DESCRIPTION

Preparation
▪ Do risk assessment on what procedure to be done to determine the appropriate
PPE to be worn.
▪ Check the availability of all PPE. It should be complete and in good condition.
Perform proper hand washing (Steps)
Don PPE in the following sequence:
1. Put on gown
✓ Fully cover torso from neck to knees, arms to end of wrists, and wrap around
the back.
✓ Fasten in back of neck and wrist.
2. A. Put on mask
✓ Secure ties or elastic bands at middle of head and neck.
✓ Fit flexible band to nose bridge.
✓ Fit snug to face and below chin.
✓ Pull pleats downwards. (“waterfall” pleat)

OR IF RESPIRATOR:

B. Put on respirator
✓ Hold the respirator in the palm of your hand with the straps facing the floor.
✓ Place the respirator on your face covering your nose and mouth.
✓ Pull the upper strap up and over top of your head, and lower strap behind your
head below your ears.
✓ Optimally position the respirator low on your nose. With both hands, mold the
malleable nosepiece to fit snugly against the nose bridge and face.
✓ Perform user seal check or fit check. During a negative and positive pressure
user seal check, the respirator user inhales and exhales sharply while
blocking the paths for air to enter the face piece. A successful check is when
the face piece collapses slightly under the negative pressure created and no
outward leakage of air on the edges. Reposition respirator or select other type
of respirator if unsuccessful.
3. Put on goggles or face shields
✓ Place over face and eyes and adjust to
fit
✓ Anti-fog feature improves clarity
4. Put on gloves
✓ Extend to cover wrist of isolation gown
 CHECKLIST FOR PROPER DONNING OF PPE (Type B)

EVALUATED BY:

_________________________________ BASIC ENHANCEMENT SKILLS

TRAINING FOR NURSES

DISCHARGE PROCEDURE
Name: ______________________________________ Date: ______________________

Position: ____________________________________ Area: ______________________

NOT
DESCRIPTION OBSERVED REMARKS
OBSERVED
1. On the day of discharge, review the patient’s
discharge care plan (initiated on admission
and modified during his hospitalization) with
the patient and his family. List prescribed drugs
on the patient instruction sheet along with the
dosage, prescribed time schedule, and
adverse reactions that he should report to the
physician.
2. Review procedures the patient or his family will
perform at home. If necessary, demonstrate these
procedures, provide written instructions, and
check performance with a return demonstration.

3. List dietary and activity instructions, if applicable,

on the patient instruction sheet, and review the
reasons for them.
4. Check with the physician about the patient’s next
office appointment; inform the patient of the date,
time and location.
5. Obtain from the pharmacy any drugs the patient
brought with him.
6. If appropriate, take and record the patient’s vital
signs on the discharge summary form. Notify the
physician if any signs are abnormal such as an
elevated temperature.
7. Help the patient get dressed if necessary
8. Collect the patient’s personal belongings from his
room.
9. After checking the room for misplaced belongings,
help the patient into the wheelchair, and escort
him to the exit
10. After the patient has left the area, strip the bed
linens and notify the housekeeping staff that the
room is ready for cleaning.
 TOTAL:

EVALUATED BY:

__________________________
17. Moisten the catheter by dipping it into the container of sterile saline. Occlude the
suction valve on the catheter to check for suction.
18. Encourage the patient to take several deep breaths.
19. Apply lubricant to the first 2 to 3 inches of the catheter, using the lubricant that was
placed on the sterile field.
20. Remove the oxygen delivery device, if appropriate. Do not apply suction as the
catheter is inserted. Hold the catheter between your thumb and forefinger.
21. Insert the catheter. For nasopharyngeal suctioning, gently insert the catheter
through the naris and along the floor of the nostril toward the trachea. Roll the
catheter between your fingers to help advance it. Advance the catheter
approximately 5 to 6 inches to reach the pharynx

For oropharyngeal suctioning, insert the catheter through the mouth, along the side
of the mouth toward the trachea. Advance the catheter 3 to 4 inches to reach the
pharynx.
22. Apply suction by intermittently occluding the suction valve on the catheter with the
thumb of your nondominant hand and continuously rotate the catheter as it is being
withdrawn.
a. Suction only on withdrawal and do not suction for more than 10 to 15 seconds at a time
to minimize tissue trauma.
23. Replace the oxygen delivery device using your nondominant hand, if appropriate,
and have the patient take several deep breaths.
24. Flush the catheter with saline. Assess the effectiveness of suctioning by listening
to lung sounds and repeat, as needed, and according to the patient’s tolerance.
Wrap the suction catheter around your dominant hand between attempts:
a. Repeat the procedure up to three times until gurgling or bubbling sounds stop and
respirations are quiet. Allow 30 seconds to 1 minute between passes to allow
reoxygenation and reventilation.
25. When suctioning is completed, remove gloves from the dominant hand over the
coiled catheter, pulling them off inside out.
26. Remove the glove from the nondominant hand and dispose of gloves, catheter,
and the container with solution in the appropriate receptacle.
 Name of Procedure: Oropharyngeal or Nasopharyngeal Suctioning
Purpose:
To remove the secretions that obstruct the airway
To facilitate ventilation
To obtain secretions for diagnostic procedures
To prevent infection that may result from accumulated secretions
Tools:
suction catheter, suction machine or wall suction device, suction canister, connecting tubing,
pulse oximeter, stethoscope, PPE (e.g., mask, goggles or face shield, non sterile gloves),
sterile gloves for suctioning with sterile suction catheter, towel or disposable paper drape, non
sterile basin or disposable cup, and normal saline or tap water
Persons Responsibilities:
Nurse and Nursing Attendant

1 . Perform safety steps:

a) Perform hand hygiene
b) Check the room for transmission-based precautions.
c) Introduce yourself, your role, the purpose of your visit, and an estimate of the time it
will take.
d) Confirm patient ID using two patient identifiers (e.g., name and date of birth).
e) Explain the process to the patient.
f) Be organized and systematic.
g) Use appropriate listening and questioning skills
h) Listen and attend to patient cues.
i) Ensure the patient’s privacy and dignity.
j) Assess ABCs.
2. . Adjust the bed to a comfortable working height and lower the side rail closest to
you.
3. Position the patient:
a. If conscious, place the patient in a semi-Fowler’s position.
b. If unconscious, place the patient in the lateral position, facing you.
4. Move the bedside table close to your work area and raise it to waist height.
5. Place a towel or waterproof pad across the patient’s chest.
6. Adjust the suction to the appropriate pressure:
a. Adults and adolescents: no more than 150 mm Hg
b. Children: no more than 120 mmHg
c. Infants: no more than 100 mm Hg
d. Neonates: no more than 80 mm Hg
For a portable unit:

e. Adults: 10 to 15 cm Hg
f. Adolescents: 8 to 15 cm Hg
g. Children: 8 to 10 cm Hg
h. Infants: 8 to 10 cm Hg
i. Neonates: 6 to 8 cm Hg
8. Put on a clean glove and occlude the end of the connection tubing to check suction
pressure.
9. Place the connecting tubing in a convenient location (e.g., at the head of the bed).
10. Open the sterile suction package using aseptic technique. (NOTE: The open
wrapper or container becomes a sterile field to hold other supplies.) Carefully
remove the sterile container, touching only the outside surface. Set it up on the
work surface and fill with sterile saline using sterile technique.
17. Moisten the catheter by dipping it into the container of sterile saline. Occlude the
suction valve on the catheter to check for suction.
18. Encourage the patient to take several deep breaths.
19. Apply lubricant to the first 2 to 3 inches of the catheter, using the lubricant that
was placed on the sterile field.
20. Remove the oxygen delivery device, if appropriate. Do not apply suction as the
catheter is inserted. Hold the catheter between your thumb and forefinger.
21. Insert the catheter. For nasopharyngeal suctioning, gently insert the catheter
through the naris and along the floor of the nostril toward the trachea. Roll the
catheter between your fingers to help advance it. Advance the catheter
approximately 5 to 6 inches to reach the pharynx

For oropharyngeal suctioning, insert the catheter through the mouth, along the
side of the mouth toward the trachea. Advance the catheter 3 to 4 inches to
reach the pharynx.
22. Apply suction by intermittently occluding the suction valve on the catheter with
the thumb of your nondominant hand and continuously rotate the catheter as it is
being withdrawn.
a. Suction only on withdrawal and do not suction for more than 10 to 15 seconds at a
time to minimize tissue trauma.
23. Replace the oxygen delivery device using your nondominant hand, if
appropriate, and have the patient take several deep breaths.
24. Flush the catheter with saline. Assess the effectiveness of suctioning by listening
to lung sounds and repeat, as needed, and according to the patient’s tolerance.
Wrap the suction catheter around your dominant hand between attempts:
a. Repeat the procedure up to three times until gurgling or bubbling sounds stop and
respirations are quiet. Allow 30 seconds to 1 minute between passes to allow
reoxygenation and reventilation.
25. When suctioning is completed, remove gloves from the dominant hand over the
coiled catheter, pulling them off inside out.
26. Remove the glove from the nondominant hand and dispose of gloves, catheter,
and the container with solution in the appropriate receptacle.
27. Assist the patient to a comfortable position. Raise the bed rail and place the bed
in the lowest position.
28. Turn off the suction. Remove the supplemental oxygen placed for suctioning, if
appropriate.
29. Remove face shield or goggles and mask; perform hand hygiene
30. Perform oral hygiene on the patient after suctioning.
31. Reassess the patient’s respiratory status, including respiratory rate, effort,
oxygen saturation, and lung sounds.
32. Assist the patient to a comfortable position, ask if they have any questions, and
thank them for their time.
33. Ensure safety measures when leaving the room:
a. CALL LIGHT: Within reach
b. BED: Low and locked (in lowest position and brakes on)
c. SIDE RAILS: Secured
d. TABLE: Within reach
e. ROOM: Risk-free for falls (scan room and clear any obstacles)
34. Perform hand hygiene.
35. Document the procedure and related assessment findings. Report any concerns
according to agency policy.
 BASIC ENHANCEMENT SKILLS TRAINING FOR NURSES
CHECKLIST FOR NGT/ENTERAL FEEDING BY GRAVITY WITH
IRRIGATION
Name: _________________________________________ Date: __________________________

Position: _______________________________________ Area: __________________________

DESCRIPTION OBSERVED NOT REMARKS

OBSERVED
1. Verify the provider’s order.
2. Gather supplies: stethoscope, gloves, towel,
irrigating solution (usually water), and irrigation set
with irrigating syringe, pH tape, and prescribed tube
feeding.
3. Perform safety steps:
a. Perform hand hygiene.
b. Check the room for transmission-based precautions.
c. Introduce yourself, your role, the purpose of your visit,
and an estimate of the time it will take.

d. Confirm patient ID using two patient identifiers (e.g.,

name and date of birth).
e. Explain the process to the patient and ask if they have
any questions.
f. Be organized and systematic.
g. Use appropriate listening and questioning skills.
h. Listen and attend to patient cues.
i. Ensure the patient’s privacy and dignity.
j. Assess ABCs.
4. Don the appropriate PPE as indicated.
5. Perform abdominal and nasogastric tube
assessment:
a. Assess skin integrity on the nose and ensure the
tube is securely attached.
b. Use a flashlight to look in the nares to assess
swelling, redness, or bleeding.
c. Ask the patient to open their mouth and look for
curling of the tube in the patient’s mouth. The
tube should go straight down into the
esophagus.
d. Lower the blankets and move the gown up to
expose the abdomen. Inspect from two locations.
e. Auscultate bowel sounds and then palpate the
abdomen. If the patient is receiving NG
suctioning, turn off the suction prior to
 auscultation.
6. Check for tube placement:
a. Verify tube measurement at insertion site based
on documentation.

b. If agency policy dictates, test the pH of the

aspirate. The pH should be equal or less than
5.5.
c. If agency policy dictates, measure and document
residual amount. Instill residual back into gastric
tube if placement was confirmed.
7. Draw up 30 mL of water in a 60-mL syringe. (If
applicable, use sterile water according to agency
policy.)
8. Connect the syringe to the tubing port (not the blue
pigtail).
9. Instill 30 mL water.
10. Reconnect the plug tube or clamp tube.
11. Remove the plunger from the syringe and attach the
syringe to the NG tube.
12. Complete tube feeding administration:
a. Verify the order for the type of formula, amount,
method of administration, and rate.
b. Check the expiration date on the formula.
c. Verify if the tops of the containers need cleaning
or if feeding needs mixing/shaking.
d. Add the formula to the syringe until the ordered
amount is administered. Hold the syringe
above the insertion site and allow it to enter via
gravity.
e. Assess the patient for tolerance of the feeding.
Slow infusion as necessary. Do not allow air to
enter the tube when refilling the syringe.
f. After formula is administered,
g. flush the NG tube with 30 mL of water.
h. If a patient is unable to tolerate the feeding,
slow or stop the infusion. Document and report
the intolerance.
13. Disconnect the syringe and plug the NG tube.
14. Maintain the patient at or above a 30-degree angle
for a minimum of one hour to prevent aspiration.
Ask the patient if they have any questions and
thank them for their time.
15. Perform hand hygiene.
16. Ensure safety measures when leaving the room:
a. CALL LIGHT: Within reach
b. BED: Low and locked (in lowest position and
brakes on)
c. SIDE RAILS: Secured
 d. TABLE: Within reach
e. ROOM: Risk-free for falls (scan room and clear
any obstacles)
17. Document assessment findings and report any
concerns according to agency policy. When
documenting the procedure, include the following:
a. Time performed
b. Irrigation solution used
c. Quantity instilled
d. Residual amount, color, odor, and consistency
e. Method for checking the placement (including pH
of gastric contents, if performed)
f. Related assessments
g. Amount of tube feeding
h. Patient tolerance for the procedure.
TOTAL:

EVALUATED BY:

__________________________
 BASIC SKILLS ENHANCEMENT FOR NURSING ATTENDANT
CHECKLIST ON PROPER DONNING OF PPE (Type A)

Name of Participant: ___________________________________ Date: ________________

Position: _____________________________________________ Area: ________________

NOT
DESCRIPTION OBSERVED REMARKS
OBSERVED
Preparation
▪ Do risk assessment on what procedure to
be done to determine the appropriate
PPE to be worn.
▪ Check the availability of all PPE. It should
be complete and in good condition.

Perform proper hand washing (Steps)

Don PPE in the following sequence:
1. Put on shoe covers
✓ Make sure that all areas of the foot are
covered and the shoe covers are snug
over your ankle and calf.
✓ Try not to touch the floor or other areas
with your hands while putting the shoe
covers on. If you do, disinfect your hands
before putting on your inner gloves.
2. Put on your inner gloves (1 st pair)
✓ Right size of gloves. Gloves should cover
your wrist/ above wrist.
3. Put on your coverall
✓ Step into legs of coverall and place
coverall over safety boots/ shoes with
shoe cover.
✓ Pull coverall towards arms and
shoulders.
✓ Cover sleeves over inner gloves.
✓ Make thumb holes.
✓ Pull zipper halfway up.
10.5.1.1 Put on your respirator
✓ Hold the respirator in the palm of your
hand with the straps facing the floor.
✓ Place the respirator on your face
covering your nose and mouth.
✓ Pull the upper strap up and over top of
your head, and lower strap behind your
head below your ears.
✓ Optimally position the respirator low on
your nose. With both hands, mold the
malleable nosepiece to fit snugly against
the nose bridge and face.
✓ Perform user seal check or fit check.
During a negative and positive pressure
user seal check, the respirator user
inhales and exhales sharply while
blocking the paths for air to enter the
face piece. A successful check is when
the face piece collapses slightly under
the negative pressure created and no
outward leakage of air on the edges.
Reposition respirator or select other type
of respirator if unsuccessful.
5. Put on bouffant/ hood
✓ Pull hood over to cover head.
✓ Zip up coverall to chin and ensure hood
fits tightly to face.
✓ Seal zipper flaps with adhesive tape.
✓ Stretch to ensure coverall fits
appropriately
6. Put on apron ( if available)
✓ Tie apron strap in a way that would be
easy for you to pull or untie during
doffing.
7. Put on outer gloves (2 nd pair)
✓ The outer gloves should cover the end
sleeves of your cover all.
8. Put on googles or face shield
✓ Place over your face/ eyes and adjust to
fit.
TOTAL:

EVALUATED BY:

_________________________________ BASIC SKILLS ENHANCEMENT FOR

NURSING ATTENDANT
CHECKLIST ON PROPER DOFFING (REMOVING) OF PPE ( Type A)

Name of Participant: ___________________________________ Date: ________________

Position: _____________________________________________ Area: ________________

NOT
DESCRIPTION OBSERVED REMARKS
OBSERVED
Preparation
▪ The trained observer will read each step
aloud, giving you the time to take the
required action. Take your time and be
careful.
▪ Check the availability of hand sanitizer,
infectious waste bin, foot bath container,
container with disinfectant for your
reusable items.
▪ Inspect your PPE.
▪ Disinfect your gloves after each step.
Remove PPE in the following sequence (not
touching contaminated parts)
1. Disinfect outer gloves.
2. Remove Apron (if used)
✓ Untie the strap and remove apron by
breaking the neck strap or lifting the
strap over your head, rolling from the
inside to outside and away from your
body then discard properly.
3. Disinfect outer gloves.
4. Remove shoe covers
✓ Grasp the outside of the shoe cover and
pull it off your foot. Discard properly.

5. Disinfect, remove and discard outer gloves.

✓ Using a gloved hand, grasp the palm
area of the other gloved hand and peel
off first glove. (Hold removed glove in
gloved hand)
✓ Slide fingers of ungloved hand under
remaining glove at wrist and peel off
second glove over first glove.
✓ Discard gloves in an infectious waste
container.
6. Inspect and disinfect inner gloves.
7. Remove Goggles or Face Shield
✓ Remove goggles or face shield from the
back by lifting head band or earpiece.
✓ If reusable, put direct into a container
with disinfectant.
8. Inspect and disinfect inner gloves.
9. Remove hood or head cap
✓ Grab the outside of the hood and carefully
pull it off your head.
10. Inspect and disinfect inner gloves.
11. Remove coverall
✓ If your coverall has a flap covering the
zipper, you must gently pull it open. Then
tilt your head back and reach for the
zipper at the top of the suit by starting at
the bottom going up to avoid accidental
touching of your skin. Grasp the zipper
with two fingers of one hand and unzip
completely.
✓ Grasp the outside of the coverall at the
shoulders, and pull it off your body in a
downward motion until coverall is off
your shoulders completely.
✓ Remove your arms by gently pulling it
out then pull down cover all until it’s at
your waist, being careful not to touch
your scrub suit or skin.
✓ Remove the rest of coverall by moving
your legs upward one at a time.
✓ Once coverall is off completely, roll it
inside to outside then discard properly.
12. Inspect and disinfect inner gloves.
13. Disinfect boots/ shoes with disinfectant
wipes
✓ Thoroughly disinfect all the surfaces of
your shoes, moving from top to bottom
and including the soles. Be sure not to
touch your ankles.
14. Disinfect, remove and discard inner gloves.
15. Disinfect hands (if with trained observer), if
alone; put on new
16. Remove respirator (Don’t touch front part!!)
✓ Grasp first the bottom tie of the mask or
respirator then carefully lift and remove
without touching front part.
✓ Then grasp top tie, lift, and remove
carefully.
✓ Discard in an infectious waste container.
17. Disinfect, remove and discard gloves.
18. Disinfect hands (if with trained observer) if
alone: directly put on new mask or respirator.
19. Disinfect hands (if with trained observer)
20. Step on the foot bath.
21. Hand washing using soap and water
TOTAL:
EVALUATED BY:

________________________________
 BASIC ENHANCEMENT SKILLS TRAINING FOR NURSES
CHECKLIST FOR TRACHEOSTOMY SUCTIONING

Name: ________________________________________ Date: ___________________________

Position: ______________________________________ Area: ___________________________

Not
Description Observed Remarks
Observed
1. Gather supplies: sterile gloves, trach suction kit, mask
with face shield, gown, goggles, pulse oximetry, and
bag valve device. It is helpful to request assistance
from a second nurse if preoxygenating the patient
before suction passes.
2. Perform safety steps.
a. Perform hand hygiene.
b. Check the room for transmission-based precautions.
c. Introduce yourself, your role, the purpose of your visit,
and an estimate of the time it will take.
d. Confirm patient ID using two patient identifiers (e.g.,
name and date of birth).

e. Explain the process to the patient and ask if they have

any questions.
f. Be organized and systematic.
g. Use appropriate listening and questioning skills.
h. Listen and attend to patient cues.
i. Ensure the patient’s privacy and dignity.
j. Assess ABCs.
3. Verify that there are a backup tracheostomy and bag
valve device available at the bedside.
4. Assess lung sounds, heart rate and rhythm, and pulse
oximetry.
5. Raise the head of the bed to waist level. Place the
patient in a semi-Fowler’s position and apply the pulse
oximeter for monitoring during the procedure.
6. Turn on the suction. Set the suction gauge to
appropriate setting based on age of the patient.
7. Perform hand hygiene. Don appropriate PPE (gown and
mask).
8. Open the suction catheter package faced away from you
to maintain sterility.
9. Don the sterile gloves from the kit.
10. Remove the sterile fluid and check the expiration date.
11. Open the sterile container used for flushing the catheter
and place it back into the kit. Pour the sterile fluid into
the sterile container using sterile technique.
12. Remove the suction catheter from the packaging.
Ensure the catheter size is not greater than half of the
inner diameter of the tracheostomy tube.
13. Keep the catheter sterile by holding it with your
dominant hand and attaching it to the suction tubing

with your nondominant hand. Note that your

nondominant hand is no longer sterile.
14. Test the suction and lubricate the sterile catheter by
using your sterile hand to dip the end into the sterile
saline while occluding the thumb control.
15. Ask an assistant to preoxygenate the patient with 100%
oxygen for 30 to 60 seconds using a handheld bag
valve mask (Ambu bag) per agency protocol.
Alternatively, ask the patient to take two or three deep
breaths if able.
16. Insert the catheter into the patient’s tracheostomy tube
using your sterile hand without applying suctioning:
a. For shallow suctioning, insert the catheter the length of
the tracheostomy tube before beginning any
suctioning.
b. For deep suctioning, insert the catheter until resistance
is met (at the carina) and withdraw 1 centimeter
before beginning suctioning.
c. Do not force the catheter.
d. Keep the dominant (sterile) hand at least one inch
from the end of the trach tube.
e. To apply suction, place your nondominant thumb over
the control valve
17. Withdraw the catheter while continually rotating it
between your fingers to suction all sides of the
tracheostomy tube. Do not suction longer than 15
seconds to prevent hypoxia. Follow agency policy
regarding the use of intermittent or continuous
suctioning. Do not contaminate the catheter as you
remove it from the trach tube.
18. Suction sterile saline each time the suction catheter is
removed to flush the catheter and suction tubing of
secretions.
19. Assess the patient response to suctioning;
hyperoxygenation may be required. If dysrhythmia or
bradycardia occur, stop the procedure.
20. Allow the patient to rest. After the patient’s pulse
oximetry returns to baseline, a second suctioning pass
can be initiated if clinically indicated. Encourage the
patient to cough and deep breath to remove secretions
between suctioning passes.
21. Do not insert the suction catheter more than two times.
If the patient’s respiratory status does not improve or it
worsens, call for emergency assistance.
22. Reattach the preexisting oxygen delivery device to the
patient with your noncontaminated hand.
23. Evaluate the effectiveness of the procedure and the
patient’s respiratory status. Assess patency of the
airway and pulse oximetry.
24. Remove the catheter from the tubing and then remove
gloves while holding the catheter inside the glove.
 Perform hand hygiene.
25. Turn off the suction.
26. Perform proper hand hygiene and don clean gloves.
27. Reassess lung sounds, heart rate and rhythm, and
pulse oximetry for improvement.
28. Perform patient oral care.
29. Remove gloves and perform proper hand hygiene.
30. Assist the patient to a comfortable position, ask if they
have any questions, and thank them for their time.
31. Ensure safety measures when leaving the room:
a. CALL LIGHT: Within reach
b. BED: Low and locked (in lowest position and brakes
on)
c. SIDERAILS: Secured
d. TABLE: Within reach
e. ROOM: Risk-free for falls (scan room and clear any
obstacles)
32. Perform hand hygiene.
33. Document the procedure and related assessment
findings. Report any concerns according to agency
policy.
TOTAL:

EVALUATED BY:

_______________________
 BASIC SKILLS ENHANCEMENT FOR NURSING ATTENDANT
CHECKLIST FOR HANDWASHING

Name of Participant: ___________________________________ Date: ________________

Position: _____________________________________________ Area: ________________

NOT
DESCRIPTION OBSERVED REMARKS
OBSERVED
PREPARATION
1. Wet hands with water
2. Apply enough soap to cover all hands
surfaces
3. Rub hands palm to palm
4. Right palm over left dorsum with
interlaced fingers and vice versa
5. Palm to palm with fingers interlaced
6. Backs of fingers to opposing palms with
fingers interlocked
7. Rotational rubbing of left thumb clasped in
right palm and vice versa
8. Rotational rubbing, backwards and
forwards with clasped fingers of right
hand in left palm and vice versa
9. Rotational rubbing of left wrist clasped in
right palm and vice versa
10. Rinse hands with water
11. Dry hands with personal towel or a single
use paper towel
12. Use the towel to turn off the faucet
TOTAL:

CHECKLIST FOR HANDRUB WITH ALCOHOL BASED FORMULATION

Name of Participant: ___________________________________ Date: ________________

Position: _____________________________________________ Area: ________________

NOT
DESCRIPTION OBSERVED REMARKS
OBSERVED
1. Apply a palmful of the product in cupped
 hand, covering all surfaces.
2. Rub hands from palm to palm.
3. Right palm over left dorsum with
interlaced fingers and vice versa
4. Palm to palm with fingers interlaced
5. Backs of fingers to opposing palms with
fingers interlocked
6. Rotational rubbing of left thumb clasped in
right palm and vice versa
7. Rotational rubbing, backwards with clasped
fingers of right hand in left palm and vice
versa.
8. Rotational rubbing of left wrist clasped in
right palm and vice versa
9. Air dry hands, once dry, hands are now safe

TOTAL:
EVALUATED BY:

_________________________________
 BASIC ENHANCEMENT SKILLS TRAINING FOR NURSES
CHANGING A POUCHING SYSTEM/OSTOMY (ILEOSTOMY OR
COLOSTOMY)

Name: ______________________________________ Date: __________________________

Position: ____________________________________ Area: __________________________

Not Observe
Description Observed Remarks
1. Perform hand hygiene.
2. Gather supplies.
3. Identify the patient and review the procedure.
Encourage the patient to participate as much
as possible or observe/assist patient as they
complete the procedure.
4. Create privacy. Place waterproof pad under
pouch.
5. Apply gloves. Remove ostomy bag, and
measure and empty contents. Place old
pouching system in garbage bag.
6. Remove flange by gently pulling it toward the
stoma. Support the skin with your other hand.
An adhesive remover may be used. If a rod is
in situ, do not remove.
7. Clean stoma gently by wiping with warm water.
Do not use soap.
8. Assess stoma and peristomal skin.
9. Measure the stoma diameter using the
measuring guide (tracing template) and cut
out stoma hole. Trace diameter of the
measuring guide onto the flange, and cut on
the outside of the pen marking.
10. Prepare skin and apply accessory products as
required or according to agency policy.
11. Remove inner backing on flange and apply
flange over stoma. Leave the border tape on.
Apply pressure. Hold in place for 1 minute to
warm the flange to meld to patient’s body.
Then remove outer border backing and press
gently to create seal. If rod is in situ, carefully
move rod back and forth but do not pull up on
rod.
12. Apply the ostomy bag. Attach the clip to the
bottom of the bag.
13. Hold palm of hand over ostomy pouch for 2
minutes to assist with appliance adhering to
skin.
14. Clean up supplies, and place patient in a
comfortable position. Remove garbage from
patient’s room.
15. Perform hand hygiene.
16. Document procedure.
TOTAL:

EVALUATED BY:

__________________
 BASIC ENHANCEMENT SKILLS TRAINING FOR NURSES
Checklist for Tracheostomy Care

Name: _______________________________________ Date: _________________________

Position: _____________________________________ Area: _________________________

Not
Description Observed Remarks
Observe
1. Gather supplies: bedside table, towel, sterile gloves,
pulse oximeter, PPE (i.e., mask, goggles, or face
shield), tracheostomy suctioning equipment, bag
valve mask (should be located in the room), and a
sterile tracheostomy care kit (or sterile cotton-tipped
applicators, sterile manufactured tracheostomy split
sponge dressing, sterile basin, normal saline, and a
disposable inner cannula or a small, sterile brush to
clean the reusable inner cannula).
2. Perform safety steps:
a. Perform hand hygiene
b. Check the room for transmission-based precautions.

c. Introduce yourself, your role, the purpose of your

visit, and an estimate of the time it will take.
d. Confirm patient ID using two patient identifiers (e.g.,
name and date of birth).
e. Explain the process to the patient and ask if they
have any questions.
f. Be organized and systematic.
g. Use appropriate listening and questioning skills.
h. Listen and attend to patient cues.
i. Ensure the patient’s privacy and dignity.
j. Assess ABCs.
3. Raise the bed to waist level and place the patient in a
semi-Fowler’s position.
4. Verify that there is a backup tracheostomy kit available.
5. Don appropriate PPE.
6. Perform tracheal suctioning if indicated.
7. Remove and discard the trach dressing. Inspect
drainage on the dressing for color and amount and
note any odor.
8. Inspect stoma site for redness, drainage, and signs and
symptoms of infection.
9. Remove the gloves and perform proper hand hygiene.
10. Open the sterile package and loosen the bottle cap of
sterile saline.
11. Don one sterile glove on the dominant hand.
12. Open the sterile drape and place it on the patient’s
 chest.
13. Set up the equipment on the sterile field.

14. Remove the cap and pour saline in both basins with
ungloved hand (4″-6” above basin).
15. Don the second sterile glove.
16. Prepare and arrange supplies. Place pipe cleaners,
trach ties, trach dressing, and forceps on the field.
Moisten cotton applicators and place them in the third
(empty) basin. Moisten two 4″ x 4″ pads in saline,
wring out, open, and separately place each one in the
third basin. Leave one 4″ x 4″ dry.
17. With nondominant “contaminated” hand, remove the
trach collar (if applicable) and remove (unlock and
twist) the inner cannula. If the patient requires
continuous supplemental oxygen, place the
oxygenation device near the outer cannula or ask a
staff member to assist in maintaining the oxygen
supply to the patient.
18. Place the inner cannula in the saline basin.
19. Pick up the inner cannula with your nondominant
hand, holding it only by the end usually exposed to air.

20. With your dominant hand, use a brush to clean the

inner cannula. Place the brush back into the saline
basin.
21. After cleaning, place the inner cannula in the second
saline basin with your nondominant hand and agitate
for approximately 10 seconds to rinse off debris.
Repeat cleansing with brush as needed.
22. Dry the inner cannula with the pipe cleaners and place
the inner cannula back into the outer cannula. Lock it
into place and pull gently to ensure it is locked
appropriately. Reattach the pre-existing oxygenation
device.
23. Clean the stoma with cotton applicators using one on
the superior aspect and one on the inferior aspect.
24. With your dominant, non-contaminated hand, moisten
sterile gauze with sterile saline and wring out excess.
Assess the stoma for infection and skin breakdown
caused by flange pressure. Clean the stoma with the
moistened gauze starting at the 12 o’clock position of
the stoma and wipe toward the 3 o’clock position.
Begin again with a new gauze square at 12 o’clock
and clean toward 9 o’clock. To clean the lower half of
the site, start at the 3 o’clock position and clean
toward 6 o’clock; then wipe from 9 o’clock to 6 o’clock,
using a clean moistened gauze square for each wipe.
Continue this pattern on the surrounding skin and tube
flange. Avoid using a hydrogen peroxide mixture
because it can impair healing.
25. Use sterile gauze to dry the area.
26. Apply the sterile tracheostomy split sponge dressing
by only touching the outer edges.
 27. Replace trach ties as needed. (The literature
overwhelmingly recommends a two-person technique
when changing the securing device to prevent tube
dislodgement. In the two-person technique, one
person holds the trach tube in place while the other
changes the securing device). Thread the clean tie
through the opening on one side of the trach tube.
Bring the tie around the back of the neck, keeping one
end longer than the other. Secure the tie on the
opposite side of the trach. Make sure that only one
finger can be inserted under the tie.
28. Remove the old tracheostomy ties.
29. Remove gloves and perform proper hand hygiene.
30. Provide oral care. Oral care keeps the mouth and teeth
not only clean, but also has been shown to prevent
hospital-acquired pneumonia.
31. Lower the bed to lowest the position. If the patient is
on a mechanical ventilator, the head of the bed should
be maintained at 30-45 degrees to prevent ventilator-
associated pneumonia.
32. Assist the patient to a comfortable position, ask if they
have any questions, and thank them for their time.
33. Ensure safety measures when leaving the room:
a. CALL LIGHT: Within reach
b. BED: Low and locked (in lowest position and brakes
on)
c. SIDE RAILS: Secured
d. TABLE: Within reach
e. ROOM: Risk-free for falls (scan room and clear any
obstacles)
34. Perform hand hygiene.
35. Document the procedure and related assessment
findings. Report any concerns according to agency
policy.
TOTAL:

EVALUATED BY:

_____________________
 BASIC SKILLS ENHANCEMENT FOR NURSING
CHECKLIST FOR BLOOD GLUCOSE MONITORING

Name: _____________________________________ Date: ___________________________

Position: ___________________________________ Area: ___________________________

Not
Description Observed Remarks
Observe
1. Prepare before completing the procedure:
a. Review the patient’s medical history and current
medications.
b. Note if the patient is receiving anticoagulant therapy.
Anticoagulant therapy may result in prolonged
bleeding at the puncture site and require pressure to
the site.
c. Assess the patient for signs and symptoms of
hyperglycemia or hypoglycemia to correlate data to
pursue acute action due to an onset of symptoms.
d. Determine if the test requires special timing, for
example, before and after meal.
e. Blood glucose monitoring is typically performed prior
to meals and the administration of antidiabetic
medications.
2. Gather supplies: nonsterile gloves, alcohol swab, lancet,
2″ x 2″ gauze or cotton ball, reagent strips, and blood
glucose meter.
a. Determine if the blood glucose meter needs to be
calibrated according to agency policy to ensure
accuracy of readings.
3. Perform safety steps:
a. Perform hand hygiene.
b. Check the room for transmission-based precautions.

c. Introduce yourself, your role, the purpose of your visit,

and an estimate of the time it will take.
d. Confirm patient ID using two patient identifiers (e.g.,
name and date of birth).
e. Explain the process to the patient and ask if they have
any questions.
f. Be organized and systematic.
g. Use appropriate listening and questioning skills.
h. Listen and attend to patient cues.
 i. Ensure the patient’s privacy and dignity.
j. Assess ABCs.
4. Have the patient wash their hands with soap and warm
water, and position the patient comfortably in a
semiupright position in a bed or upright in a chair.
Encourage the patient to keep their hands warm.
Washing reduces transmission of microorganisms and
increases blood flow to the puncture site.
a. Agency policy may require use of an alcohol swab to
clean the puncture site.

b. Ensure that the puncture site is completely dry prior to

skin puncture.
5. Remove a reagent strip from the container and reseal the
container cap to keep the strips free from damage from
environmental factors. Do not touch the test pad portion
of the reagent strip.
6. Follow the manufacturer’s instructions to prepare the
meter for measurement.
7. Place the unused reagent strip in the glucometer or on a
clean, dry surface (e.g., paper towel) with the test pad
facing up, based on manufacturer recommendations.
8. Apply nonsterile gloves.
9. Keep the area to be punctured in a dependent position. Do
not milk or massage the finger site:
a. Dependent position will increase blood flow to the
area.
b. Do not milk or massage the finger because it may
introduce excess tissue fluid and hemolyze the
specimen.
c. Warm water, dangling the hand for 15 seconds, and a
warm towel stimulate the blood flow to the fingers.
d. Avoid having the patient stand during the procedure to
reduce the risk of fainting.
10. Select the appropriate puncture site. Cleanse the site
with an alcohol swab for 30 seconds and allow it to dry.
Perform the skin puncture with the lancet, using a quick,
deliberate motion against the patient’s skin:

a. The patient may have a preference for the site used.

For example, the patient may prefer not to use a
specific finger for the skin puncture. However, keep
in mind their preferred site may be contraindicated.
For example, do not use the hand on the same side
as a mastectomy.
b. Avoid fingertip pads; use the sides of fingers.
c. Avoid fingers that are calloused, have broken skin, or
are bruised.
11. Gently squeeze above the site to produce a large droplet
of blood.
a. Do not contaminate the site by touching it.
b. The droplet of blood needs to be large enough to cover
the test pad on the reagent strip.
 c. Wipe away the first drop of blood with gauze.
12. Transfer the second drop of blood to the reagent strip per
manufacturer’s instructions:
a. The test pad must absorb the droplet of blood for
accurate results. Smearing the blood will alter results.
b. The timing and specific instructions for measurement
will vary between blood glucose meters. Be sure to
read the instructions carefully to ensure accurate
readings.
13. Apply pressure, or ask the patient to apply pressure, to
the puncture site using a 2″ x 2″ gauze pad or clean
tissue to stop the bleeding at the site.
14. Read the results on the unit display.
15. Turn off the meter and dispose of the test strip, 2″ x 2″
gauze, and lancet according to agency policy. Use
caution with the lancet to prevent an unintentional
sharps injury.
16. Remove gloves.
17. Perform hand hygiene.
18. Assist the patient to a comfortable position, review test
results with the patient, ask if they have any questions,
and thank them for their time.
19. Ensure safety measures when leaving the room:
a. CALL LIGHT: Within reach
b. BED: Low and locked (in lowest position and brakes
on)
c. SIDE RAILS: Secured
d. TABLE: Within reach
e. ROOM: Risk-free for falls (scan room and clear any
obstacles)
20. Document the result and related assessment findings.
Report critical values according to agency policy, such
as value below 70 or greater than 300 and any
associated symptoms.
TOTAL:

EVALUATED BY:

________________________
 BASIC SKILLS ENHANCEMENT FOR NURSING ATTENDANT
CHECKLIST FOR PROPER DOFFING (REMOVING) OF PPE (Type B)

Name of Participant: ___________________________________ Date: ________________

Position: _____________________________________________ Area: ________________

NOT
DESCRIPTION OBSERVED REMARKS
OBSERVED
PREPARATION
▪ The trained observer will read each step
aloud, giving you the time to take the
required action. The trained observer
will help you if necessary. Remember,
don’t rush through the doffing process.
Take your time and be careful.
▪ Check the availability of hand sanitizer,
infectious waste bin, foot bath container,
container with disinfectant for your
reusable items.
▪ Inspect your PPE. Are there any signs of
contamination or materials on it? If so,
you need to disinfect the surface of your
PPE with a disinfectant wipes.
▪ Disinfect your gloves after each step.
Remove PPE in the following sequence (not
touching contaminated parts)
1. Disinfect, remove and discard gloves.
✓ Remember: Outside of gloves are
contaminated!
✓ If your hands get contaminated during
glove removal, immediately wash your
hands or use an alcohol-based hand rub.
✓ Using a gloved hand, grasp the palm
area of the other gloved hand and peel
off first glove. ( Hold removed glove in
gloved hand)
✓ Slide fingers of ungloved hand under
remaining glove at wrist and peel off
second glove over first glove.
✓ Discard gloves in an infectious waste
container.

2. Remove Goggles or Face Shield

✓ Remove goggles or face shield from the
back by lifting head band or ear piece.
✓ If reusable, put direct into a container
with disinfectant. Otherwise, discard in a
waste container.
3. Remove gown
✓ Gown front and sleeves are
contaminated!
✓ Unfasten gown ties while taking care that
sleeves do not contact your body when
reaching for the ties.
✓ Pull gown away from neck and
shoulders, touching inside of gown only.
✓ Turn gown inside out.
✓ Fold or roll into a bundle and discard in a
waste container
4. Remove mask
✓ Grasp bottom ties or elastics of the
mask, then ones at the top, remove
without touching the front.
✓ Discard in a waste container.
If respirator:
✓ Grasp first the bottom tie of the mask or
respirator then carefully lift and remove
without touching front part.
✓ Then grasp top tie, lift and remove
carefully.
✓ Discard in an infectious waste container.
5. Do your handwashing using soap and water
EVALUATED BY:

_________________________________
 BASIC ENHANCEMENT SKILLS TRAINING FOR NURSES
PROCEDURE CHECKLIST ON ADMITTING A PATIENT

Name: ______________________________________ Date: ______________________

Position: ____________________________________ Area: ______________________

NOT
DESCRIPTION OBSERVED REMARKS
OBSERVED
PROCEDURE STEPS:
1. Introduces self to patient and family.
2. Assists patients into hospital gown.
3. If possible, measures weight while standing on a
scale
4. Transfer patient to the bed.
5. Checks patient’s identification band to ensure
information, including allergies, is correct. Verifies
this information with the patient or family.
6. Measure patient’s vital signs.
7. Explains equipment, including how to use call
system and location of personal care items.
8. Explain hospital routines, including use of side
rails, meal time, etc., and answer patient’s and
family’s question.
9. Obtains nursing admission assessment (including
health history) and physical assessment.
10. Completes inventory of patient’s belongings.
Encourage family to take home valuable items. If
that is not possible, arranges to have valuables
placed in the hospital safe.
11. Ensure that all admission orders have been
completed.
12. Initiates care plan or clinical pathway.
13. Documents all findings.
TOTAL:

EVALUATED BY:

_______________________

BASIC ENHANCEMENT SKILLS TRAINING FOR NURSES

CHECKLIST FOR CENTRAL VENOUS PRESSURE MONITORING

Name: ________________________________________ Date: ___________________________

Position: ______________________________________ Area: ___________________________

Not
Description Observed Remarks
Observed
34. Gather supplies: sterile gloves, mask, gown,
goggles, 3 way stop cock, CVP manometer. It is
helpful to request assistance from a second
nurse if necessary.
35. Perform safety steps.
k. Perform hand hygiene.
l. Check the room for transmission-based
precautions.
m. Introduce yourself, your role, the purpose of
your visit, and an estimate of the time it will
take.
n. Confirm patient ID using two patient
identifiers (e.g., name and date of birth).

o. Explain the process to the patient and ask if

they have any questions.
p. Be organized and systematic.
 q. Use appropriate listening and questioning
skills.
r. Listen and attend to patient cues.
s. Ensure the patient’s privacy and dignity.
t. Assess ABCs.
36. Don the sterile gloves.
37. Place the patient in supine position
38. Position the zero point of the manometer. It
should be on level with the patient right atrium.

39. Turn the 3 way stop cock so the solution will

flow into the manometer
40. Fill the manometer to about 20-25 cm level
41. Observe the fall in the height of the column of
fluid in the manometer
42. Record the level at which the solution stabilizes
or stops moving downward
43. Turn the stopcock again to allow IV solution to
flow from solution bottle into the patient’s veins.

44. Prevent and observe for complication

45. Remove gloves and perform proper hand
hygiene.
46. Assist the patient to a comfortable position, ask
if they have any questions, and thank them for
their time.
47. Ensure safety measures when leaving the room:

f. CALL LIGHT: Within reach

g. BED: Low and locked (in lowest position and
brakes on)
h. SIDERAILS: Secured
i. TABLE: Within reach
j. ROOM: Risk-free for falls (scan room and clear
any obstacles)
48. Perform hand hygiene.
49. Document the procedure and related
assessment findings. Report any concerns
according to agency policy.
TOTAL:
EVALUATED BY:

_______________________