Republic of the Philippines

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
NURSING DEPARTMENT
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

Performance Evaluation Checklist

Application of Moist Heat (Compress and Sitz Bath)

Name of Student: _______________________________________

Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ___First Semester ____Second Semester ___ Summer
Inclusive Dates of Clinical Rotation: __________________
Instructor: _____________________________________________

Purposes:
1. Relief of muscle spasms, decreasing of joint stiffness
2. Stimulates circulation thus promotes healing
3. Reducing inflammation/ edema
4. Extensibility of collagen tissues
5. Provides relief and comfort (e.g hemorrhoids)

Preparation SCORE REMARKS

ASSESSMENT
1. Assess: 2 1 0
 Identified patient using at least two
identifiers.
 Referred to health care provider’s order
for type of moist heat application, location
and duration of application, desired
temperature, and agency policies
regarding temperature.
 Perform hand hygiene and assessed skin
around area to be treated, performed
neurovascular assessments for sensitivity
to temperature and pain.
 Referred to patient’s medical record to
identify contraindications to moist heat
application.
 Inspected wound for size, color, drainage,
tenderness, and odor.
 Assessed patient’s blood pressure and
pulse.
 Assessed patient’s mobility.
 Assessed patient’s level of comfort.
 Assessed patients and family member’s
understanding of application and related
safety factors.
PLANNING
1. Identified expected outcomes.

Assembled and prepared equipment and

supplies.

Explained steps of procedure and purpose to

patient, described sensations patient would
feel and precautions to prevent burning.

IMPLEMENTATION
Procedure
1. Provided privacy
2. Positioned patient in bed, kept affected body
part in proper alignment, exposed body part to
be covered, draped patient as needed.
3. Perform hand hygiene, applied clean gloves.
4. Placed waterproof pad under patient if
appropriate.
5. Applied moist sterile compress:

a. Heated solution to desired

temperature properly.
b. Prepared aquathermia pad if needed,
set temperature if needed.
c. Removed any dressing present,
inspected condition of wound and
surrounding skin, disposed of gloves
and dressings in biohazard bag.
d. Performed hand hygiene
e. Prepared compress.
1) Poured warm solution into
container used sterile technique if
needed.
2) Opened gauze, used sterile
technique if needed.
3) Added gauze to container of
solution to immerse gauze, used
proper aseptic technique.
4) Followed instructions for warming
using commercially prepared
compress.
f. Applied sterile or clean gloves as
appropriate.
g. Picked up one layer of gauze, wrung
out excess solution, applied to
wound, avoided surrounding skin.
h. Lifted edge of gauze to assess for
redness.
i. Packed gauze snugly if patient
tolerated compress, covered all
wound surfaces with compress.
j. Covered moist compress with dry
sterile dressing and bath towel,
pinned or tied in place, removed and
disposed of gloves, performed hand
hygiene.
k. Applied aquathermia, heat pack, or
water-proof heating pad over towel;
kept in place for desired duration.
l. Changed warm compress using
sterile technique as ordered if pad or
heat pack was not used.
m. Applied clean gloves; removed pad,
towel and compress; reassessed
wound and condition of skin; replaced
dry sterile dressing.
n. Helped patient to preferred
comfortable position.
o. Disposed of equipment and soiled
compress, performed hand hygiene.
6. Sitz bath or warm soak to intact skin or wound

a. Performed hand hygiene, applied

clean gloves, removed any existing
dressing covering wound, disposed of
gloves and dressings, performed
hand hygiene
b. Inspected condition of wound and
skin, paid attention to suture line.
c. Applied gloves and cleansed intact
skin around open area when exudate
was present, disposed of gloves,
performed hand hygiene.
d. Filled bath with warmed solution,
checked temperature.
e. Assisted patient to bathroom,
immersed body part in bath, covered
 patient with blanket or towel as
needed.
f. Assessed heart rate, ensured that
patient was not lightheaded and that
call light was within reach.
g. Removed patient from soak, dried
body throughout.
h. Drained solution from basin or tub,
cleaned and placed in proper storage
area, disposed of soiled linen and
gloves, performed hand hygiene.
EVALUATION
1. Inspected condition of body part or wound for
evidence of healing, observed skin color,
temperature, edema, and sensitivity to touch.
2. Asked patient to describe level of comfort,
asked about any sensation of burning
following treatment.
3. Obtained vital signs, compared with baseline.

4. Asked patient to demonstrate how to apply

compress at home.
5. Identified unexpected outcome.
RECORDING AND REPORTING
1. Recorded and reported all pertinent
information of procedure.
2. Recorded pre-procedure and post-procedure
vital signs.
3. Documented evaluation of patient or caregiver
learning.

Shown to me by:

________________________________
Signature over Printed Name
Clinical Instructor

Shown to me:
________________________________
Signature over Printed Name
Student
 Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

Performance Evaluation Checklist

APPLICATION OF COLD THERAPY

Name of Student: _______________________________________

Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ___First Semester ____Second Semester ___ Summer
Inclusive Dates of Clinical Rotation: __________________
Instructor: _____________________________________________

Purposes:
1. To slow or stop bleeding
2. Slows bacterial activity in clients with infection
3. Reduces swelling in injured tissues, including sprains and fractures
4. Controls pain and fluid loss in the initial treatment of burns
5. Prevents peristalsis in clients with abdominal inflammation
6. prevents escape of heat from the body by slowing circulation, which also relieves
congestion

Preparation SCORE REMARKS

ASSESSMENT
1. Identified patient using at least two identifiers. 2 1 0

2. Referred to health care provider’s order for type,

location, and duration of application.
3. Performed hand hygiene, inspected condition or
affected part, palpated area for edema.
4. Considered time elapsed since injury occurred.
5. Asked patient to describe severity and character
of pain.
6. Performed neurovascular check, inspected
surrounding skin for integrity, circulation,
color, temperature and sensitivity to touch.
7. Reviewed medical history for conditions that
contraindicate use of cold therapy.
8. Assessed patient’s LOC and responsiveness.
9. Assessed patient’s understanding and awareness
of procedure.
PLANNING
1. Identified expected outcomes.
2. Prepared equipment and supplies.
3. Explained procedure and precautions.
IMPLEMENTATION
Procedure
1. Provided privacy, performed hand hygiene,
applied clean gloves.
2. Positioned patient properly, exposed area to be
treated, draped patient with blankets.
3. Placed towel or pad under area to be treated.
4. Applied cold compress:
a. Placed ice water in basin, tested
temperature.
b. Submerged gauze into basin, wrung out
excess moisture.
c. Applied compress to affected area,
molded over site.
d. Removed, remoistened, and reapplied to
maintain temperature as needed.
5. Applied ice pack or bag:
 a. Filled bag with water, secured cap, and
inverted bag.
b. Emptied water, filled bag properly with
ice chips and water.
c. Expressed excess air from bag, secured
bag closure, wiped bag dry.
d. Squeezed or kneaded commercial ice
pack.
e. Wrapped pack or bag with towel, applied
over injury, secured with tape as needed.
6. Applied commercial gel pack:
a. Removed from freezer.
b. Wrapped in towel, applied over injury.
c. Secured with tape or gauze as needed.
7. Applied electrically controlled cooling device:
a. Prepared device appropriately.
b. Ensured all connections are intact and
temperature is set.
c. Wrapped cool-water flow pad in towel or
pillowcase.
d. Wrapped cool pad around body part.
e. Turned device on and set correct
temperature.
f. Secured with elastic wrap bandage,
gauze roll, or ties.
8. Removed gloves, disposed of properly, performed
hand hygiene.
9. Checked condition of skin at appropriate intervals:
a. Used extra caution if area was
edematous, assessed site more often.
b. Stopped if patient complained of burning
sensation or skin began to feel numb.
10. Applied clean gloves, remove compress or pad at
appropriate time, dried any moisture.
11. Helped patient to comfortable position.
12. Removed and disposed of supplies, emptied
basin and dried, disposed of soiled linens and
gloves, performed hand hygiene.
EVALUATION
1. Inspected affected area for integrity, color,
temperature, and sensitivity to touch; reevaluated
at appropriate interval.
2. Palpated affected area for edema, bruising and
bleeding.
3. Asked patient to report pain level.
4. Asked patient to demonstrate how to apply ice
pack.
5. Identified unexpected outcome.
RECORDING AND REPORTING
1. Recorded procedure and patient’s response in
the appropriate log.
2. Documented evaluation of patient or caregiver
learning.
3. Reported any sensations of burning, numbness,
or unrelieved skin color changes to healthcare
provider.

Shown to me by:

________________________________
Signature over Printed Name
Clinical Instructor

Shown to me:

________________________________
Signature over Printed Name
Student