on the gauge at

2. Records the temperature,

DATE TIME INTAKE TOTAL OUTPUT TOTAL

INTRADERMAL (ID) RUBRICS

12. Hold swab or gauze between

INTRAMUSCULAR (IM) RUBRICS

5. Introduce self and Identify patient

13. Remove needle cap or sheath

ADMINISTERING ORAL MEDICATION RUBRICS

Proficient Approaching Developing Beginning Rating

PROCEDURE Independentl Performs skills Performs Performs

PREPARING MEDICATION FROM A VIAL RUBRICS

Proficient Approachin Developing Beginning Rating

PROCEDURE Independently Performs Performs Performs

1. Perform hand hygiene.

3. Check label of medication vial

4. Perform dosage calculations if

5. Remove thin seal cap from top of

6. Firmly wipe rubber stopper on top

6.1. Read the instruction at vial

6.2. Dilute/reconstitute the

Name: ________________________ Yr.& Sec. Date: _ C.I.