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
 Identify patient suing at least two
identifiers.
 Refer 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 assess skin
around area to be treated, perform
neurovascular assessments for sensitivity
to temperature and pain.
 Refer to patient’s medical record to
identify contraindications to moist heat
application.
 Inspect wound for size, color, drainage,
tenderness, and odor.
 Assess patient’s blood pressure and
pulse.
 Assess patient’s mobility.
 Assess patient’s level of comfort.
 Assess patient’s and family member’s
understanding of application and related
safety factors.
PLANNING
2. Identify expected outcomes.

Assemble and prepare equipment and

supplies.
a. Sitz tub (half-filled)
b. Pitcher of water
c. Bath thermometer
d. Bath towel
e. Bath blanket
f. EPSOM salt (optional)

IMPLEMENTATION
Procedure
1. Introduce yourself and verify the client’s
identity. Explain to the client what you are
going to do, why it is necessary, and how
the client can cooperate.

Explain steps of procedure and purpose to

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

2. Provide privacy. Position patient in bed, keep

affected body part in proper alignment, expose
body part to be covered, drape patient as
needed.
3. Perform hand hygiene, apply clean gloves.
4. Place waterproof pad under patient if
appropriate.
5. Apply moist sterile compress:

a. Heat solution to desired temperature

properly.
b. Prepare aquathermia pad if needed,
set temperature if needed.
c. Remove any dressing present,
inspected condition of wound and
surrounding skin, dispose of gloves
and dressings in biohazard bag.
d. Perform hand hygiene
e. Prepare compress.
1) Pour warm solution into container
using sterile technique if needed.
2) Open gauze, use sterile
technique if needed.
3) Add gauze to container of
solution to immerse gauze, use
proper aseptic technique.
4) Follow instructions for warming
using commercially prepared
compress.
f. Apply sterile or clean gloves as
appropriate.
g. Pick up one layer of gauze, wrung out
excess solution, apply to wound,
avoid surrounding skin.
h. Lift edge of gauze to assess for
redness.
i. Pack gauze snugly if patient tolerated
compress, cover all wound surfaces
with compress.
j. Cover moist compress with dry sterile
dressing and bath towel, pin or tie in
place, remove and dispose of gloves,
perform hand hygiene.
k. Apply aquathermia, heat pack, or
water-proof heating pad over towel;
keep in place for desired duration.
l. Change warm compress using sterile
technique as ordered if pad or heat
pack was not used.
m. Apply clean gloves; remove pad,
towel and compress; reassess wound
and condition of skin; replace dry
sterile dressing.
n. Help patient to preferred comfortable
position.
o. Dispose of equipment and soiled
compress, perform hand hygiene.
6. Sitz bath or warm soak to intact skin or wound
 a. Perform hand hygiene, apply clean
gloves, remove any existing dressing
covering wound, dispose of gloves
and dressings, perform hand hygiene
b. Inspect condition of wound and skin,
paid attention to suture line.
c. Apply gloves and clean intact skin
around open area when exudate was
present, dispose of gloves, perform
hand hygiene.
d. Fill bath with warmed solution, check
temperature.
e. Assist patient to bathroom, immerse
body part in bath (10 to 25 mins or as
ordered), cover patient with blanket or
towel as needed.
f. Assess heart rate, ensure that patient
was not lightheaded and that call light
was within reach.
g. Remove patient from soak, dry body
throughout.
h. Drain solution from basin or tub, clean
and place in proper storage area,
dispose of soiled linen and gloves,
perform hand hygiene.
EVALUATION
1. Inspect condition of body part or wound for
evidence of healing, observe skin color,
temperature, edema, and sensitivity to touch.
2. Ask patient to describe level of comfort, ask
about any sensation of burning following
treatment.
3. Obtain vital signs, compare with baseline.

4. Ask patient to demonstrate how to apply

compress at home.
5. Identify unexpected outcome.
RECORDING AND REPORTING
1. Record and report all pertinent information of
procedure.
2. Record pre-procedure and post-procedure
vital signs.
3. Document 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. Identify patient using at least two identifiers. 2 1 0

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

location, and duration of application.
3. Perform hand hygiene, inspect condition or
affected part, palpate area for edema.
4. Consider time elapsed since injury occurred.
5. Ask patient to describe severity and character of
pain.
6. Perform neurovascular check, inspect
surrounding skin for integrity, circulation,
color, temperature and sensitivity to touch.
7. Review medical history for conditions that
contraindicate use of cold therapy.
8. Assess patient’s LOC and responsiveness.
9. Assess patient’s understanding and awareness of
procedure.
PLANNING
1. Identify expected outcomes.
2. Prepare equipment and supplies.
a.
3. Explain procedure and precautions.
IMPLEMENTATION
Procedure
1.
Introduce yourself and verify the client’s
identity. Explain to the client what you are
going to do, why it is necessary, and how the
client can cooperate.

Explain steps of procedure and purpose to

patient

Provide privacy, perform hand hygiene, wear

clean gloves.
2. Position patient properly, expose area to be
treated, drape patient with blankets.
 3. Place towel or pad under area to be treated.
4. Apply cold compress:
a. Place ice water in basin, test
temperature.
b. Submerge gauze into basin, wrung out
excess moisture.
c. Apply compress to affected area, mold
over site.
d. Remove, remoisten, and reapply to
maintain temperature as needed.
5. Apply ice pack or bag:
a. Fill bag with water, secure cap, invert
bag.
b. Empty water, fill bag properly with ice
chips and water.
c. Express excess air from bag, secure bag
closure, wipe bag dry.
d. Squeeze or knead commercial ice pack.
e. Wrap pack or bag with towel, apply over
injury, secure with tape as needed.
6. Apply commercial gel pack:
a. Remove from freezer.
b. Wrap in towel, apply over injury.
c. Secure with tape or gauze as needed.
7. Apply electrically controlled cooling device:
a. Prepare device appropriately.
b. Ensure all connections are intact and
temperature is set.
c. Wrap cool-water flow pad in towel or
pillowcase.
d. Wrap cool pad around body part.
e. Turn device on and set correct
temperature.
f. Secure with elastic wrap bandage, gauze
roll, or ties.
8. Remove gloves, dispose of properly, perform
hand hygiene.
9. Check condition of skin at appropriate intervals:
a. Use extra caution if area was
edematous, assess site more often.
b. Stop if patient complained of burning
sensation or skin began to feel numb.
10. Apply clean gloves, remove compress or pad at
appropriate time, dry any moisture.
11. Help patient to comfortable position.
12. Remove and dispose of supplies, empty basin
and dry, dispose of soiled linens and gloves,
perform hand hygiene.
EVALUATION
1. Inspect affected area for integrity, color,
temperature, and sensitivity to touch; re-evaluate
at appropriate interval.
2. Palpate affected area for edema, bruising and
bleeding.
3. Ask patient to report pain level.
4. Ask patient to demonstrate how to apply ice pack.
5. Identify unexpected outcome.
RECORDING AND REPORTING
1. Record procedure and patient’s response in the
appropriate log.
2. Document evaluation of patient or caregiver
learning.
3. Report 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