level iii performance checklist

PREPARING A STERILE FIELD:

USING A COMMERCIALLY PREPARED STERILE KIT/TRAY
Purpose

 To prepare a sterile field following the principles of sterile technique

Equipment

 Commercially prepared sterile kit

 Sterile gauze
 Normal saline solution
 Sterile Kidney basin

Goal

 A sterile field is created without contamination, the contents of the package remain
sterile, and the patient remains free of exposure to potential infection-causing
microorganisms.

Criteria Done Not Remarks Rating

done
ASSESSMENT:
1. Gather all the materials needed.
2. Check that the packaged kit or tray is dry and
unopened. Also note expiration date, making sure
that the date is still valid.

PLANNING
1. Select a work area that is waist level or higher.

IMPLEMENTATION
a. SPECIAL CONSIDERATIONS
1. Wash hands
2. Inspect all sterile package’s for package
integrity, contamination, or moisture
3. During the entire procedure never turn
back on the sterile field or lower hands
below the level of the field.
b. OPENING A STERILE DRAPE
1. Remove the sterile drape from the outer
wrapper and place the inner drape in the
surface of the work surface, at or above
waist level, with the outer flap facing
away from you.

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 level iii performance checklist
2. Touching the outside of the flap, reach
around (rather than over) the sterile field
to open the flap away from you
3. Open the side flaps in the same manner,
using the right hand for the right and the
left hand for the left flap.
4. Open the innermost flap that faces you,
being careful that it does not touch your
clothing or any object.
c. ADDING STERILE SUPPLIES
1. Open the unsealed edge of prepackaged
sterile supplies, taking care not to touch
the supplies with the hands.
2. Hold supplies 10-12 inches above the
field and allow them to fall to the middle
of the sterile field.
3. Wrapped sterile supplies are added by
holding the sterile object with one hand
and unwrapping the flaps with the other
hand. Carefully drop the object onto the
sterile field.
d. POURING SOLUTION ON A STERILE
FIELD.
1. Check the label and expiration date of the
solution. Note any signs of
contamination.
2. Remove the cap and place it with facing
up on a flat surface. Do not touch inside
of cap or rim of bottle.
3. Pour a small amount of solution into a
sink or waste container. (this is done
when pouring weak solution like sterile
normal saline solution. Distilled water).
4. Hold bottle 6 inches above receptacle on
the sterile field and pour slowly to avoid
spills.
5. Recap the solution bottle. Place it outside
the sterile field and label it with date and
time of opening if the solution is to be
reused.
6. Add any additional supplies and do
sterile gloves before stating the

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 level iii performance checklist
procedure

Evaluator

________________________ ________________________ ________________________

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

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 level iii performance checklist
PREPARING THE OPERATION SITE

Purpose

 To reduce the resident and transient microbial counts at the surgical site immediately
prior to making the surgical incision.
 To minimize rebound microbial growth during the intraoperative and postoperative
period.
 To reduce the risk of post surgical site infection.
 To prevent injury to the patient during surgical skin preparation.

Equipment

 Adequate lightning for clear visibility of the hair on the skin.

 Bath blanket
 Skin preparation set
 Disposable razor
 Basin for solution
 Moisture proof drape
 Soap solution
 Sponges
 Cotton tipped application
 Warm water
 Disposable gloves

Goal

 The sterile field is created without contamination, the sterile supplies are not
contaminated, and the patient remains free of exposure to potential infection-causing
microorganisms.

Criteria Done Not Remarks Rating

done
ASSESSMENT:
1. Identify presence of growth, moles, rashes,
pustules, irritations, exudates, bruises or broken
or ischemic areas.
PLANNING
1. Prepare all the equipment needed.

IMPLEMENTATION

1. Wash Hands

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 level iii performance checklist
2. Identify the patient
3. Explain the procedure
4. Drape the client appropriately
5. Don the disposable gloves
6. Place the moisture proof drape under the area to
be prepared. Lather the skin well with soap
solution. Stretch the skin taut, and hold the razor
at about 450 angle to the skin. Share in the
direction in which hair grows. Wipe excess hair
off the skin with sponges.
7. Clean and disinfect the surgical area according to
hospital policy.
8. Inspect the skin after hair removal. Check for
redness, presence of broken areas.
9. Dispose used equipment appropriately.
EVALUATION
1. Document all relevant information. Record the
procedure, area prepared and status of the skin.

Evaluator

________________________ ________________________ ________________________

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

SURGICAL HAND WASHING

(SCRUBBING)

Purpose

 To remove or deactivate natural skin oil, hand lotions and transient microorganisms of
those who will attend sterile situations

Equipment

 Antiseptic soap

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 level iii performance checklist
 Antiseptic agent
 Running water
 Soft stick with pinpoint end or brush for cleaning underneath fingernails
 Hand towels

Goal

 The hands will be free of visible soiling and transient microorganisms will be
eliminated.

Criteria Done Not Remarks Rating

done
ASSESSMENT:
1. Assess client care situations that require surgical
hand washing.
2. Examine hands and forearms for cuts or
blemishes.
3. Ensure that fingernails are in good condition and
no longer than the tips of the fingers.
PLANNING:
1. Gather all the materials needed.
2. Prepare yourself.
2.1 Put on surgical attire (scrub garments)
2.2 Put on cap and mask.
2.3 Remove watches, rings or bracelets.
2.4 Remove nail polish and/ or artificial nails if
worn and clip nails so they are no longer in
length than the fingertips.

IMPLEMENTATION:
A. A. Perform the pre-scrub
1. Turn on water and adjust temperature.

2. . At a deep sink with knee or foot controls, turn on

water and wet forearms and the hands, from elbow to
fingertips.
3. Apply a liberal amount of soap onto hands. Rub
arms and hands with soap to 3 inches above
elbows.
4. Rinse hands with water from hands down to the
elbow
5. Keep hands and arms above elbow level at all

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 level iii performance checklist
times.
6. Clean each nail with file then rinse it under
running water.

B. Scrub
Counted brush stroke method
1. Wet and apply soap to scrub brush.
2. Place a brush in dominant hand and use a circular
motion to scrub nails and skin area of non-
dominant hand and arm.
3. Use different strokes to each of these areas:
 Nails – 30 strokes
 Palms – 20 strokes
 Side of the thumb – 20 strokes
 Posterior of thumb – 20 strokes
 Sides and posterior surface of the fingers –
20 strokes
 Back of the hand – 20 strokes
4. Rinse brush thoroughly and reapply soap.
5. Using 20 strokes for each third of the arm of non-
dominant arm then the elbow.
6. Rinse brush and reapply soap and repeat the same
procedure to scrub your dominant hand and arm
then the elbow.
7. Rinse the brush and return it to the container.

C. Rinse
1. Rinse both hands from finger tips down to the
elbow.
2. Keep your hands in front of you, above the waist
and not higher than the axilla, and move to location of
sterile towels.
3. Walk in the operating room with both hands still
pointing upward.
D. Dry hands and arms
1. Pick up sterile towel

2. Allow towel to unfold

3. Use of first half to dry first hand and arm
4. Use second half to dry second hand and arm

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 level iii performance checklist
Documentation
1. Document the procedure

Evaluator

________________________ ________________________ ________________________

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

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 level iii performance checklist
DONNING AND REMOVING STERILE GLOVES

Purpose

 To reduce the risk from transmission of microorganisms by the direct contact from body
substances

Equipment

 Sterile pair of appropriate sized-gloves

Goal

 The gloves are applied and removed without contamination

Criteria Done Not Remarks Rating

done
ASSESSMENT:
1. Perform hand hygiene and put on PPE, if
indicated.
2. Identify the patient. Explain the procedure to the
patient.
3. Check that the sterile glove package is dry and
unopened. Also note expiration date, making sure
that the date is still valid.
PLANNING
1. Prepare equipment and supplies.

IMPLEMENTATION

A. GLOVING (OPEN METHOD)

1. Do surgical hand washing and scrubbing
2. If gloves are not prepowdered, take packet of
powder from package and apply lightly to
hands held over wastebasket or sink.
3. Arrange glove package on a flat surface.
4. Read the manufacturer’s instruction on the
package of the sterile gloves; proceed as
directed in removing the outer wrapper from
the package, placing the wrapper into a clean,
dry surface. Open the inner wrapper to expose
the gloves. Be aware of the immediate
environment to avoid accidental
contamination.
5. Identify the right and the left hand, glove the

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 level iii performance checklist
dominant hand first.
6. Grasp the 2-inches (5cm) wide cuff with the
thumb and the first two fingers of the non
dominant hand, touching only the inside of
the cuff.
7. Gently full the glove over the dominant hand
making sure that the thumb and fingers fit into
proper spaces of the gloves. Leave the folded
cuff.
8. Make a pleat at the left cuff of the gown and
secure this in place with your right thumb.
9. Slip the four fingers of the right hand under
the fold of the glove and pull it over the
pleated cuff of the sleeves. Fit the gloves and
pull it over the pleated cuff of the sleeves.
10. Repeat the same procedure for the left hand.
B. ASSISTED ( SERVING OTHERS)
1. Open the powder pack and serve it to the
surgeon over the bucket.
2. Get the right hand glove and inflate it to first
for easy insertion to defect for holes.
3. In serving for the gloves, the palmer surface or
the thumb portion should be facing the one
who is being served.
4. Evert the cuff one inch wide. Insert four inside
the everted cuff.
5. Stretch the gloves well. Pull your thumbs out.
6. Allow the surgeon to explore the finger hole.
7. When the surgeon move, or jerks his, hand
downward release your hold upward so that
the cuff of the gloves covers the cuff of the
gown.
8. Repeat the same procedure to the left hand.
C. GLOVING (CLOSED METHOD)
1. With fingers within the cuff of the gown, open
the inner sterile glove package and pick up the
first glove by the cuff, using the non-dominant
hand.
2. Position the glove over the cuff of the gown so
the fingers are in alignment, and stretch the
entire glove over the cuff of the gown, being
careful not to touch its edge. Fingers remain

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 level iii performance checklist
within the cuff of the gown.
3. Work the fingers into the glove and pull the
glove up over wrist with the non-dominant
hand that still remains within the cuff of the
gown.
4. Use the sterile gloved hand to pick up the
second glove, placing it over the cuff of the
gown of the other hand and repeat the glove
application process.
5. Adjust gloves for comfort and fit, taking care
to keep gloved hands above waist level at all
times.

Evaluator

________________________ ________________________ ________________________

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

DONNING A STERILE GOWN AND GLOVES

Purpose

 To reduce the risk from transmission of microorganisms by the droplet contact, airborne
routes and splatters of body substances
Equipment
 Gown
 Gloves

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 level iii performance checklist
Goal

 Gowning is performed without contamination, the gown is not contaminated, and the
patient remains free of exposure to potential infection-causing microorganisms.

Criteria Done Not Remarks Rating

done
ASSESSMENT
1. Check that the sterile glove package is dry and
unopened. Also note expiration date, making sure
that the date is still valid.
2. Review the principles and practices of sterile
technique.
PLANNING
1. Wear complete OR attire.

2. Perform thorough surgical hand wash.

3. Proceed to the assigned OR room and back table
and take gown and gloves.

IMPLEMENTATION
A. A. UNASSISTED (SELF-SERVICE)
1. Pick up gown by neck edge.
2. Step one two feet away from the sterile field to
have an adequate working space.
3. Facing the sterile field, unfold the gown and
expose the hemline portion. Dry your hands
and arms with this small portion. Use each
side of the folded gown in drying each hand
and arm.
4. Continue unfolding the gown and locate for
the armhole.
5. Position gown so that you are facing the
wrong side of the front part of the gown.
6. Slip your hand into each armhole and your
hands and arms straight and obliquely
upward. The circulating nurse will fix it.
7. Stop and swing your body to the right, then to
the left. The circulating nurse will catch the
belt on its ends as you swing.
B. GLOVING (CLOSED METHOD)
1. With fingers within the cuff of the gown, open
the inner sterile glove package and pick up the

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 level iii performance checklist
first glove by the cuff, using the non-dominant
hand.
2. Position the glove over the cuff of the gown so
the fingers are in alignment, and stretch the
entire glove over the cuff of the gown, being
careful not to touch its edge. Fingers remain
within the cuff of the gown.
3. Work the fingers into the glove and pull the
glove up over wrist with the non-dominant
hand that still remains within the cuff of the
gown.
4. Use the sterile gloved hand to pick up the
second glove, placing it over the cuff of the
gown of the other hand and repeat the glove
application process.
5. Adjust gloves for comfort and fit, taking care
to keep gloved hands above waist level at all
times.
C. ASSISTED (SERVING OTHERS)
1. Pick up the gown directly from the table.
2. Unfold the gown slowly and serve the hemline
portion to the surgeon.
3. Continue unfolding the gown while the
surgeon is drying his hands and arms.
4. When serving the gown, your gloved hands
should come in contact with the right side
portion of the gown under the protecting cuff
made.
5. Show the opening and armholes to the
surgeon.
6. As soon as the surgeon inserted his hands
through the armholes, leave it. The circulating
nurse will fix it.
D. OPEN ASSISTED GLOVING
1. Holding the right glove open with the
palm facing toward the person being
gloved
2. Evert the cuff one inch wide. Insert four
fingers inside the everted cuff.
3. Scrub person keeps thumbs extended
(abducted) to avoid being touched by bare
hands of person donning gloves.

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 level iii performance checklist
4. Stretch the gloves well.
5. Allow the surgeon to explore the finger
hole.
6. When the surgeon move, or jerks his hand
downward release your hold upward so
that the cuff of the gloves covers the cuff of
the gown.
7. Repeat the same procedure to the left
hand.
E. WORKING IN STERILE ATTIRE
1. Keep your hands in front of you and above
waist level, below axilla.
2. Do not turn your back on sterile field.
3. Pass front to front or back to back with
others in sterile field.
4. Change attire when contaminated.
5. Warn others of your movements.

Evaluator

________________________ ________________________ ________________________

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

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 level iii performance checklist
INSERTING A STRAIGHT OR INDWELLING CATHETER TO A MALE PATIENT

Purpose

 To relieve discomfort due to bladder distention or to provide gradual decompression of

a distended bladder
 To assess amount of residual urine if the bladder empties incompletely
 To obtain a sterile urine specimen
 To empty the bladder completely prior to surgery
 To facilitate accurate measurement of urinary output for critically ill clients whose
output needs to be monitored hourly
 To provide for intermittent or continuous bladder drainage and/or irrigation
 To prevent urine from contaminating an incision after perineal surgery
 To manage incontinence when other measures have failed

Equipment

 Sterile catheter of appropriate size (an extra should be on hand)

 Catheterization kit:
 1-2 pair of sterile gloves
 Waterproof drape
 Antiseptic solution
 Cleansing cotton balls
 Forceps
 Water soluble lubricant
 Urine receptacle
 Specimen container
 For indwelling catheter:
 Syringe prefilled with sterile water in amount specified by the manufacturer
 Collection bag and tubing
 Disposable clean gloves
 Bath blanket for draping the client
 Adequate lighting

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Goal

 The patient’s urinary elimination is maintained, with a urine output of at least 30

mL/hour, and the patient’s bladder is not distended.

Criteria Done Not Remarks Rating

done
ASSESSMENT
1. Assess status of client.
• When client last voided
• Level of awareness or developmental stage
• Mobility & physical limitations
• Bladder distention
• Any pathological conditions & allergies
• Sex & age
2. Review client’s medical record, including
physician’s order.
PLANNING
1. Gather all materials needed.
2. Explain the procedure to the client & provide
privacy.
IMPLEMENTATION
1. Wash hands.
2. Facing client, stand on the left side of the bed if
right handed (right side if left handed). Clear
beside table and arrange equipment.
3. Place the side rail on opposite of the bed.
4. Close the cubicle or room curtains.
5. Place the waterproof pad under patient.
6. Position client. Assist to supine position with
thighs slightly abducted.
7. Drape patient. Drape upper trunk with a bath
blanket and cover lower extremities with bed
sheets, exposing only genitalia.
8. If inserting indwelling catheter, open package
containing draining system. Place drainage bag
over edge of bottom bed frame. Bring drainage
tube up between side rail and mattress.
9. Open catheterization kit according to directions,
using aseptic technique. Place waste receptacle in
accessible places.
10. Don sterile gloves.

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 11. Organize supplies on sterile field:
 Open sterile package containing catheter; pour
sterile package of antiseptic solution in correct
compartment containing sterile cotton balls.
 Lubricate tip of catheter, remove specimen
container (lid should be loosely placed on top)
and prefilled syringe from collection
compartment of tray and set them aside on
sterile field.
12. Nurse may want to ensure that inflatable balloon
of indwelling catheter is intact by inserting
syringe tip through valve of intake lumen &
injecting sterile fluid until balloon inflates. Then
aspirate all fluid out of the inflated lumen.
13. Apply sterile drape: Apply sterile drape over
thighs just below the penis. Pick up fenestrated
sterile drape and allow it to unfold without
touching any unsterile object. Apply drape over
the penis with fenestrated slit resting over penis.
14. Place sterile tray & contents on sterile drape
between thighs.
15. Determine that catheter tip is properly lubricated.
Male 12.5 – 17.5 cm (5-7 in).
16. Cleanse urethral meatus:
 If patient is not circumcised, retract foreskin
with non-dominant hand.
 Grasp penis at shaft just below glands.
 Retract urethral meatus between thumb and
forefinger.
 Maintain non-dominant hand in this position
throughout procedure.
B. With dominant hand pick up cotton balls and
clean penis. Move it in circular motion from
meatus down to base of glans. Repeat
cleansing two more time using clean cotton
balls each time.
17. Pick up catheter with gloved dominant hand 7.5-
10 cm (3-4 in) from catheter tip. Hold end of
catheter loosely coiled in palm of dominant hand
(optional: May grasp catheter with forceps). Place
distal end of catheter in urine tray receptacle.
18. Insert catheter:
 Lift penis to position perpendicular to client’s

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 body and apply light traction.
 Ask patient to near down as if to void and
slowly insert catheter through meatus.
 Advance catheter 17.5 to 22.5 cm (7-9 in) in
adult and 5 to 7.5 cm (2-3 in) in young child or
until urine flows out the catheter’s end. When
urine appears, advance catheter another 5 cm
(2in). Do not force against resistance.
 Lower penis and hold catheter securely in
non-dominant hand. Place end of catheter in
urine tray receptacle.
19. Collect urine specimen as needed: fill the
specimen cup to desired level (20-30ml) by
holding end of catheter in dominant hand over
cup. With dominant hand, pinch catheter to stop
urine flow temporarily. Release catheter to allow
remaining urine in bladder to drain into collection
tray. Cover specimen cup & set aside for labeling.
20. Allow bladder to empty fully (about 750-1000ml)
unless institution policy restricts maximal volume
of urine to drain with each catheterization.
21. A. For straight single use catheter: Pinch catheter
& remove slowly but smoothly when urine cease
to flow.
B. For indwelling catheter, inflate balloon of
indwelling catheter.
 While holding catheter with thumb & little
finger of non-dominant hand at meatus,
take end of catheter and place it between
first two fingers of non-dominant hand.
 With free dominant hand, attach syringe to
injection port at end of catheter.
 Slowly inject total amount of solution. If
patient complains of sudden pain, aspirate
back solution and advance catheter
further.
 After inflating balloon fully, release
catheter with non-dominant hand and pull
gently to feel resistance.
22. Attach end of catheter to collecting tube of
drainage system. Drainage bag must be below
level of bladder.
23. Tape catheter tubing on top of thigh or lower

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 abdomen. Allow slack in catheter so movement of
thigh does not create tension on catheter.
24. Be sure there are no obstructions or kinks in
tubing. Place excess coil of tubing on bed & fasten
it to bottom sheet with clip from drainage set or
with rubber band & safety pin.
25. Remove gloves & disposed of equipment, drapes
and urine in proper receptacles.
26. Assist patient to comfortable position. Wash dry
perineal area as needed.
27. Instruct client on ways to lie in bed with catheter:
 side-lying facing drainage system with
catheter & tubing draped over thigh
 Side-lying facing away from the system,
catheter and tubing extended between legs.
28. Caution client against pulling on catheter.
29. Put on clean gloves. Obtain urine specimen
immediately, ifneeded, from drainage bag. Label
specimen. Send urinespecimen to the laboratory
promptly or refrigerate it.
30. Remove gloves and additional PPE, if used.
Perform handhygiene.
31. Wash hands
EVALUATION
1. Palpate bladder & ask if client remains
uncomfortable
2. Determine that there is no urine leaking from
catheter or tubing connections.
3. Record of procedure, characteristics, amount of
urine in drainage system.

Evaluator

________________________ ________________________ ________________________

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

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20 | P a g e
 ROUTINE CATHETER CARE

Purpose

 To minimize the trauma and infection risk associated with urinary catheters.

Equipment

 Soap and washcloth

 Anti-infective solution
 Antibiotic ointment
 Sterile swabs
 Forceps
 Tape
 Measurement container
 Sterile gloves
 Sterile drape

Goal

 The patient’s urinary elimination is maintained, with a urine output of at least 30

mL/hour, and the patient’s bladder is not distended.

Criteria Done Not Remarks Rating

done
ASSESSMENT
1. Determine how long catheter has been in place.
2. Observe any discharge or encrustation around
urethral meatus. Assess for complaints of pain or
discomfort.
3. Wash hands.
PLANNING
1. Prepare the necessary equipment and supplies
IMPLEMANTATION
1. Wash hands and close curtains around or close
door to room.
2. Organize equipment for perineal care.
3. Position patient correctly and cover with bath
blanket exposing only perineal area.
 Female – dorsal recumbent
 Male – supine
4. Place waterproof pad under patient.
5. Drape bath blanket on bath clothes so only
perineal area is exposed.
6. Open sterile catheter care kit using sterile aseptic

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 technique.
7. Put on sterile gloves.
8. Apply sterile drapes over patient’s perineum.
9. Pour antiseptic solution on cotton balls or swabs.
Apply antiseptic ointment on cotton balls (check
patient for allergies to antiseptic).
10. With non-dominant hand:
 Gently retract labia of female client to fully
expose urethral meatus & catheter insertion
site. Maintain position of hand throughout the
procedure.
 Retract foreskin of an uncircumcised male
client and hold penis at shaft below glands.
Maintain position of hand throughout the
procedure.
11. Assess urethral meatus and surrounding tissues
for inflammation, swelling & discharge. Note
amount, color, odor, consistency of discharge. Ask
patient if burning & discomfort is felt.
12. Cleanse perineal tissues:
A. Female client:
 Use separate cotton balls &forceps to
cleanse each labia majora, moving down
toward anus. Repeat process to cleanse
each side.
B. Male client
 While spreading urethral meatus, cleanse
around catheter first, then use clean cotton
ball to wipe in circular motion around
meatus and glans.
13. Reassess urethral meatus for discharge.
14. Get new cotton ball & wipe in circular motion
along length of catheter for about 10 cm (4 inch).
15. Apply antiseptic ointment at urethral meatus
along 2.5 cm of catheter.
16. Replace adhesive tape anchoring catheter to client
as necessary. Remove adhesive tape residue from
the skin.
17. Replace urinary tubing and collection bag
adhering to principles of surgical asepsis as
necessary but at least 8 hours.
18. Check drainage tubing. No tube should be coiled,
kinked or clamped.

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 19. Collection bag is emptied as necessary but at least
8 hours.
20. Assist patient to safe, comfortable position.
21. Dispose of contaminated gloves & supplies &
wash hands.
EVALUATION
1. Inspect condition of urethra, note character of
urine & assess client’s temperature.
2. Record on nurse’s notes when catheter care was
given, assessment of urethral meatus and
character of urine.

Evaluator

________________________ ________________________ ________________________

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

23 | P a g e
 PERFORMING CLOSED CONTINUOUS CATHETER IRRIGATION

Purpose

 To prevent blood clot accumulation that may occlude the catheter thus the procedure
maintains patency of the catheter and tubing

Equipment

 Sterile irrigating solution, correct bag of solution

 Irrigation tubing with clamp (with or without Y connector
 Metric container
 IV pole
 Antiseptic swab
 Y connector
 Bath blanket

Goal

 The patient exhibits free flowing urine through the catheter.

Criteria Done Not Remarks Rating

done
ASSESSMENT
1. Check the patient’s record to determine:
 Purpose of the close bladder irrigation.
 Physician’s order.
 Type of irrigating solution to be used.
 Frequency if irrigation
 Type of catheter used.
 Triple lumen (1 lumen to inflate balloon, 1
to install irrigation solution, and 1 to allow
outflow of urine)
 Double lumen (1 lumen to inflate balloon,
1 to allow outflow of urine)
2. Assess the ff:
 Color of urine & presence of mucus/sediment.
 Patency of drainage tubing
 Closed system:
 Note if fluid entering bladder & fluid draining
from the bladder are appropriate proportions.
 Note amount of fluid remaining in existing
irrigating solution container.
 Check irrigation tubing to ensure it has no

24 | P a g e
 kinks and is opened/ clamped according to
physician’s order.
3. Review patient’s medical record, including
physician’s order.
4. Review I and O record.
PLANNING
1. Develop individualize goals of care for patient
based on nursing diagnoses:
 Maintain patent, free-flowing urinary drainage
system.
 Minimize risk of infection
 Minimize discomfort
2. Collect necessary equipment and supplies
3. Explain the procedure to the client.
IMPLEMENTATION
1. Confirm the order for catheter irrigation in the
medical record. Calculate the drip rate via gravity
infusion for the prescribed infusion rate.
2. Bring necessary equipment to the bedside.
3. Perform hand hygiene and put on PPE, if
indicated.
4. Identify the patient.
5. Close curtains around the bed and close the door
to the room, if possible. Discuss the procedure
with patient.
6. Adjust bed to comfortable working height, usually
elbowheight of the caregiver (VISN 8 Patient
Safety Center,2009).
7. Empty the catheter drainage bag and measure the
amount of urine, noting the amount and
characteristics of the urine.
8. Assist patient to comfortable position and expose
the irrigation port on the catheter setup. Place
waterproof pad under the catheter and aspiration
port.
9. Prepare sterile irrigation bag for use as directed by
manufacturer.
 Clearly label the solution as ‘Bladder Irrigant.’
 Include the date and time on the label. Hang
bag on IV pole 2.5 to 3 feet above the level of
the patient’s bladder.
 Secure tubing clamp and insert sterile tubing

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 with drip chamber to container using aseptic
technique. Release clamp and remove
protective cover on end of tubing without
contaminating it. Allow solution to flush
tubing and remove air. Clamp tubing and
replace end cover.
10. Put on gloves. Cleanse the irrigation port on the
catheter with an alcohol swab. Using aseptic
technique, attach irrigation tubing to irrigation
port of three-way indwelling catheter.
11. Check the drainage tubing to make sure clamp, if
present, is open.
12. Release clamp on irrigation tubing and regulate
flow at determined drip rate, according to the
ordered rate. If the bladder irrigation is to be done
with a medicated solution, use an electronic
infusion device to regulate the flow.
13. Remove gloves. Assist the patient to a comfortable
position. Cover the patient with bed linens. Place
the bed in the lowest position.
14. Assess patient’s response to the procedure, and
quality and amount of drainage.
15. Remove equipment. Remove gloves and
additional PPE, if used. Perform hand hygiene.
16. As irrigation fluid container nears empty, clamp
the administration tubing. Do not allow drip
chamber to empty. Disconnect empty bag and
attach a new full irrigation solution bag.
17. Put on gloves and empty drainage collection bag
as each new container is hung and recorded.
EVALUATION
1. Calculate fluid used to irrigate bladder and
catheter and subtract from volume drained.
2. Assess characteristics of output; viscosity, color,
presence of clots & observe catheter patency.
DOCUMENTATION
1. Record amount of solution used as irrigant,
amount returned as drainage, in nurse’s notes and
in I & O sheet..
2. Report catheter occlusion, sudden bleeding,
infection or increased pain to the physician

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 Evaluator

________________________ ________________________ ________________________

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

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 PERFORMING CLOSEDIN TERMITTENT CATHETER IRRIGATION

Purpose

 To flush clots and debris out of bladder

 To instill medication to bladder lining
 To restore patency of the catheter.

Equipment

 Sterile irrigating solution

 Sterile graduated cup
 Sterile 30-50 ml syringe
 Sterile 19-22 gauge, 1 in needle
 Antiseptic swab
 Screw clamp
 Bath blanket

Goal

 The patient exhibits the free flow of urine through the catheter.

Criteria Done Not Remarks Rating

done
ASSESSMENT
a. Check the patient’s record to determine:
 Purpose of the close bladder irrigation.
 Physician’s order.
 Type of irrigating solution to be used.
 If patient is to receive continuous/intermittent
flow into the bladder
 Frequency of irrigation
 Type of catheter used.
 Triple lumen (1 lumen to inflate balloon, 1
to install irrigation solution, and 1 to allow
outflow of urine)
 Double lumen (1 lumen to inflate balloon,
1 to allow outflow of urine)
b. Assess the ff:
 Color of urine & presence of mucus/sediment.
 Patency of drainage tubing
 Closed system:
 Note if fluid entering bladder & fluid draining
from the bladder are appropriate proportions.
 Note amount of fluid remaining in existing

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 irrigating solution container.
 Check irrigation tubing to ensure it has no
kinks and is opened/clamped according to
physician’s order.
2. Review patient’s medical record, including
physician’s order.
3. Review I and O record.
PLANNING
1. Develop individualize goals of care for patient
based on nursing diagnoses:
 Maintain patent, free-flowing urinary drainage
system.
 Minimize risk of infection
 Minimize discomfort
2. Collect necessary equipment and supplies
3. Explain the procedure to the client.
IMPLEMENTATION
1. Confirm the order for catheter irrigation in the
medical record.
2. Bring necessary equipment to the bedside.
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
patient.
6. Adjust bed to comfortable working height, usually
elbow height of the caregiver (VISN 8 Patient
Safety Center,2009).
7. Put on gloves. Empty the catheter drainage bag
and measure the amount of urine, noting the
amount and characteristics of the urine. Remove
gloves.
8. Assist patient to comfortable position and expose
access port on catheter setup. Place waterproof
pad under catheter and aspiration port. Remove
catheter from device or tape anchoring catheter to
the patient.
9. Open supplies, using aseptic technique. Pour
sterile solution into sterile basin. Aspirate the
prescribed amount of irrigant (usually 30 to 60
mL) into sterile syringe. Put on gloves.

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 10. Cleanse the access port on catheter with
antimicrobial swab.
11. Clamp or fold catheter tubing below the access
port.
12. Attach the syringe to the access port on the
catheter using a twisting motion. Gently instill
solution into catheter.
13. Remove syringe from access port. Unclamp or
unfold tubing and allow irrigant and urine to flow
into the drainage bag. Repeat procedure, as
necessary.
14. Remove gloves. Secure catheter tubing to the
patient’s inner thigh or lower abdomen (if a male
patient) with anchoring device or tape. Leave
some slack in the catheter for leg movement.
15. Assist the patient to a comfortable position. Cover
the patient with bed linens. Place the bed in the
lowest position.
16. Secure drainage bag below the level of the
bladder. Check that drainage tubing is not kinked
and that movement of side rails does not interfere
with catheter or drainage bag.
17. Remove equipment and discard syringe in
appropriate receptacle. Remove gloves and
additional PPE, if used. Perform hand hygiene.
18. Assess patient’s response to the procedure and the
quality and amount of drainage after the
irrigation.
EVALUATION
1. Calculate fluid used to irrigate bladder and
catheter and subtract from volume drained.
2. Assess characteristics of output; viscosity, color,
presence of clots & observe catheter patency.
DOCUMENTATION
1. Record amount of solution used as irrigant,
amount returned as drainage, in nurse’s notes and
in I & O sheet.
2. Report catheter occlusion, sudden bleeding,
infection or increased pain to the physician.

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 Evaluator

________________________ ________________________ ________________________

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

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 REMOVING AN INDWELLING CATHETER

Equipment

 Syringe same size as volume solution used to inflate balloon

 Waterproof pad
 Sterile specimen container, labeled correctly
 25-gauge 1/2” needle
 Alcohol swab
 non-sterile disposable gloves

Goal

 The catheter is removed without difficulty and with minimal patient discomfort.

Criteria Done Not Remarks Rating

done
ASSESSMENT
1. Review patient’s medical record including
physician’s order and note period of time catheter
was in place.
PLANNING
1. Prepare necessary equipment and supplies:
2. Close curtains around the 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.
IMPLEMENTATION
1. Adjust bed to comfortable working height, usually
elbow height of the caregiver (VISN 8 Patient
Safety Center,2009).
2. Stand on the patient’s right side if you are right-
handed, and on the patients’ left side if you are
left-handed.
3. Wash hands and don gloves.
4. If bladder conditioning is to be performed:
 Hours before removal, clamp indwelling
catheter for 3 hours.
 Unclamp and drain urine for 5 minutes.
 Repeat clamping for 3 hours and draining for
5 minutes two more times.
5. Provide privacy by closing room door or bedside
curtain.
6. Position patient in supine position.

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 7. Place water proof pad between female’s thighs or
over male’s thigh.
8. Obtain urine specimen, if required.
9. Remove adhesive tape anchoring catheter; cleanse
any residue from skin.
10. Insert hub of syringe into inflate valve. Aspirate
entire amount of fluid used to inflate balloon.
11. Pull catheter out smoothly and slowly.
12. Wrap contaminated catheter in water proof pad.
Unhook collection bag and drainage tubing from
bed.
13. Reposition patient as necessary. Lower level of
bed and position side rails accordingly.
14. Measure and empty contents of collection bag.
15. Dispose all contaminated supplies properly and
wash hands.
EVALUATION
1. Observe time and amount of first voided
specimen and note any discomfort experienced by
the client when voiding and condition of the skin
from adhesive tape.
DOCUMENTATION
1. Record and report time catheter was removed, time
and amount of next voiding.

Evaluator

________________________ ________________________ ________________________

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

ADMINISTERING VAGINAL INSTALLATION

Purpose

 To treat or prevent infection

 To reduce inflammation
 To relieve vaginal discomfort

Equipment
 Drape

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  Correct vaginal cream/suppository
 Applicator for cream
 Lubricating jelly for suppository
 Clean gloves
 Disposable towel
 Clean perineal pad
 Medication card

Goal

 The medication is administered successfully into the vagina.

Criteria Done Not Remarks Rating

done
ASSESSMENT
1. Know the actions, special nursing considerations,
safe dose ranges, purpose of administration, and
adverse effects of the medication to be
administered. Consider the appropriateness of the
medication for this patient.
PLANNING
1. Gather equipment. Check medication order
against the original order in the medical record,
according to facility policy. Clarify any
inconsistencies. Check the patient’s chart for
allergies.
2. Ensure that the patient receives the medications at
the correct time.
3. Prepare medications for one patient at a time.
IMPLEMENTATION
1. Perform hand hygiene and put on PPE, if
indicated.
2. Identify the patient. Usually, the patient should be
identified
 Check the name and identification number on
the patient’s identification band.
 Ask the patient to state his or her name and
birth date, based on facility policy.
 If the patient cannot identify herself, verify the
patient’s identification with a staff member
who knows the patient for the second source.
3. Prepare the materials needed.
4. Ensure privacy

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 5. Inspect the condition of the external genitalia and
vaginal canal.
6. Assess the client’s ability to manipulate applicator
or suppository and to position self to inset
medication.
7. Arrange supplies at bedside.
8. Position bed in lowest possible height. Assist
client in dorsal recumbent position.
9. Keep abdomen and lower extremities drape.
10. Apply disposable gloves.
11. Be sure that the vaginal orifice is well illuminated
by room light or gooseneck lamp.
12. FOR SUPPOSITORY INSERTION WITH
GLOVED HAND:
 Remove suppository from foil wrapper and
apply liberal amount of petroleum jelly to
smooth round end. Lubricate gloved index
finger of dominant hand.
 With non dominant hand, gently retract labial
folds.
 Insert rounded end of suppository along
posterior wall of vaginal canal entire length of
finger.
 Withdraw finger and wipe away remaining
lubricant from around orifice and labia.
13. FOR APPLICATION OF CREAM OR FOAM:
 Fill cream or foam applicator following
package directions.
 With non dominant gloved hand, gently
retract labia folds.
 With dominant gloved hand, insert applicator
approximately 5-7.5 cm. push applicator to
deposit medication into vagina.
 Withdraw applicator and place on paper
towel. Wipe off residual cream from labia or
vaginal wall.
14. Remove gloves by pulling them inside out and
discard in appropriate receptacle.
15. Wash hands
16. Instruct client to remain on her back for at least 10
minutes.
17. If applicator is used, wash with soap and water
rinse, and store for future use.

35 | P a g e
 18. Offer client perineal pad when she resumes
ambulation.
19. Dispose of applicator in appropriate receptacle or
clean ,Non disposable applicator according to
manufacturer’s directions.
20. Inspect condition of vaginal canal and external
genitalia between applications.
DOCUMENTATION
1. Evaluate the patient’s response to medication
within appropriate time frame.
2. Record drug name, dosage route and time of
administration on medication record.

Evaluator

________________________ ________________________ ________________________

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

PROVIDING POST MORTEM CARE

Purpose

 To aid in preserving the physical appearance of the deceased

 To prevent discoloration and damage of the corpse skin
 To safeguard all the belongings of the deceased
 To support family members during the initial hours of their bereavement
 To show respect for the deceased

Equipment

 Disposable gloves
 Cloth or disposable gown
 2 washcloths and towel
 4x4 inch gauze or other dressing (optional)
 Identification bracelet or body bag
 Dilute bleach mixture (optional)
 Scissor
 Clean linens
 Wash basin with warm, soapy water
 Moist cotton balls

36 | P a g e
  Clean gown
 Tape
 Clamps
 Linen savers

Goal

 To understand the role of the nurse during the dying process and death. Describe
phases and associated signs/symptoms involved in the dying process.

Criteria Done Not Remarks Rating

done
ASSESSMENT
1. Check the vital functions, and notify the physician
2. Review hospital policy regarding postmortem
care and notification process.
3. Need for autopsy if death occurs within 24 hours
of hospitalization or is the result of suicide,
homicide or unknown causes; or if the family
request an autopsy.

OUTCOME IDENTIFICATION
1. Body and environment are clean, with a natural
appearance.
2. Family views body with no signs of extreme
distress at its physical appearance.
3. There is no contact with body fluid.
IMPLEMENTATION:
1. Record on the client’s chart the time of death and
the time pronounced dead by physician or other
appropriate authority.
2. Notify family members that client’s status has
changed for the worse, and assist them to a
private room until the physician is available.
3. Return to client’s room and close door.
4. Perform hand hygiene. Don gloves and isolation
gown.
5. Remove tubes, such as IV line, nasogastric
catheter, or urinary catheter if allowed and
autopsy is to be done.
6. Hold eyelids closed and until they remain closed.
If they do not remain closed, place moist 4x4 inch

37 | P a g e
 gauze or cotton balls on lids until they remain
closed on their own.
7. If unable to remove tubes:
 Clamp IV’s and tubes.
 Coil NG and urinary tubes and tape them
down
 Cut IV tubings as close to clamp as possible,
cover with 4x4 inch gauze and tape securely.
8. Remove extra equipment from room to utility
room.
9. Wash secretions from face and body.
10. Replace soiled linens and gowns with clean
articles.
11. Place linen savers under body and extremities, if
needed.
12. Put soiled linens and pads in bag and remove
from room.
13. Position client in a supine position with arm at
side, palms down.
14. Place dentures in mouth, put a pillow under head,
close mouth, and place rolled towel under chin.

15. Remove all jewelry (except wedding band, unless

band is requested by family members) and give to
family with other personal belongings; record the
name(s) or receiver(s).
16. Place clean top covering over body, leaving face
exposed.
17. Place chair at bedside.
18. Dim lighting.
19. After body has been viewed by family, tag client
with appropriate identification.
20. Send completed death certificate with body to
funeral home or complete paper worked required
by hospital and send body to morgue.
21. Close doors of clients on hall through which body
is transported, if hospital policy.
22. Restore and dispose of equipment, supplies and
linens properly; remove gown and gloves and
perform hand hygiene.
23. Have room cleaned: use special cleaning supplies
if client had infection.

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 EVALUATION
1. Desired outcome met when:
 Body and environment are clean, with a
natural appearance
 Family viewed body with no signs of extreme
distress at its physical appearance
 There was no contact (staff or others) with
body fluids)
DOCUMENTATION
1. The following should be noted on the client’s
chart:
 Time of death and code information, if
performed
 Notification of physician and family members
 Response of family members disposal of
valuable and belongings
 Time body was removed from room
 Location to which body was transferred

Evaluator

________________________ ________________________ ________________________

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

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