Level 2

2023
Level 2: Skills CHECKLIST

NCM 103. FUNDAMENTALS OF NCM 104. CHN 1
NURSING
Administering an Intradermal Injection Bag technique
Administering An Intramuscular Injection Heat and Acetic Acid Test
Administering A Subcutaneous Injection Benedict’s Test
HANDWASHING: VISIBLY SOILED Removing Medication from An Ampule

HANDS
Removing Medication From A Vial
APPLYING AND REMOVING STERILE
GLOVES (OPEN METHOD)
Mixing Medications From Two Vials in One
DONNING A STERILE GOWN Syringe
DONNING AND REMOVING CLEAN

AND CONTAMINATED GLOVES, CAP,
AND MASK
MAKING THE OCCUPIED BED
MAKING THE UNOCCUPIED BED
ASSISTING WITH THE USE OF A
BEDPAN
TURNING A PATIENT IN BED: BACK TO
SIDE
TURNING A PATIENT: LOGROLLING
MOVING A PATIENT UP IN BED: ONE

PERSON ASSIST
ORAL CARE
COMPLETE BED BATH
ASSISTING WITH THE USE OF URINAL
ASSISTING WITH THE USE OF BEDSIDE
COMMODE
GIVING BACK MASSAGE
POSITIONING A PATIENT
Medication Administration
Oral
La Consolacion University Philippines
Catmon, City of Malolos, Bulacan
Bachelor of Science in Nursing

Evaluation Tool
STUDENT’S NAME: _______________________________________ YR/SEC________ DATE:__________
INSTRUCTOR: __________________________________________ SCORE: _______
BAG TECHNIQUE
Definition:
• Bag Technique is a tool making use of a public health bag through which the nurse,
during his/her home visit, can perform nursing procedures with ease and deftness, saving
time and effort with the end in view of rendering effective nursing care.
• Public Health Bag is an essential and indispensible equipment of the public health nurse
which he/she has to carry along when he/she goes out home visiting. It contains basic
medications and articles which are necessary for giving care.
Rationale:
• To render effective nursing care to clients and/or members of the family during home visit.
Principles:
1. The use of the bag technique should minimize of not totally prevent the spread of infection
from individuals to families, hence, to the community.
2. Bag technique should save time and effort on the part of the nurse in the performance of
nursing procedures.
3. Bag technique should not overshadow concern for the patient rather should show the
effectiveness of total care given to an individual or family.
4. Bag technique can be performed in a variety of ways depending upon agency policies,
actual home situation, etc., as long as principles of avoiding transfer of infection is carried
out.
Special Considerations in the Use of the Bag”

1. The bag should contain all necessary articles, supplies and equipment which may be used
to answer emergency needs.
2. The bag and its contents should be cleaned as often as possible, supplies replaced and ready
for use any time.
3. The bag and its contents should be well protected from contact with any article in the home
of the patients. Consider the bag and its contents clean and/or sterile while any article
belonging to the patient a dirty and contaminated.
4. The arrangement of the contents of the bag should be the one most convenient to the user
to facilitate efficiency and avoid confusion.
5. Handwashing is done as frequently as the situation calls for. It helps in minimizing or
avoiding contamination of the bag and its contents.
6. The bag when used for a communicable case should be thoroughly cleaned and disinfected
before keeping and re-using.
Contents of the Bag:

• Paper lining
• Extra paper for making waste receptacle
• Plastic/linen lining
• Apron
• Hand towel in plastic bag
• Soap in soap dish

Evaluation Tool
• Thermometers (1 oral, 1 rectal)

• 2 pairs of scissor (1 surgical, 1 bandage)
• 2 pairs of forceps ( 1 curved, 1 straight)
• Syringes (5 ml and 2 ml)
• Hypodermic needles ( g. 19, 22, 23, 25)
• Sterile dressings (OS)
• Sterile Plastic cord clamp
• Adhesive plaster
• Cotton balls
• Tape measure
• Baby’s scale
• Alcohol lamp
• 1 pair of rubber gloves
• 2 test tubes
• Medicine Tray
• Medicines:
o Betadine
o 70% alcohol
o Ophthalmic ointment
o Hydrogen peroxide
o Spirit of ammonia
o Acetic acid
o Benedict’s solution
Note: BP apparatus and stethoscope are carried separately
DONE NOT REMARKS

DONE
1. After entering client’s house, take paper lining
from top of bag.
2. Lay paper on flat surface of table, chest or box, if
none use floor.
3. Place bag on the left side of paper lining with the
bag opening facing the working area.
4. Open the bag and take out the plastic lining.
5. Lay the plastic lining over the paper lining
6. Bring out soap with soap dish and towel
7. Close the bag without locking and perform
handwashing.

Evaluation Tool
8. After handwashing, put the soap and soap dish on

the paper lining (outside the plastic lining) with
hand towel on top of the soap dish.
9. Put on the apron observing proper technique.
10. Remove from bag articles needed for care
making sure that they are placed within the plastic
lining.
11. Place a paper receptacle outside the work area.
12. Close the bag then complete care.
13. Perform aftercare of articles used. (Articles are
usually disinfected using alcohol including the top
of the plastic lining.
14. Close and discard the paper receptacle
15. Wash hands
16. After handwashing, open the bag and return all
articles used.
17.Return the soap and the soap dish inside the bag
last (with the hand towel under the soap dish)
18. Take off and fold apron using the proper
technique and return to bag
19. Fold the plastic lining (clean-side out) and
return to bag
20. Close and lock the bag
21. Get the bag; fold the paper lining without
touching the contaminated side and discard.
_______________________
_________________________ Clinical Instructor’s ___________________
Student’s Signature Printed Name & Signature Date

Evaluation Tool
Heat and Acetic Acid Test
Criteria DONE NOT REMARKS

DONE
1) Fill test tube 2/3 of clear urine.
2) Heat the upper third of the test tube. Lower position is not
heated to serve as control.
3) If cloud forms, add few drops of 5% acetic acid.
4) Heat again and allow to cool. Read after 5 minutes.
Benedict’s Test
DONE
1. Place 5cc. of Benedict’s solution in a clear test tube.
Heat. If color changed, discard.
2. Add 8-10 drops of urine and mix thoroughly.
3. Boil for several minutes (at least 2 minutes).
* BLUE (-) - no sugar present
* GREEN (+) - slight trace
* YELLOW (++) - trace
* ORANGE (+++) - moderate amount
* RED (++++) - large amount
_______________________ _______________________ _______________________

Student’s Signature CI’s Printed Name & Signature Date

Evaluation Tool
Removing Medication from An Ampule
Done Not remarks

done
ASSESSMENT
1. Review physician’s order and medication record for
medication to be given.
PLANNING
1. Determine materials needed
2. Wash your hands.
3. Gather materials needed
IMPLEMENTATION
4. Verify the right drug to be administered by:
a. Read the name of the medication from the record
b. Check the label on the medication before picking it
up
c. Check the label again before calculating and
preparing the dose
5. Carefully break the ampule at its neck, making sure to
keep self safe from accidental cuts or injuries
6. Discard the head part of the ampule into proper waste
receptacle.
7. Insert needle into the ampule bevel up and bring
ampule and needle at eye level.
8. Aspirate the calculated dosage of the medication
9. If any air bubbles accumulate in the syringe, tap the
barrel of the syringe once and move the needle past the
fluid into the air space. Re-insert tip of the needle to
the ampule and continue withdrawal of the medication.
10. Wash your hands
11. Administer medication depending on physician’s order
_______________________ ______________________________ _______________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

Evaluation Tool
Removing Medication From A Vial
Done Not Remarks

Done
ASSESSMENT
1. Review physician’s order and medication record for medication
to be given.
PLANNING
2. Determine materials needed
3. Wash your hands.
4. Gather materials needed
IMPLEMENTATION
5. Verify the right drug to be administered by:
a. Read the name of the medication from the record
b. Check the label on the medication before picking it up
c. Check the label again before calculating and preparing the
dose
6. Remove the metal or plastic cap on the vial that protects the
rubber stopper.
7. Swab the rubber top with the alcohol swab.
8. Remove the cap from the needle by pulling it straight off. Before
medication is to be taken fro the vial, aspirate an equal amount of
air into the syringe.
9. Pierce the rubber stopper in the center with the needle tip and
inject the measured air into the space above the solution. The
vial may be positioned upright on a flat surface or inverted.
10. Invert the vial and withdraw the needle tip slightly so that it is
below the fluid level.
11. Draw the prescribed amount of medication while holding the
syringe at eye level and vertically.
12. If any air bubbles accumulate in the syringe, tap the barrel of the
syringe once and move the needle past the fluid into the air
space, re-inject tip to the vial and continue withdrawal of the
medication.
13. Once the correct dose is withdrawn, remove the needle from the
vial and cap it.
14. If a multi-dose vial is being used, store the vial containing the
remaining medication according to agency policy.
15. Wash your hands.
16. Administer medication depending on physician’s order
_____________________ ____________________________ _____________________

__ __ __
Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

Evaluation Tool
Administering an Intradermal Injection

DONE
1. Assemble the equipment and check the physician’s order.

2. Explain the procedure to the client.
3. Wash your hands.
4. Withdraw medication from an ampule or vial.
5. Select an area on the inner aspect of the forearm that is not
heavily pigmented or covered with hairs.
6. Cleanse the area with an alcohol swab while wiping with a
firm, circular motion and moving outward from the injection
site. Allow the skin to dry. If the skin is oily, clean the area
with a Pledge moistened with acetone.
7. Use the non-dominant hand to spread the skin taut over the
injection site.
8. Remove the needle cap with the non-dominant hand by
pulling it straight off.
9. Place the needle almost flat against the client’s skin, level
side up, and insert the needle into the skin so that the point of
the needle can be seen through the skin. Insert the needle
only about 1/8 inch.
10. Slowly inject the agent while watching for a small wheal or
blister to appear. If none appears, withdraw the needle
slightly.
11. Withdraw the needle quickly at the same.
12. Do not massage the area after moving the needle.
13. Do not recap the used needle. Discard the needle and syringe
in the appropriate receptacle.
14. Assist the client to a position of comfort.
15. Wash your hands.
16. Chart the administration of the medication.
_______________________ ______________________________ _______________________


Evaluation Tool
Administering An Intramuscular Injection

DONE
IMPLEMENTATION
1. Assemble equipment and check the physician’s
order.
3. Wash your hands.
5. Provide for privacy. Have the assume position
appropriate for the site selected
i. Dorsogluteal – the client may lie prone with toes
pointing inward or on the side with the upper leg
flexed and placed in front of the lower leg.
ii. Ventrogluteal – the client may lie on the back or
side with the hip and knee flexed.
iii. Vastus lateralis – the client may lie on the back or
may assume a sitting position
iv. Deltoid – the client may sit or relax with arm
relaxed
6. Locate the site of choice. Ensure that the area is non-
tender and free of lumps and nodules.
7. Clean the area thoroughly with an alcohol swab, using
friction.
8. Remove the needle cap by pulling it straight off.
9. Spread the skin at the site using your non-dominant
hand.
10. Hold the syringe in your dominant hand between the
thumb and the forefinger. Quickly dart the needle into
the tissue at a 90º angle.
11. As soon as the needle is in place, move your non-
dominant hand to hold the lower end of the syringe.
Slide your dominant hand to the tip of the barrel.
12. Aspirate by slowly pulling back on the plunger.
Determine whether the needle is in a blood vessel. If
blood is aspirated, discard the needle, syringe, and
medication. Prepare a new sterile setup, and inject
another site, needle and syringe, in the appropriate
receptacle.
13. If no blood is aspirated, inject the solution slowly,
followed by the air bubble.
14. Remove the needle quickly.
15. Massage the injection site with an alcohol swab using
gentle pressure.
16. Do not recap the used needle. Discard in the sharp
container provided.

Evaluation Tool
18. Evaluate the response of the client to the medication

within an appropriate time frame.
_____________________ ____________________________ _____________________

__ __ __

Evaluation Tool
Administering A Subcutaneous Injection

DONE
IMPLEMENTATION
1. Assemble equipment and check the physician’s
order.
3. Wash your hands.
5. Identify the client carefully.
6. Have the client assume a position appropriate for the site
selected.
i. Outer aspect of upper arm – the client’s arm should
be relaxed and at the side of the body
ii. Anterior thighs – the client may sit or lie with the leg
relaxed
iii. Abdomen – the client may lie in a semi-recumbent
position
iv. Scapular area – the client may be prone, on side, or
in sitting position
7. Locate the site of choice according to directions given.
Ensure that the area is not tender and is free of lumps
and nodules.
8. Clean the area around the injection site with an alcohol
swab in a firm, circular motion while moving outward
from the injection site and allow the antiseptic to dry.
Leave the alcohol swab in a lean area for reuse when
withdrawing the needle.
9. Remove the needle cap with the non-dominant hand,
pulling it straight off.
10. Grasp and bunch the area surrounding the injection site
or spread the skin at the site.
11. Hold the syringe in the dominant hand between the
thumb and forefinger. Inject the needle quickly at an
angle of 45º-90º depending on the amount and turgor of
the tissue and length of the needle.
12. After the needle is in place, release the tissue and
immediately move your non-dominant hand to steady the
lower end of the syringe. Slide your dominant hand to
the tip of the barrel.
13. Aspirate by pulling back, gently on the plunger of the
syringe to determine whether the needle should be
discarded and a new syringe with new medication should
be withdrawn and the medication, syringe, and needle
are prepared.
14. If no blood appears, inject the solution slowly.
15. Withdraw the needle quickly at the same angle at which
it was inserted.

Evaluation Tool
16. Massage the area gently with an alcohol swab except the
heparin or insulin injection site.
17. Do not recap the used needle. Discard the needle and
syringe in the appropriate receptacle.
19. Chart the administration of the medication.
20. Evaluate the response of the client to medication within
an appropriate time frame.
_______________________ _______________________ _______________________

Student’s Signature CI’s Printed Name & Date
Signature

Evaluation Tool
HANDWASHING: VISIBLY SOILED HANDS

Procedure DONE NOT REMARKS
DONE
1. Remove jewelry. Wristwatch can be pushed up above wrist. (mid
forearm.) Push sleeves of uniform or shirt up above wrist at mid
forearm level.
2. Assess hands for hangnails, cuts or breaks in skin, and areas that are
heavily soiled.
3. Turn on water. Adjust flow and temperature. Water temperature should
be warm.
4. Wet hands and lower forearm thoroughly by holding under running
water. Keep hands and forearms in down position with elbows straight.
Avoid splashing water and touching sides of sink.
5. Apply about 5 ml (1 teaspoon) of liquid soap. Lather thoroughly.

6. Vigorously rub hands together for 15 seconds.
7. Rinse with hands in down position, elbows straight, in direction of
forearm to wrist to fingers.
8. Blot hands and forearms to dry thoroughly. Dry in direction of fingers
to wrist and forearms. Discard paper towels in proper receptacle.
9. Turn off water faucet with clean, dry paper towel.
_______________________ _______________________ _______________________


Evaluation Tool
APPLYING AND REMOVING STERILE GLOVES (OPEN METHOD)
Purpose:
• To enable the nurse to handle or touch sterile objects freely without contaminating them.
• To prevent transmission of potentially infective organisms from the nurse’s hands to
clients at high risk for infection
Goal:
• The patient remains free of exposure to potential infection-causing microorganisms.
Equipment:
• Sterile Gloves
• PPE, if indicated
CRITERIA DONE NOT REMARKS
DONE
ASSESSMENT
1. Review the client’s record or discuss with the
client exactly what procedure will be performed
that requires a sterile gloves.
PLANNING
2. Ensure the sterility of the package of gown.
Check that the sterile glove package is dry and
unopened and is still valid and not beyond the
expiration date.
IMPLEMENTATION
3. Prior to performing the procedure, introduce self
and verify the client’s identity using agency
protocol. Explain to the client what you are
going to do, why it is necessary.
4. Perform hand hygiene and observe other
appropriate infection prevention procedures.
5. Provide for client privacy.
6. Open the package of the sterile gloves.
• Place the package of gloves on a clean, dry
surface.
• Some gloves are packed in an inner as well as an
outer package. Open the outer package without
contaminating the gloves or the inner package.
• Remove the inner package from the outer
package.
• Open the inner package according to the
manufacturer’s directions. Some manufacturers
provide a numbered sequence for opening the
flaps and folded tabs to grasp for opening the

Evaluation Tool
flaps. If no tabs are provided, pluck the flap so

that the fingers do not touch the inner surfaces.
7. Put the first glove on the dominant hand.
• If the gloves are packaged so that they lie side by
side, grasp the glove for the dominant hand by
its folded cuff edge (on the palmar side) with the
thumb and first finger of the nondominant hand.
Touch only the inside of the cuff.

DONE
• If the gloves are packaged one on top of the
other, grasp the cuff of the top glove as above,
using the opposite hand.
• Insert the dominant hand into the glove and pull
the glove on. Keep the thumb of the inserted
hand against the palm of the hand during
insertion.
• Leave the cuff in place once the unsterile hand
releases the glove.
8. Put the second glove on the non-dominant hand.
• Pick up the other glove with the sterile gloved
hand, inserting the gloved fingers under the cuff
and holding the gloved thumb close to the
gloved palm.
• Pull on the second glove carefully. Hold the
thumb of the gloved first hand as far as possible
from the palm.
• Adjust each glove so that it fits smoothly, and
carefully pull the cuffs up by sliding the fingers
under the cuffs.
9. Remove and dispose of used gloves.
• Remove the first glove by grasping it on its
palmar surface, taking care to touch only glove to
glove.
• Pull the first glove completely off by inverting or
rolling the glove inside out.
• Continue to hold the inverted removed glove by
the fingers of the remaining gloved hand. Place
the first two fingers of the bare hand inside the
cuff of the second glove.
• Pull the second glove off to the fingers by
turning it inside out. This pulls the first glove
inside the second glove. Rationale: The soiled
part of the glove is folded to the inside to reduce
the chance of transferring any microorganisms
by direct contact.

Evaluation Tool
• Using the bare hand, continue to remove the

gloves, which are now inside out, and dispose of
them in the refuse container.
10. Perform hand hygiene
EVALUATION
11. Evaluate if there is a break in the sterile
technique during the entire procedure.
DOCUMENTATION
12. Document that sterile technique was used in the
performance of the procedure.
_______________________ _______________________ _______________________


Evaluation Tool
DONNING A STERILE GOWN
Purpose:
• To provide a barrier between microorganisms on the nurse’s uniform and the client.
• To maintain a microbe free covering over the nurse’s uniform.
• To prevent a nosocomial infection associated with an invasive procedure, such as
handling delivery.
Equipment:
• Surgical Mask
• Surgical cap/bonnet
• Sterile gown
DONE
ASSESSMENT
1. Review the client’s record or discuss with the
client exactly what procedure will be performed
that requires a sterile gowning technique.
PLANNING
2. Ensure the sterility of the package of gown.
Check that the sterile gown package is dry and
unopened. Inspect the autoclaving tape used to
secure the gown. Note that it confirms the
sterility of the contents.
IMPLEMENTATION
3. Prior to performing the procedure, introduce self
and verify the client’s identity using agency
protocol. Explain to the client what you are
going to do, why it is necessary.
4. Don mask and cap. Carry out surgical hand
scrubbing for at least 5 minutes each hand.
5. Pick up a gown, grasping inside surface at the
collar.
6. Stand away from the sterile pack and table. Hold
gown at arm’s length away from your body to
allow the gown to unfold by itself. Be careful not
to allow gown to touch the floor or any unsterile
field.
Rationale: Contact of outer surface of gown with
a dirty or clean surface would result in gown
contamination.
7. Hold gown by inside, open shoulder seams and
insert each hand through armholes.
Rationale: Inside surface of gown is considered
contaminated.

Evaluation Tool
8. Keeping your upper arms in front of you at

shoulder height, extend hands toward gown cuff.
Do not push hands through cuffs.
Rationale: Extension of arms straight ahead
keeps sterile outer surface of gown in view and
reduces risk of touching floor or a portion of
your body.

DONE
EVALUATION
9. Evaluate if there is a break in the sterile
technique during the entire procedure.
DOCUMENTATION
10. Document that sterile technique was used in the
performance of the procedure.
Evaluator
________________________ ________________________ ________________________

Clinical Instructor’s Name Student’s Name and Date
and Signature Signature

Evaluation Tool
DONNING AND REMOVING CLEAN AND CONTAMINATED GLOVES, CAP, AND

MASK
Procedure DONE NOT REMARKS

DONE
1. Wash hands/ hand hygiene.
2. Don cap or surgical hat or hood first. Hair should be tucked and
covered so that all hair is covered.
3. Apply a mask around mouth and nose and secure to prevent
venting.
4. Open gown, slip arms into sleeves, and secure at neck and side.
5. Wear protective eyewear, goggles or glasses, or face shields.
6. Apply clean gloves. If sterile gloves are required for a procedure,
use open or closed method.
7. Open glove technique:
a. Slide hands into gown through cuffs on gown.

b. Pick up cuff of left gloves using thumb and index finger of right
hand
c. Pull glove onto left hand, leaving cuff of glove turned down.
d. Take gloved left hand and slide fingers inside cuff of right glove,
keeping gloved fingers under folded cuff.
e. Pull glove onto right hand.
f. Rotate arm as cuff of glove is pulled over gown.
8. Closed glove techniques:
a. Slide hands into gown through cuffs on gown.

b. Use right hand to pick up left glove.
c. Place glove on upward-turned left hand-palm side down, thumb
to thumb with fingers extending along forearm pointing toward
elbow.
d. Hold glove cuff and sleeve cuff together with thumb of left
hand.
e. Right hand stretches cuff of left glove over opened and of
sleeve.
f. Work fingers into glove as cuff is pulled onto wrist.

Evaluation Tool
g. Left glove is donned in same manner.

9. Enter client’s room and explain rationale for wearing isolation
attire.
10. After performing necessary tasks, remove gown, gloves, mask, and
cap before leaving room.
_______________________ _______________________ _______________________


Evaluation Tool
MAKING THE OCCUPIED BED
ASSESSMENT DONE NOT REMARKS

DONE
1. Check activity order for patient & order for position of
restrictions.
2. Assess patient
3. Check condition of linen on bed
4. Check for patient special needs
PLANNING
1. Wash hands
2. Obtain laundry bag or hamper
3. Gather linen to be used
4. Obtain other needed items or equipment including gloves if
linen is soled with body secretions
IMPLEMENTATION
1. Explain the procedure
2. Provide privacy
3. Raise bed to appropriate height & lock wheels
4. Remove attached equipment, spread & blanket from bed.
Fold if to be reuse. Put on gloves if linen is soiled with body
secretions.
5. Place bath blanket over top sheet, pull sheet from under it
6. If mattress needs repositioning, get assistance.
7. Elicit pt. help then roll pt to other side w/ siderails up
8. Loose bed linen
9. Fanfold each linen item to be used towards center of bed,
tucking under pt back
10. Strengthen mattress pad
11. Lay clean bottom sheet lengthwise. Fanfold far side
towards pt

Evaluation Tool
12. Tuck clean sheet so that it does not touch used soiled
bottom sheet.
13. Miter top corner & tuck length under mattress
14. If plastic drawsheet is used, pull over folded bottom sheets
& tuck
15. Cover plastic drawsheet if used, with cloth drawsheet
16. Tuck nearest side, fanfold another portion towards pt back
17. Raising side rails assist pt in rolling towards you over
linen raising side rail.
18. Move to the other side of bed & lower rail
19. Remove soiled linen & place in hamper. Remove gloves &
wash hands.
20. Straighten mattress pad
21. Pull & tuck drawsheet, if used
22. Move pt to center of the bed
23. Place top sheet on bed, removing bath blanket
24. Add blanket & spread, make toe pleat if appropriate, &
miter bottom corners.
25. Put clean case on pillow
26. reattach cell light & reinstate equipment
27. Place bed in low position
EVALUATION
1. Evaluate using the ff. criteria
a. patient comfort
b. smooth, wrinkled free surface
c. tight corners
d. bed in low position
e. bed & side rails correct position
f. call light & other items within pt reach

Evaluation Tool
DOCUMENTATION
1. Document any assessment data or change in pts clinical
status.
_______________________ _______________________ _______________________


Evaluation Tool
MAKING THE UNOCCUPIED BED

ASSESSMENT NOT
DONE DONE REMARKS
1. Check activity order for pt
2. Assess the pt
3. Check condition of linen on bed
4. Check for pt special needs
PLANNING
1. Wash hands
2. Obtain laundry bag or hamper
3. Gather linen to be used
4.Obtain other needed items or equipment including gloves
IMPLEMENTATION
1. Raise bed to appropriate working height. Be certain wheels
are locked
2. Removed attached equipment. Put on gloves before handling
linen soiled with body secretions.
3. Remove cases from pillows
4. Looses top or bottom linen from mattress
5. Removed clean item to be reused, fold & place across back
of chair
6. Remove remaining linen & place in hamper ( and so with the
gloves) wash hands before touching clean item
7. Turn mattress if necessary
8. Place mattress pad on mattress
9. Place bottom sheet on bed
10. Miter top corner of bottom sheet or if fitted sheet tuck
diagonally.
11. Tuck remainder of sheet under
12. Place plastic draw sheet on bed, tuck near edge
13. Place cloth drawsheet over plastic drawsheet, tuck near
edge

Evaluation Tool
14. Place & unfold top sheet on bed

15. Make top pleat (optional)
16. Place blanket on bed using center fold as guide
17. Place bed spread on bed tuck all three together or separately
18. Miter corner of top linen at foot of bed
19. Move to other side of bed
20. Tuck bottom sheet
21. Tuck plastic drawsheet snugly under mattress
22.Tuck cloth drawsheet
23. Smooth top sheet, blanket & spread, miter bottom corner
24. Fold top sheet back top edge of blanket & spread
25. Apply pillow case, keeping pillow & case away from
uniform
26 Replace call light & leave bed in appropriate position
EVALUATION
1. Evaluate using the ff. criteria
a. smooth, wrinkle-free surface
b. tight corners
c. low position
d. call light attach to appropriate place
DOCUMENTATION
1. Document linen change according to policy of the hospital
_______________________ _______________________ _______________________


Evaluation Tool
ASSISTING WITH THE USE OF A BEDPAN
PROCEDURE DONE NOT REMARKS

DONE
1. Review the patient’s chart for any limitations in physical
activity.
2. Bring bedpan and other necessary equipment to the bedside
stand or overbed table.
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around bed and close the door to the room, if
possible. Discuss the procedure with the patient and assess the
patient’s ability to assist with the procedure, as well as
personal hygiene preferences.
6. Place bedpan and cover on chair next to bed. Put on gloves.
7. Adjust bed to comfortable working height, usually elbow
height of the nurse. Place the patient in a supine position, with
the head of the bed elevated about 30 degrees, unless
contraindicated.
8. Fold top linen back just enough to allow placement of
bedpan. If there is no waterproof pad on the bed and time
allows, consider placing a waterproof pad under patient’s
buttocks before placing bedpan.
9. Ask the patient to bend the knees. Have the patient lift his
or her hips upward. Assist patient, if necessary, by placing
your hand that is closest to the patient palm up, under the
lower back, and assist with lifting. Slip the bedpan into place
with other hand.
10. Ensure that bedpan is in proper position and patient’s
buttocks are resting on the rounded shelf of the regular
bedpan or the shallow rim of the fracture bedpan.
11. Raise head of bed as near to sitting position as tolerated,
unless contraindicated. Cover the patient with bed linens.
12. Place call bell and toilet tissue within easy reach. Place the
bed in the lowest position. Leave patient if it is safe to do so.
Use side rails appropriately
13. Remove gloves and additional PPE, if used. Perform hand
hygiene.
Removing the Bedpan
14. Perform hand hygiene and put on gloves and additional
PPE, as indicated. Adjust bed to comfortable working height,
usually elbow height of the caregiver (VISN 8 Patient Safety
Center, 2009). Have a receptacle, such as plastic trash bag,
handy for discarding tissue.
15. Lower the head of the bed, if necessary, to about 30
degrees. Remove bedpan in the same manner in which it was
offered, being careful to hold it steady. Ask the patient to
bend the knees and lift the buttocks up from the bedpan.

Evaluation Tool
Assist patient, if necessary, by placing your hand that is

closest to the patient palm up, under the lower back, and assist
with lifting. Place the bedpan on the bedside chair and cover
it.
16. If patient needs assistance with hygiene, wrap tissue
around the hand several times, and wipe patient clean, using
one stroke from the pubic area toward the anal area. Discard
tissue, and use more until patient is clean. Place patient on his
or her side and spread buttocks to clean anal area.
17. Do not place toilet tissue in the bedpan if a specimen is
required or if output is being recorded. Place toilet tissue in
appropriate receptacle.
18. Return the patient to a comfortable position. Make sure
the linens under the patient are dry. Replace or remove pad
under the patient, as necessary. Remove your gloves and
ensure that the patient is covered.
19. Raise side rail. Lower bed height and adjust head of bed to
a comfortable position. Reattach call bell.
20. Offer patient supplies to wash and dry his or her hands,
assisting as necessary.
_______________________ _______________________ _______________________


Evaluation Tool
TURNING A PATIENT IN BED: BACK TO SIDE

DONE
1.Assess patient’s need.
2. Assess patient’s ability.
3. Check on assistive devices available.
PLANNING
1.Plan moving technique.
2. Wash your hands.
3. Obtain assistive devices.
IMPLEMENTATION
1. Identify patient.
2. Raise bed to high position.
3. Put bed in flat position.
4. Move the patient as follows:
a. Move patient to one side of bed.
b. Raise rail and move to other side.
c. Prepare pillows fore support.
d. Turn lower body, using one of two methods described.
e. Move patient’s near arm out of patient’s way.
f. Place patient’s far arm across chest.
g. Grasp patient behind far shoulder.
h. Roll patient toward you.
i. Position patient as needed.
5.Position patient correctly.
6. Make sure safety devices are in place.
7. Wash your hands.
EVALUATION

Evaluation Tool
1. Evaluate position for alignment.

2. Evaluate patient comfort.
DOCUMENTATION
1. Record time and position on flow sheet or nurse’s notes.

2. Record technique for moving on Nursing Care Plan.
_______________________ _______________________ _______________________


Evaluation Tool
TURNING A PATIENT: LOGROLLING

DONE
1.Assess patient’s need.
3. Check on assistive devices available.
PLANNING
1.Plan moving technique.
2. Wash your hands.
3. Obtain assistive devices.
IMPLEMENTATION
a. With help move patient to side of bed in one unit.
b. Raise side rail on the side of bed.
c. All assistants move to other side of bed.
d. Place pillows correctly.
e. Assistant reaches across and grasp patient’s body.
f. At count, all turn patients in one unit.
5.Position patient correctly.
7. Wash your hands.
EVALUATION
DOCUMENTATION

Evaluation Tool

_______________________ _______________________ _______________________


Evaluation Tool
MOVING A PATIENT UP IN BED: ONE PERSON ASSIST

DONE
1. Assess patient’s need.
3. Check on assisstive devices available.
PLANNING
1. Plan moving technique.
2. Wash your hands.
3.Obtain assisstive devices.
IMPLEMENTATION
a. Have the patient bend knees and places sole firmly on bed.
b. Have patient grasp overhead trapeze, side rails, or headboard.
c. Slide your hands and arms under patient’s hips, facing foot of
bed, without foot ahead of inside foot.
d. Instruct the patient to move with you at count.
e. On count, patient pulls with arms and pushes with feet as you
pull.
5. Position patient correctly.
7. Wash your hands.
EVALUATION
DOCUMENTATION

Evaluation Tool
_______________________ _______________________ _______________________


Evaluation Tool
POSITIONING A PATIENT
DONE NOT
DONE
REMARKS
CHAIR
1. Move patient into chair.
2. Place feet flat against floor.
3. Position knees and hips at right angle.
4. Straighten spine.
5. Support elbows on armrests.
6.Place handrolls, footrest, or bolsters if needed.
FOWLER’S POSITION
1. Place patient in supine position.
2. Elevate head of bed 18-20 inches
(approximately 45 degrees)
HIGH FOWLER’S POSITION
2. Elevate head of bed to angle of over 45
degrees.
SEMI-FOWLER’S POSITION
2. Elevate head of bed to angle less than 45
degrees (usually 20 – 30 degrees).
ORTHOPNEIC POSITION
1. Have patient sit up in bed with overbed table
across lap.
2. Pad table with pillows and elevate to
comfortable lap.
3. Have patient lean forward with head and arms
resting on table.
DORSAL RECUMBENT POSITION
1. Position patient on back.

Evaluation Tool
2. Raise knees and separate legs.

3. Feet remain in position on bed.
LITHOTOMY POSITION
1. Position patient on back.
2. Raise knees and separate legs.
3. If on table, place feet in stirrups.
SIM’S POSITION
1. Use side lying position with single pillow only
under head.
2. Turn far enough onto abdomen so lower arm
extends behind patient’s back.
KNEE-CHEST POSITION
1. Have patient kneel on bed or table with hips in
air and chest on bed or table.
2. If special table is available, have patient kneel
on platform with head and chest on table.
TRENDELENBURG POSITION
1. Place patient in supine position with head of
bed lowered. Tilt entire bed frame downward
with heads approximately 30 degree below
horizontal level.
2. Use pillow to protect the patient’s head.
_______________________ _______________________ _______________________


Evaluation Tool
COMPLETE BED BATH

DONE
1. Check chart for information related to patient’s ability to
participate in the procedure being planned.
2. Assess patient for specific symptoms.
3. Check to see what supplies are in room.
PLANNING
1. Determine assistance needed.
2. Determine what supplies and equipment are needed.
3. Wash your hands.
4. Obtain supplies basin, soap, hamper, clean linen, bath blanket,
clean garment, toilet articles, gloves.
IMPLEMENTATION
2. Explain procedure to patient.
3. Provide for patient’s privacy.
4. Raise bed for appropriate working level.
5. Carry out the bed bath.
a. Remove top linen and place bath blanket.
b. Give oral care if not already done.
c. Obtain water.
d. Position patient. Supine or semi-fowler’s position.
e. Bathe the patient in the following order:
1. Spread towel across patient’s chest.
2. Make mitt out of washcloth.
3. Wash patient face
4. Remove pt gown.
5. Place towel under far arm & bathe, rinse & dry far hand,
arms & axilla
6. Place towel under near arm and bathe, rinse and dry near
hand, arm & axilla
7.Spread across patient’s chest and wash, rinse, and dry
abdomen.

Evaluation Tool
8. Wash, rinse, and dry abdomen.

9. Place towel under far leg.
10. Place patient’s foot in bath basin.
11. Wash, rinse, and dry far leg
12. Wash, rinse, and dry far foot.
13. Wash near leg and foot.
14. Change the bath water and put on gloves.
15. Wash genital area or give patient an opportunity to do so.
16. Remove and dispose of gloves.
17. Change water.
18. Assist patient to turn and drape.
19. Wash, rinse, and dry neck and back.
20. Put on gloves.
21. Wash, rinse, and dry buttocks.
22. Remove and discard gloves.
23. Give back rub if desired
f. Help patient put on clean garment.
g. Assist patient with hair care.
h. Assist patient with nail care.
i. Assist male patient with shaving.
j. Make occupied bed and return to low position.
k. Tidy up area.
6. Watch patient for adverse responses.
7. Care for equipment and supplies.
8. Wash your hands.
EVALUATION
1. Evaluate in terms of the following criteria:
a. Fatigue
b. Feelings about comfort and cleanliness.

Evaluation Tool
c. Objective signs of cleanliness.

DOCUMENTATION
1. Document as appropriate for your facility.
_______________________ _______________________ _______________________


Evaluation Tool
ORAL CARE
DONE
1. Check chart for information related to patient’s ability to
participate in the procedure being planned.
2. Assess patient for specific symptoms.
3. Check to see what supplies are in room.
PLANNING
1. Determine assistance needed.
2. Determine what supplies and equipment are needed.
3. Wash your hands.
4. Obtain supplies: Toothbrush, toothpaste or powder, cup of
water, emesis basin, face towel, dental floss, clean gloves.
IMPLEMENTATION
2. Explain procedure to patient.
3. Provide for patient’s privacy.
4. Raise bed for appropriate working level.
5. Provide oralcare
a. Place towel under patient’s chin.
b. Put on clean gloves.
c. Moisten toothbrush and apply cleansing agent.
d. Brush teeth.
e. Allow patient to rinse with water.
f. Wipe patient mouth
g. Use swabs or gauze to cleanse all surfaces of the mouth.
h. Rinse patients mouth.
i. Wipe patient’s mouth.
j. Lubricate lips as needed.
k. Return bed to low positioning.

Evaluation Tool
6. Watch patient for adverse responses.

7. Care for equipment and supplies.
8. Wash your hands.
EVALUATION
1. Evaluate in terms of the following criteria.
a. Fatigue
b. Feelings about comfort and cleanliness.
c. Objective signs of cleanliness.
DOCUMENTATION
1.Document as appropriate for your facility.
_______________________ _______________________ _______________________


Evaluation Tool
ASSISTING WITH THE USE OF URINAL

DONE
activity.
2. Bring urinal and other necessary equipment to the bedside
stand or overbed table.
5. Close the curtains around the bed and close the door to the
room, if possible. Discuss procedure with patient and assess the
patient’s ability to assist with the procedure, as well as personal
hygiene preferences.
6. Put on gloves.
7. Assist the patient to an appropriate position, as necessary:
standing at the bedside, lying on one side or back, sitting in bed
with the head elevated, or sitting on the side of the bed.
8. If the patient remains in the bed, fold the linens just enough to
allow for proper placement of the urinal.
9. If the patient is not standing, have him spread his legs slightly.
Hold the urinal close to the penis and position the penis
completely within the urinal. Keep the bottom of the urinal lower
than the penis. If necessary, assist the patient to hold the urinal in
place.
10. Cover the patient with the bed linens.
11. Place call bell and toilet tissue within easy reach. Have a
receptacle, such as plastic trash bag, handy for discarding tissue.
Ensure the bed is in the lowest position. Leave patient if it is safe
to do so. Use side rails appropriately.
hygiene.
Removing the Urinal
13. Perform hand hygiene. Put on gloves and additional PPE, as
indicated.
14. Pull back the patient’s bed linens just enough to remove the
urinal. Remove the urinal. Cover the open end of the urinal.
Place on the bedside chair. If patient needs assistance with
hygiene, wrap tissue around the hand several times, and wipe
patient clean. Place tissue in receptacle.
15. Return the patient to a comfortable position. Make sure the
linens under the patient are dry. Remove your gloves and ensure
that the patient is covered.
16. Ensure patient call bell is in reach.
17. Offer patient supplies to wash and dry his hands, assisting as
necessary.

Evaluation Tool
18. Put on clean gloves. Empty and clean the urinal, measuring
urine in graduated container, as necessary. Discard trash
receptacle with used toilet paper per facility policy.
19. Remove gloves and additional PPE, if used, and perform
hand hygiene.
_______________________ _______________________ _______________________


Evaluation Tool
ASSISTING WITH THE USE OF BEDSIDE COMMODE

DONE
activity.
2. Bring the commode and other necessary equipment to the
bedside. Obtain assistance for patient transfer from another staff
member, if necessary.
5. Close the curtains around the bed and close the door to the
room, if possible. Discuss procedure with the patient and assess
the patient’s ability to assist with the procedure, as well as
personal hygiene preferences.
6. Place the commode close to, and parallel with, the bed. Raise
or remove the seat cover.
7. Assist the patient to a standing position and then help the
patient pivot to the commode. While bracing one commode leg
with your foot, ask the patient to place his or her hands one at a
time on the armrests. Assist the patient to lower himself/herself
slowly onto the commode seat.
8. Cover the patient with a blanket. Place call bell and toilet
tissue within easy reach. Leave patient if it is safe to do so.
Assisting Patient Off Commode
9. Perform hand hygiene. Put on gloves and additional PPE, as
indicated.
10. Assist the patient to a standing position. If patient needs
assistance with hygiene, wrap toilet tissue around your hand
several times, and wipe patient clean, using one stroke from the
pubic area toward the anal area. Discard tissue in an appropriate
receptacle, according to facility policy, and continue with
additional tissue until patient is clean.
11. Do not place toilet tissue in the commode if a specimen is
required or if output is being recorded. Replace or lower the seat
cover.
12. Remove your gloves. Return the patient to the bed or chair.
If the patient returns to the bed, raise side rails, as appropriate.
Ensure that the patient is covered and call bell is readily within
reach.
13. Offer patient supplies to wash and dry his or her hands,
assisting as necessary.
14. Put on clean gloves. Empty and clean the commode,
measuring urine in graduated container, as necessary.
hygiene.

Evaluation Tool
_______________________ _______________________ _______________________


Evaluation Tool
GIVING BACK MASSAGE
DONE NOT REMARKS

DONE
Implementation
1. Identify factors or conditions such as rib
fractures, burns, or open wounds that
contraindicate backrub.
2. For client with history of hypertensions or
dysrhythmias, assess pulse and blood pressure.
3. Remove rings and watch. Wash hands.
4. Explain procedure and desired position to the
client.
5. Prepare a necessary equipments and supplies.
6. Adjust bed to high comfortable position.
7. Adjust light temperature and sound within
room.
8. Lower side rails and help client to assume
prone or side lying(sim’s) position with back
towards you, depending on client’s condition.
Close curtain around bed.
9. Expose the client’s back, shoulder, upper
arms, and the sacral area. Cover remainder of the
body with the bath blanket. Lay towel
underneath client’s body.
10. Warm the massage lotion or oil before use by
pouring it into your hand before applying it to
the client’s back.
11. Apply lotion using figure of 8 starting at the
sacral area.
12. Effleurage the entire back. Place your hands
next to the lower spine, using your palms and
fingers, slowly massage upwards to the neck,
gradually decreasing pressure as you get close to
the neck, circle shoulder blades.
13. Petrissage the back and the shoulders of the
client. Petrissage first along side of vertebral
column and then over the entire back. Observe
client carefully to ensure that petrissage doesn’t
cause pain or discomfort. If the client grimaces
or withdraws from the touch, ease the kneading
pressure.
14. Apply hard pressure movements up the back.
Using moderate pressure, walk your hands up
the outer edges of the back from the hips to the
neck.

Evaluation Tool
15. Apply friction strokes next to the spine. Use

your thumbs to apply friction strokes (strong
circular motion). Massage back, moving from
side to side in smooth, tiny circles, starting at the
neck and ending at the waist.
16. Apply pressure strokes along the spinal
column. Place one hand on the top of the other
and move slowly from the lower spine, using
moderate to light pressure.
17. Using gentle pressure , apply large circular
movements to the back. Move from the waist
line to the lower hips, then across the hips and up
the spine.
18. Finish treatment with effleurage lessen the
pressure.
19. Wipe excess lubricant from client to
comfortable position. Open curtain and raise side
rails as needed.
20. Dispose of soiled towel and wash hands.
21. Ask client about comfort. Note any areas of
muscle pain or tension.
22. Reassess pulse and blood pressure.
23. Record response to massage and condition of
the skin.
_______________________ _______________________ _______________________


Evaluation Tool
Mixing Medications From Two Vials in One Syringe

Goal: The proper dosage of medication is withdrawn into a syringe using sterile technique.
DONE NOT REMARKS

DONE
1. Gather equipment. Check medication order against the

original order in the medical record, according to
facility policy.
2. Know the actions, special nursing considerations, safe
dose ranges, purpose of administration, and adverse
effects of the medications to be administered.
Consider the appropriateness of the medication for this
patient.
3. Perform hand hygiene.
4. Move the medication cart to the outside of the
patient’s room or prepare for administration in the
medication area.
5. Unlock the medication cart or drawer. Enter pass code
and scan employee identification, if required.
6. Prepare medications for one patient at a time.
7. Read the CMAR/MAR and select the proper
medications from the patient’s medication drawer or
unit stock.
8. Compare the labels with the CMAR/MAR.
Check expiration dates and perform calculations,
if necessary. Scan the bar code on the package, if
required.
9. If necessary, remove the cap that protects the
rubber stopper on each vial.
10. If medication is a suspension (e.g., NPH insulin),
roll and agitate the vial to mix it well.
11. Cleanse the rubber tops with antimicrobial
swabs.
12. Remove cap from needle by pulling it straight
off. Touch the plunger at the knob only. Draw
back an amount of air into the syringe that is
equal to the dose of modified insulin to be
withdrawn.
13. Hold the modified vial on a flat surface. Pierce
the rubber stopper in the center with the needle
tip and inject the measured air into the space
above the solution. Do not inject air into the
solution. Withdraw the needle.
14. Draw back an amount of air into the syringe that
is equal to the dose of unmodified insulin to be
withdrawn.

Evaluation Tool
15. Hold the unmodified vial on a flat surface. Pierce

the rubber stopper in the center with the needle
tip and inject the measured air into the space
above the solution. Do not inject air into the
solution. Keep the needle in the vial.
16. Invert vial of unmodified insulin. Hold the vial
in one hand and use the other to withdraw the
medication. Touch the plunger at the knob only.
Draw up the prescribed amount of medication
while holding the syringe at eye level and
vertically. Turn the vial over and then remove
needle from vial.
17. Check that there are no air bubbles in the
syringe.
18. Check the amount of medication in the syringe
with the medication dose and discard any
surplus.
19. Recheck the vial label with the CMAR/MAR.
20. Calculate the endpoint on the syringe for the
combined insulin amount by adding the number
of units for each dose together.
21. Insert the needle into the modified vial and invert
it, taking care not to push the plunger and inject
medication from the syringe into the vial. Invert
vial of modified insulin. Hold the vial in one
hand and use the other to withdraw the
medication. Touch the plunger at the knob only.
Draw up the prescribed amount of medication
while holding the syringe at eye level and
vertically. Take care to withdraw only the
prescribed amount. Turn the vial over and then
remove needle from vial. Carefully recap the
needle. Carefully replace the cap over the needle.
22. Check the amount of medication in the syringe
with the medication dose.
23. Recheck the vial label with the CMAR/MAR.
24. Label the vials with the date and time opened,
and store the vials containing the remaining
medication according
to facility policy.
25. Lock medication cart before leaving it.
26. Perform hand hygiene.
27. Proceed with administration, based on prescribed
route.

Evaluation Tool
_______________________ _______________________ _______________________


Evaluation Tool
ADMINISTERING ORAL MEDICATIONS

Materials Needed:
• Medication card
• Sterile gloves (optional)
• Medicine Tray
• Medicine cup (calibrated)
• Medicine dropper
• Face towel prescribed syrup medication
• prescribed medicine in a blister foil pack
• prescribed medicine in a multidose bottle
PROCEDURES DONE NOT REMARKS
DONE
ASSESSMENT
1. Verify the physician’s order of medication,
check for the medication listed on the
medicine card against the physician’s
order sheet and standing order sheet/
2. Check the client’s chart for allergies.
3. Know the actions, special nursing
considerations, safe-dose ranges, purpose
of administration, and adverse effects of
medications to be administered.
PLANNING
1. Wash your hands
2. Prepare medications for one client at a
time.
3. Ensure proper lighting to facilitate ease in
administration
IMPLEMENTATION
1. Select the proper medication from the
drawer or stock and compare with the
Kardex. Check expiration dates and
perform calculations.
2. For unit-dose packaged medications, place
capsule or tablet directly in a disposable
cup. Do not open package until at bedside.
3. For medications in a stock container, pour
the necessary number into the bottle cap
and then place the tablets in a medication
cup.
4. For liquid medications, remove the cap
and place it upside down. Hold the bottle
with the label against the palm. Place the
medication cup on a flat surface at eye
level. Pour the desired amount of liquid
and read the amount of medication at the
bottom of the meniscus.
5. Recheck each medication that has been
prepared for one client; recheck once

Evaluation Tool
again with the medication order before

taking them to the client.
6. Transport medications to the client’s
bedside carefully and keep the
medications in sight at all times.
7. See that the client receives medications at
the correct time.
8. Identify the client carefully. There are
three correct ways to do this:
o Check the name of the client’s
identification band.
o Ask the client his or her name.
o Verify the client’s identification
with a staff member who knows
the client.
9. Assist the client to an upright or lateral
position.
10. Administer medications:
o Offer water or other permitted
fluids withpills, capsules, tablets,
and some liquid medications.
o Ask the client’s preference
regardingmedications to be taken
by hand or in cup and one at a time
or all at once.
o If the capsule or tablet falls to the
floor, it must be discarded and a
new one administered.
11. Record any fluid intake and output
measurement as ordered.
12. Remain with the client until each
medication is swallowed.
8. Wash your hands.
EVALUATION
1. Evaluate using the following criteria:
o 10 rights followed
o Correct site used
o Effectiveness of medication
assessed
o Any side effect promptly identified
DOCUMENTATION
1. Record pertinent data in terms of:
o Medication dosage
o Route of administration
o Time of administration
o Signature
_______________________ _______________________ _______________________


Evaluation Tool

Level 2

Uploaded by

Copyright:

Available Formats

Level 2

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Level 2

Uploaded by

Copyright:

Available Formats

2023

Level 2: Skills CHECKLIST

Administering An Intramuscular Injection Heat and Acetic Acid Test

Administering A Subcutaneous Injection Benedict’s Test

HANDWASHING: VISIBLY SOILED Removing Medication from An Ampule

DONNING AND REMOVING CLEAN

MOVING A PATIENT UP IN BED: ONE

Bachelor of Science in Nursing

STUDENT’S NAME: _______________________________________ YR/SEC________ DATE:__________

INSTRUCTOR: __________________________________________ SCORE: _______

Special Considerations in the Use of the Bag”

Contents of the Bag:

Bachelor of Science in Nursing

STUDENT’S NAME: _______________________________________ YR/SEC________ DATE:__________

INSTRUCTOR: __________________________________________ SCORE: _______

• Thermometers (1 oral, 1 rectal)

DONE NOT REMARKS

Bachelor of Science in Nursing

STUDENT’S NAME: _______________________________________ YR/SEC________ DATE:__________

INSTRUCTOR: __________________________________________ SCORE: _______

8. After handwashing, put the soap and soap dish on

Bachelor of Science in Nursing

STUDENT’S NAME: _______________________________________ YR/SEC________ DATE:__________

INSTRUCTOR: __________________________________________ SCORE: _______

Heat and Acetic Acid Test

Criteria DONE NOT REMARKS

_______________________ _______________________ _______________________

Bachelor of Science in Nursing

STUDENT’S NAME: _______________________________________ YR/SEC________ DATE:__________

INSTRUCTOR: __________________________________________ SCORE: _______

Removing Medication from An Ampule

Done Not remarks

_______________________ ______________________________ _______________________

Bachelor of Science in Nursing

STUDENT’S NAME: _______________________________________ YR/SEC________ DATE:__________

INSTRUCTOR: __________________________________________ SCORE: _______

Removing Medication From A Vial

Done Not Remarks

_____________________ ____________________________ _____________________

Bachelor of Science in Nursing

STUDENT’S NAME: _______________________________________ YR/SEC________ DATE:__________

INSTRUCTOR: __________________________________________ SCORE: _______

Administering an Intradermal Injection

Criteria DONE NOT REMARKS

1. Assemble the equipment and check the physician’s order.

_______________________ ______________________________ _______________________

Bachelor of Science in Nursing

STUDENT’S NAME: _______________________________________ YR/SEC________ DATE:__________

INSTRUCTOR: __________________________________________ SCORE: _______

Administering An Intramuscular Injection

Criteria DONE NOT REMARKS

Bachelor of Science in Nursing

STUDENT’S NAME: _______________________________________ YR/SEC________ DATE:__________

INSTRUCTOR: __________________________________________ SCORE: _______

18. Evaluate the response of the client to the medication

_____________________ ____________________________ _____________________

Bachelor of Science in Nursing

STUDENT’S NAME: _______________________________________ YR/SEC________ DATE:__________

INSTRUCTOR: __________________________________________ SCORE: _______

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

___________ _ _____________

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

_ ___

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

_ _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

_ ___

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

_ _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

___________ _ _____________

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

___________ _ _____________

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

___________ _ _____________

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

___________ _ _____________

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

___________ _ _____________

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

STUDENT’S NAME: _____________________________ YR/SEC DATE:

INSTRUCTOR: ____________________________________ SCORE: _

___________ _ _____________