COLLEGE OF ALLIED HEALTH SCIENCES

SCHOOL OF NURSING
nd
2 Semester, A.Y. 2022 – 2023

FUNDAMENTALS OF NURSING PRACTICE (RLE) CHECKLIST

NURSING SKILLS CHECKLIST PAGE

Dusting 3

Basic Infection Control:

● Mechanical Hand Washing 4
● Hand Gloving (Open Method) 5
Basic Body Mechanics:
● Assisting the Patient to move up in Bed 6
● Log Rolling 7
● Transferring a Patient from Bed to Chair/Wheelchair or vice versa 8
Proper Positioning:
● Supine
● Lateral
● Sim’s Lateral
● Fowler’s 9
● Semi-Fowler’s
● Prone
● Trendelenburg
Hygiene:
● Hair Care 10
● Assisting Patient in Oral Care 11
● Cleansing Bed Bath 14
● Tepid Sponge Bath 15
Bed Making:
● Un-Occupied Bed 16
● Occupied Bed 18
Body Massage:
● Effleurage
● Petrissage 19
● Friction
● Tapotement
Medications and Administration of Therapeutic Agents:
● Oral Medications
● Parenteral Medication 21
✔ Intradermal Injection
✔ Intramuscular Injection 22
✔ Z-Technique of Intramuscular Injection 23

Urinary Elimination:
24
● Collection of Urine specimen
Insertion of Indwelling Foley Catheter:
● Male 25
● Female 27
 Bowel Elimination:
29
● Stool Specimen Collection
Administration of Enema:
● Cleansing Enema
● Small Volume, Prepackaged Enema 30
● Return-Flow Enema

Sputum Specimen Collection 32

Administration of Oxygen
● Via Cannula 33
● Via Facemask
● Via Face Tent

Nasogastric Tube Insertion 35

Suctioning:
● Nasopharyngeal 37
● Oropharyngeal

CBG Monitoring 40

REFERENCES:

▪ Potter, Patricia A., Stockert, Patricia A., et al (2017). Fundamentals of Nursing, 9th Edition, Elsevier (Singapore) Pte,
Ltd.
▪ Kozier, Barbara; Erb, Glenora; et. Al, (2008). Kozier and Erb’s Fundamentals of Nursing, 8th Edition, Pearson
Education, Inc.
▪ Lynn, Pamela; & Evans-Smith, Pamela (2008). Taylor’s Clinical Nursing Skills: Nursing Process Approach, 2nd
Edition, Lippincott Williams & Wilkins
 Nursing Skill: DUSTING

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1

1. Assess the environment.

2. Obtain equipment from central supply and take it to the utility room.

Not Varnished Furniture

3. Place your preparation at a convenient place on the table but
not on the floor.

4. Take a piece of cloth and dip in clean water.

5. Apply to this small amount of soap.

6. Dust with a small area at a time. Begin from top to bottom.

Rinse the dusting cloth in water. Wipe the part soaped until
clean.

7. Rinse the dusting cloth.

8. Wipe with clean dry one.

9. Continue the procedure until all the parts have been dusted.

Varnished Furniture
10. If the furniture is varnished, do not use soap but dust only
with damp cloth and wipe dry.

11. Follow dusting with soiled cloth.

12. Wipe again to dry.

Surface
13. Soak a duster in a pail and wring.
14. Remove equipment from the surface, dust with damp duster
and follow with dry one.

15. Clean corners and cervices with cleaning stick.

16. Documentation.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: HANDWASHING

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Perform
Assistance
3 1
2
Assessment:
1. Assess the environment.

2. Assess your hands.

Planning / Expected Outcomes:

3. The caregiver's hands will be cleansed adequately to remove
microorganisms, transient flora, and soil from the skin.
Implementation:
4. Remove jewelry. Push sleeves of uniform or shirt up.
5. Assess hands for hangnails, cuts or breaks in the skin, and
areas that are heavily soiled.

6. Turn on the water. Adjust the flow and temperature.

7. Wet hands from wrist area thoroughly by holding under warm

running water. Keep hands and forearms in the down position
with elbows straight.
8. Apply about 5 ml (1 teaspoon) of liquid soap. Lather
thoroughly.
9. With firm rubbing and circular motions, wash the palms and
back of the hands, each finger, the areas between the
fingers, the knuckles, thumbs, wrists, and forearms. Gently
rub the forearms at least as high as the contamination is
likely to be present.

10. Continue this friction motion for 10 to 30 seconds.

11. Optional: Use brush or fingernails of the other hand to clean under
fingernails of the other hand.
12. Rinse with hands in the down position, elbow straight. Rinse in
the direction of forearm to wrist to fingers.
13. Blot hands and forearms to dry thoroughly. Dry in the
direction of fingers to wrist and forearms. Discard the paper
towels in the proper receptacle.

14. Turn off the water faucet with a clean, dry paper towel.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: STERILE HAND GLOVING (OPEN METHOD)

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Choose an appropriate glove size

2. Remove rings, bracelets or other jewelry on your hands

3. Wash your hands thoroughly.

4. Open the glove package. Inspect the package for rips,
discoloring, or dampness, and discard if the package is
compromised.
5. Open the outer wrap of the pack. Make sure to open from top
then bottom and then on the side
6. Remove the inner wrap. Take out the inner wrap and place it on
a clean surface.
7. Pick up glove for dominant hand by touching the inside cuff of the
glove. Do not touch the outside of the glove. With Dominant
hand flat and palm facing up, insert fingers, pull glove
completely over dominant hand. Pull glove on up to wrist.
8. Insert gloved hand into the cuff of the remaining glove. Pull
remaining glove on non-dominant hand and insert fingers. Adjust
gloves if necessary.
9. Once gloves are on, interlock gloved hands and keep at least
six inches away from clothing, keeping hands above waist level and
below the shoulders.
10. Check the gloves for rips.

To Remove Gloves:
1. To remove gloves, grasp the outside of the cuff (1/2 inch below
the cuff) or palm of glove and gently pull the glove off, turning it
inside out and placing it into gloved hand.
2. With ungloved hand, place or insert fingers inside the other
glove, and pull glove off inside out drawing it over the first glove.
Then discard according to hospital waste management.
3. Perform hand hygiene.

4. Document after the procedure.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: MOVING A CLIENT IN BED

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Assess the client's ability to assist with repositioning.
2. Assess the client's ability to understand and follow directions.
Comments:
Planning / Expected Outcomes
1. The client will be moved in bed without injury.

2. The client will be moved in bed without injury to the staff.

3. The client will report an increase in comfort.

4. All tubes, linens, and drains will remain patent and intact.
Implementation: Moving a Client Up in Bed with One Nurse
1. Wash hands.
2. Inform client of reason for the move.

3. Elevate bed. Lower head of bed. Lower side rails.

4. Place pillow against the headboard.

5. Have the client fold arms across the chest, if no overhead
trapeze is present.

6. Have the client bend knees and place feet flat on the bed.

7. Stand at head of the bed, feet apart, knees bent.

8. Slide one hand and arm under the client's shoulder, the other
under the client's thigh.

9. Lift the client while client pushes with the legs.

10. If available, have the client pull up using the trapeze as you
move the client.
11. Repeat these steps until the client is high enough in bed.

12. Return the client's pillow under the head.

13. Elevate head of bed, if tolerated by client.

14. Assess client for comfort.

15. Adjust the client's bedclothes as needed for comfort.

16. Lower bed and elevate side rails.

17. Wash hands.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: LOGROLLING A CLIENT IN BED

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1

1. Assess the client's ability to assist in logrolling.

2. Assist the client's flexibility.

3. Assess the client's overall condition.

4. Assess orders that restrict client positioning or movement.

Planning/Expected Outcomes.
1. Client will maintain proper body alignment.

2. The client will be comfortable.

3. The client will be turned as a unit without sustaining injury.

Implementation
1. Wash hands and apply gloves.

2. Inform the client of reason and need for turning.

3. Elevate the bed to a working height.

4. Using one or more assistants, place a turn sheet under the
client.
5. The lead nurse provides directions for the client and the other
nurses.
6. With one staff member on each side of the bed:
● The lead nurse gives the signal for the move.
● The staff member on the side of the bed holds the
turn/draw sheet to guide to direction of the move.
● The second staff member applies gentle pressure at the
client’s back in the direction of the move, using the draw
sheet.
● The client assists with the turning as much as possible.

7. Position pillows at the client’s back and abdomen.

8. Assess for client’s comfort and proper alignment.

9. Elevate side rails and lower the bed height.

10. This procedure can be repeated for turning the client to the
supine position.

TOTAL

COMMENTS: GRADE:
.

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: TRANSFERRING A CLIENT FROM BED TO WHEELCHAIR, COMMODE, OR CHAIR

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Assess the client's current level of mobility.
2. Assess for any impediments to mobility.
3. Assess the client's level of understanding and anxiety
regarding the procedure.
4. Assess the client's environment.
5. Assess the equipment.
Planning / Expected Outcomes
1. The client will be transferred without pain or injury.
2. Drainage tubes, IVs, or other devices will be intact.
3. The client's skin will be intact and undamaged.
Implementation
1. Inform client about desired purpose and destination.
2. Assess client for ability to assist with and understand the
transfer.
3. Lock the bed in position.
4. Place any splints, braces, or other devices on the client.
5. Lower the height of the bed to lowest possible position.
6. Slowly raise the head of the bed if this is not contraindicated.
7. Place an arm under the client's legs and behind the client's
back. Pivot the client so he is sitting on the edge of the bed.
8. Allow client to dangle for 2 to 5 minutes.
o
9. Place the chair or wheelchair at a 45 angle close to the bed.
10. Lock wheelchair brakes and elevate the foot pedals.
11. Place gait belt around the client's waist, if needed.
12. Assist client to side of bed until feet are firmly on the floor and
slightly apart.
13. Grasp the sides of the gait belt or place your hands just below
the client's axilla. Bend your knees and assist the client to a
standing position.
14. Standing close to client, pivot until the client's back is toward
the chair.
15. Have client place hands on the arm supports.
16. Bend at the knees, easing the client into a sitting position.
17. Assist client to maintain proper posture.
18. Secure the safety belt, place client's feet on foot pedals, and
release brakes to move client. If the client is sitting on a chair, offer
a footstool.
19. Wash hands.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: TURNING AND POSITIONING A CLIENT

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Assess the client's ability to move independently.
2. Assess the client's flexibility.
3. Assess the orders for restrictions regarding client positioning.
Planning / Expected Outcomes
1. The client will maintain skin integrity.
2. The client will be comfortable.
Implementation
1. Wash hands.
2. Explain procedure to client.
3. Gather all necessary equipment.
4. Secure adequate assistance to safely complete task.
5. Adjust bed to comfortable working height. Lower side rail.
6. Follow proper body mechanics guidelines.
7. Position drains, tubes, and IVs to accommodate new client
position.
8. Place or assist client into appropriate starting position.
Moving from Supine to Side-Lying Position
9. Move the client to one side of the bed by lifting the client's body
toward you. Roll the client to side-lying position.
Maintaining Side-Lying Position
10. Follow steps 1 through 8.
11. Pillows may be placed to support the client.
Moving from Side-Lying to Prone Position
12. Repeats steps 1 through 8.
13. Remove positioning support devices. Move the client's inside arm
next to the body. Roll the client onto the stomach. Place
pillows as needed.
Maintaining Prone Position
14. Pillows or a folded towel may be used to support the client.
Moving from Prone to Supine Position
15. Repeat steps 1 through 8.
16. Remove supporting devices. Move the client to one side of the
bed. Log roll client toward you.
Maintaining the Supine Position
17. Pillows, a footboard, heel protections, or a trochanter roll may be
used to support the client.
18. Replace side rails to upright position and lower the bed.
19. Place call light within reach of the client.
20. Place items of frequent use within reach of the client.
21. Wash hands.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: HAIR SHAMPOO

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Determine routinely used shampoo products.

2. Assess the patient.

Planning
1. The client's hair will be dry and clean.
2. Any problems present will be noted and treated.

3. The client will report feeling comfortable and clean.

Implementation
1. Explain the procedure.
2. Gather all the necessary equipment at bedside.

3. Provide privacy.

4. Remove top linen and change with bath blanket.

5. Place plastic square or rubber sheet under the head and
shoulder of the patient.
6. Place towel around the patient's neck and shoulder and the
other towel on the neck.
7. Arrange Kelly pad under patient's head. Place cotton balls on
ears and cover the eye.
8. Wet hair.

9. Shampoo hair. Massage the scalp. Rinse hair thoroughly.

10. Remove Kelly pad and place the towel around patient's hair.

11. Dry hair, ear, and neck.

12. Assist the patient to comb and arrange hair.

13. Return all used equipment to proper storage place.

14. Replace top linen and remove bath blanket.

15. Allow patient to rest.

16. Documentation

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ORAL CARE

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Assess whether the client is able to assist with oral care.
2. Evaluate whether the client has an understanding of proper
oral hygiene.
3. Assess the condition of the client’s mouth.
4. Assess mouth for disease processes.
5. Assess what cultural practices must be considered.
6. Assess whether there are any appliances or devices present
in the client's mouth.
7. Ensure that the proper equipment is available.
Planning / Expected Outcomes
1. Client's mouth, teeth, gums, and lips will be clean.
2. Any disease processes present will be noted and treated.
3. The oral mucosa will be clean, intact, and well hydrated.
Implementation
Self-Care Clients: Flossing and Brushing
1. Assemble articles for flossing and brushing.
2. Provide privacy.
3. Place client in a high-Fowler's position.
4. Wash hands and apply gloves.
5. Arrange articles within client's reach
6. Assist client with flossing and brushing as necessary
7. Assist with rinsing mouth.
8. Reposition client, raise side rails, and place call button within
reach.
9. Rinse, dry, and return articles to proper place.
10. Remove gloves, wash hands, and documents care.

Self-Care Client: Denture Care

11. Assemble articles for denture cleaning.
12. Provide privacy.
13. Assist client to a high-Fowler's position
14. Wash hands and apply gloves.
15. Assist client with denture removal. Place in denture cup.
16. Apply toothpaste to brush and brush dentures hit cool water. If
brushing dentures at the client's sink, place a washcloth in
the sink basin to prevent breaking dentures if they are dropped.

17. Rinse dentures thoroughly.

18. Assist client with rinsing mouth replacing dentures.
19. Reposition client, with side rails up and call button within
reach.
20. Rinse, dry, and return articles to proper place.
21. Wash hands and apply gloves.
22. Assist client with denture removal. Place in denture cup.
23. Apply toothpaste to brush and brush dentures hit cool water. If
brushing dentures at the client's sink, place a washcloth in the
sink basin to prevent breaking dentures if they are
dropped.
24. Rinse dentures thoroughly.
25. Remove gloves, wash hands, and document care.
Full-Care: Brushing and Flossing
26. Assemble articles for flossing and brushing.
27. Provide privacy.
28. Wash hands and apply gloves.
29. Position client as condition allows.
30. Place towel across client's chest or under face and mouth.
31. Apply small amount of toothpaste, and brush teeth and
gums.
32. Floss between all teeth.
33. Assist the client in rinsing mouth.
34. Reapply toothpaste and brush the teeth and gums.
35. Assist the client in rinsing and drying mouth.
36. Apply lip moisturizer, if appropriate.
37. Reposition client, raise side rails, and place call button
within reach.
38. Rinse, dry, and return articles to proper place.
39. Remove gloves, wash hands, and document care.

Client at Risk for or with an Alteration of the Oral Cavity

40. Assemble articles for flossing and brushing.
41. Provide privacy.
42. Wash hands and apply gloves.
43. Bleeding.
a. Assess oral cavity for signs of bleeding.
b. Proceed with the oral care for a full-care client, except:
● Do not floes.
● Use a soft toothbrush, toothette, or a padded tongue
blade to swab teeth and gums.
● Dispose of padded tongue blade into a biohazard bag.
● Rinse with tepid water.
44. Infection:
a. Assess oral cavity for signs of infection.
b. Culture lesions as ordered.
c. Proceed with oral care for a full-care client except:
● Do not floss.
● Use prescribed antiseptic solution.
● Use a padded tongue blade to swab the teeth and
gums.
● Dispose of padded tongue blade into a biohazard bag.
● Rinse mouth with tepid water.
● Apply additional solution as prescribed.
45. Ulceration:
b. Assess oral cavity for signs of ulceration.
c. Culture lesions as ordered.
d. Proceed with oral care for a full-care client except:
● Do not floss.
● Use prescribed antiseptic solution.
● Use a padded tongue blade to swab the teeth and
gums.
 ● Dispose of padded tongue blade into a biohazard bag.
● Rinse mouth with tepid water.
● Apply additional solution as prescribed.

Unconscious (Comatose) Client:

46. Assemble articles for flossing and brushing.
47. Provide privacy.
48. Wash hands and apply gloves.
49. Explain the procedure to the client.
50. Place the client in a lateral position, head turned toward the
side.
51. Use a floss holder and floss between the teeth.
52. Moisten toothbrush, and brush teeth and gums. Do not use
toothpaste.
53. After flossing and brushing, rinse mouth and perform oral
suction.
54. Dry the client's mouth.
55. Apply lip moisturizer.
56. Leave the client in a lateral position for 30 to 60 minutes after
oral care. Suction one more time.
57. Dispose of non-reusable items appropriately. Rinse, dry, and
return articles to proper place.
58. Remove gloves, wash hands, and document care.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: BATHING A CLIENT IN BED (CLEANSING BED BATH)

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Assess the client's level of ability to assist with the bath.
2. Assess the client's level of comfort with the procedure.
3. Assess the environment and equipment available.
Planning / Expected Outcomes
1. Client will be cleaned without damage to skin.
2. Client's privacy will be maintained.
3. Client will participate in her own hygiene.
4. Client will not experience adverse effects as a result of the
bath.
Implementation
1. Assess client's preferences about bathing.
2. Explain procedure to client.
3. Prepare environment. Provide time for elimination, and
provide privacy.
4. Wash hands. Wear gloves.
5. Lower side rail nearest you. Position client comfortably.
6. Place bath blanket over top sheet. Remove top sheet and
client's gown.
7. Fill wash basin two thirds full with warm water.
8. Wet the washcloth and wring it out.
9. Make a bath mitten with the washcloth.
10. Wash client's face, neck, and ears. Shave client if needed.
11. Wash arms, forearms, axilla and hands.
12. Wash chest and abdomen.
13. Wash legs and feet.
14. Wash back. Give patient a back if not contraindicated.
15. Assist client to supine position. Perform perineal care.
16. Apply lotion and powder as desired. Apply clean gown.
17. Document skin assessment, type of bath and client
response.
18. Wash hands.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: TEPID SPONGE BATH

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1

1. Take vital signs and assess patient’s condition.

2. Explain the procedure to the patient or watcher.

3. Wash your hand and assemble all equipment and bring to

bedside.
4. Close doors and windows in private rooms and draw curtains in
the ward. Put off air conditioner and electric fans.

5. Adjust the bed to the working height.

6. Don Gloves

7. Change the top sheet with a blanket and remove patient’s clothing.

8. Gently put the wash cloth on each patient’s extremity for 5 minutes.
Proceed with back buttocks for 5-10 minutes.

Note: Abdomen and chest are not usually sponged.

9. Pat dry each body part after sponging with bath towel and cover
with the bath blanket.
10. Monitor the patient’s response and recheck TPR every 10 minutes
thereafter.
11. Change the patient’s clothing and replace the bath blanket
with the top sheet.

12. Lower the bed.

13. Do the after care of equipment used.

14. Document the treatment performed, patient’s VS, response to the

treatment and any complications.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: CHANGING LINENS IN AN UNOCCUPIED BED

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Assess your equipment.

2. Assess whether the bed itself needs cleaning.

3. Assess the client’s needs in the bed.

Planning / Expected Outcomes
1. The client will have clean linens on the bed.
2. The clean linens will be appropriate to the client’s needs and
condition.
Implementation
1. Place hamper close by Explain procedure to client. Assess
condition of blankets.
2. Gather linens and gloves.

3. Apply gloves.

4. Attend to the client’s needs as necessary.

5. Assist client to a safe, comfortable chair.

6. Position bed.

7. Remove and fold blanket and /or bedspread.

8. Remove soiled pillowcases.

9. Remove soiled linens.

10. Fold soiled linens.

11. Check the mattress. If soiled, clean appropriately.

12. Remove gloves, wash hands, and apply a second pair of
clean gloves
13. Place clean mattress pad onto the mattress. Unfold half of
the pad’s width to the center crease.

14. Proceed with placing bottom sheet onto the mattress.

Fitted Bottom Sheet
15. Position yourself diagonally toward the head of the bed.
16. Start the head with seamed side of the fitted sheet toward the
mattress.
17. Lift the mattress corner and tuck the fitted sheet over the
mattress corner Repeat for other corner.
18. Tuck the fitted sheet over the mattress corners foot of the
bed.
Flat Regular Sheet
19. Align the bottom edge of the sheet with the edge of the mattress
at the foot of the bed.
20. Allow the sheet to hang over the mattress on the side and at
the top of the bed.
 21. Position yourself diagonally toward the head of the bed. Lift
the mattress corner and smoothly tuck the sheet under the
mattress.
22. Miter the corner at the head of the bed.
23. Position yourself diagonally toward the head of the bed. Lift
the mattress corner and smoothly tuck the sheet under the
mattress.
24. Miter the corner at the head of the bed.
25. Lift and lay the top edge of the sheet onto the bed to form a
triangular fold.
26. Tuck the lower edge of the mattress.

27. Bring the triangular fold down over the side of the mattress.
28. Place the draw sheet on the bottom sheet and unfold it to the
middle crease.
29. Tuck both the bottom and draw sheets smoothly under the
mattress.
30. On the other side of the bed, repeat steps 13 through 18, as
used to apply the mattress pad and bottom sheet.
31. Unfold the draw sheet and grasp both sheets. Pull toward
you and tuck both sheets under the mattress.
32. Place the top sheet on the bed. Place the top edge of the
sheet even with the top of the mattress. Pull the remaining length
toward to the bottom of the bed.
33. Unfold and apply the blanket/spread as with the top sheet.

34. Miter the bottom corners.

35. Fold the top sheet and blanket over. Fan-fold the sheet and
blanket.
36. Apply clean pillowcase on each pillow.

37. Place bed in lowest position; raise the head of the bed.
38. Inquire about toileting needs of the client; assist as
necessary.
39. Assist the client back into the bed and pull up the side rails;
place call light in reach; take vital signs.
40. Remove gloves and wash hands.
41. Document your actions and the client’s response to the
activity.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: CHANGING LINENS IN AN OCCUPIED BED

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Assess your equipment.
2. Assess whether the bed itself needs cleaning.
3. Assess the client’s needs in the bed.
4. Assess the client’s ability to assist with the procedure.
Planning / Expected Outcomes
1. The client will have clean linens on the bed.
2. The Clean linens will be appropriate to the client’s needs and
condition.
Implementation
Preparation
1. Explain procedure to client.
2. Bring equipment to the bedside.
3. Apply gloves.
4. Remove top sheet and blanket. Loosen bottom sheet.
5. Position client on side, facing away from you.
6. Fan-fold or roll bottom linens toward the center of the bed.
7. Place clean bottom linen. Fan-fold or roll clean bottom linens
and tuck under soiled linen.
8. Miter bottom sheet at head and foot of bed. Tuck the sides of
the sheet under the mattress.
9. Fan-fold or roll draw sheet and tuck under soiled linen. Tuck
draw sheet under mattress.
10. Log roll client over onto side facing you. Raise side rail.
11. At the other side of bed, remove soiled linens.
12. Unfold/unroll bottom sheet, then draw sheet. Tuck in.
13. Place top sheet and blanket over client.
14. Raise foot of mattress and miter the corner. Repeat on other
side.
15. Tent top sheet and blanket over client’s toes.
16. Remove and replace pillow case.
17. Document procedure and client’s condition.
18. Remove gloves and wash hands.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: BACK MASSAGE

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Perform
Assistance
3 2 1
1. Assess the condition of the patient and make sure that there is
no contradiction for the procedure.
2. Assess the patient’s heart rate, respiratory rate and blood
pressure.

3. Assess client’s skin in the back.

4. Ensure that proper equipment is available.

PLANNING/EXPECTED OUTCOMES:

5. Rest and sleep of the patient will be promoted

6. Tense muscle will be relaxed thereby relieving pain.

7. Concern for the patients comfort thru non-verbal

communication will be established.
8. Providing opportunity for the nurse to assess the skin on the
blank.

IMPLEMENTATION:

9. Offer to give the patient a back massage and explain the

procedure.
10. Remove jewelry. Wash your hands. Assemble necessary
equipment.
11. Provide privacy. Raise the bed to working height and lower
the side rails closest to you.

12. Assess the patient’s heart rate. RR and BP.

13. Assist the patient to a prone or side-lying position with the

back exposed. Bath blanket is used to cover from the
buttocks down to the lower extremities and towel alongside the
patients back.
14. Warm the lubricant or lotion in palm of hand or place the
container in warm water.
15. Using light strokes (effleurage) apply lotion/powder starting
from the sacral area towards the back and shoulders.
16. Place hands beside each other at the base of the patients,
spine and stroke upward to the shoulders and back downward
to the buttocks in slow continuous strokes to continue 3-5
minutes and applying additional lotion/lubricant
or powder as necessary.
17. Massage the shoulders, the entire back, areas over the iliac
crests and sacrum with circular stroking motion for 3-5
 minutes and applying additional lotion/lubricant or powder as
necessary.
18. If other strokes like petrissage, friction rub or tapotement are
used, complete the massage with additional long stroke
movements.
19. Observe the skin for reddened or open areas, and pay
attention to skin over long prominences while avoiding
rubbing any areas that remain red after pressure has been
relieved.
20. Use towel to pat dry and remove excess lotion and apply
lotion per patient’s demand.
21. Reposition client, adjust bed clothes and linens, side rails up
and call button within patient’s reach.

22. Wash hands.

23. Assess the patient’s response and record observation on the

chart.

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ADMINISTERING ORAL, SUBLINGUAL, AND BUCCAL MEDICATIONS

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Check the doctor’s orders for the drugs to be given.

2. Determine the accuracy of the drugs to be administered.

3. Arrange the medication tray and cups.

4. Identify the patient and explain the effects and actions of the
drug, entertain any question the client may have.
5. Assess the client’s ability to swallow food and liquid.
6. Assess for any contraindications for the drug as well as the
client’s record for allergies.
7. Perform hand washing and put on clean gloves when
necessary.
8. Following the rights in giving the medication, prepare the
tablet or capsule by pouring into the medication cup without touching
it.
9. To prepare liquid medication, remove cap and place cap upside
down. Pour the medication at eye level until desired dose
is reached.
10. For Buccal medications, instruct the client to dissolve the
medication in the mouth against the cheek while for Sublingual
drugs, instruct the client to dissolve medication under the
tongue.
11. Dispose properly soiled supplies and reposition patient
comfortably.

12. Evaluate the client’s response to the drug

13. Record full detail about the procedure done.

14. Restore and clean unit, restock when needed. Wash hands.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ADMINISTERING AN INTRADERMAL INJECTION

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Perform
Assistance
3 2 1
1. Verify doctor’s orders for the medication and prepare materials
and solution for injection and applies and sterile
technique during in the entire procedure.
2. Identifies the patient and explains the procedure, reads the
medicine cards.
3. Allay any tears/anxiety clients may have.

4. Places the patient in comfortable and right position.

5. Identifies the anatomical landmarks by palpation and
inspection and identifies injections site correctly.
6. Cleans the injection site with cotton ball with alcohol using
circular motion working from the site of injection outward.
7. Place dry cotton ball in-between fingers, removes needle
cap and expels air bubbles.
8. Uses free hands to stretch the skin.
9. Insert needle, level up 10-15 degree angle just under the
skin.
10. Releases the skin, anchors the barrel and injects the
medication slowly until the wheal is formed.
11. At the same angle, withdraws the needle.
12. Wipes dry cotton ball excess medication from skin without
pressing the wheal.
13. Encircles the site of the wheal with blue or black ball pen
and mark the due date and time.
14. Does not recap the needle and make the patient
comfortable.
15. Explains the patient possible outcomes.

16. Disposes the needle and syringe properly.

17. Performs proper and correct documentation of the
procedure ( verbalize the written documentation).
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ADMINISTERING AN INTRAMUSCULAR INJECTION (DELTOID)

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Check doctor’s order for medication administration and prepare
materials and solution for injection and applies and
sterile technique during in the entire procedure.
2. Identifies the patient and explain the procedure read the
medication card.

3. Place the patient in comfortable position.

4. Identifies anatomical landmarks by palpation and
inspection and identifies injection site correctly.
5. Clean injection site with alcohol using circular motion
working from site of injection outward.
6. Place cotton ball with alcohol in between fingers, removes
needle cap and maintain sterility of needle.
7. While maintaining the sterility of the needle, taut skin of
the injection site and thrust the needle into the muscle at
90° angles.
8. Checks for the presence of blood by pulling the plunger
backward and verbalizes what to do in case blood is
aspirated.
9. If blood is not aspirated, inject the solution.

10. Removes the needle smoothly and quickly at 90° angles.

11. Applies gentle pressure against injection site using a
swab.
12. Does not recap a needle and dispose needle syringe
properly.

13. Position the patient comfortably.

14. Performs proper correct documentation of the procedure
done.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: COLLECTION OF URINE SPECIMEN

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
Clean Catch Midstream Urine
1. Wash your hands.
2. Assemble equipment and place on bedside.
3. FEMALE
a. Instruct to cleanse the peri-urethral area with soap and
water and dry. Advise to sit with legs separate at the
toilet.
b. Open the sterile container, placing the lid up on a firm
surface within easy reach.
c. Using thumb and forefinger, separate the labia.
4. MALE
a. Instruct patient to cleanse the head of the penis by
retracting the glans penis to effectively cleanse the
meatus.
5. Let the patient urinate into the toilet and to place the collection
cup under the stream of urine. Instruct to fill the container
with approximately 15-30cc of urine and to close
tightly.
6. Label and transport to the laboratory with the request form.
Close Drainage System
1. Gather equipment.
2. Explain procedure to patient.
3. Manipulate the drainage tubing so that the urine in the
tubing goes into the bag.
4. Clamp the drainage tubing just above the port using the
plaster or clamp. Leave clamped for 20-30 minutes.
5. Wash hands and don gloves.
6. Provide privacy.
7. Unclamp the drainage tube and disconnect from the
collecting tube of the urine bag
8. Hold a sterile container firmly near the outlet of the drainage
tube to collect the urine. See to it that the tip of the outlet of
the drainage tube will not touch any part of the sterile
container. Make sure that the container is filled with
at least ¾ full of urine and then cover.
9. Re-connect the drainage tube back to the collecting tube.
10. Remove gloves and dispose properly. Wash your hands.
11. Label specimen and send to laboratory together with the
accomplish request slip.
12. Record collection of specimen and any pertinent
observations.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: INSERTING AN INDWELLING CATHETER: MALE

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Assess the following:
● Need for catheterization & the type ordered
● Need for peritoneal care prior to catheterization
● Urinary meatus & ask for any history of urinary
difficulty
● Client’s ability to assist in procedure
● Allergy to povidone-iodine
● Indications of distress or embarrassment

Planning/Expected Outcomes:
1. The catheter will be inserted without trauma to the client.
2. The client’s bladder will be emptied without complication.
3. The ruse will maintain the sterility of the catheter during
Insertion.
Implementation:
1. Gather the equipment needed.
2. Provide for privacy and explain the procedure.
3. Set the bed to a comfortable height to work, and raise the
Opposite side of rail.
4. Assist the client to a supine position with legs slightly
Spread.
5. Drape the client’s abdomen and thighs if needed.
6. Ensure adequate lighting of penis and perineal area.
7. Wash hands, apply disposable gloves, & wash perineal area.

8. Remove gloves & wash hands.

9. Open the catheterization kit. Use the wrapper to establish a
sterile field.
10. Add the catheter or any other items needed using sterile
technique.
11. Apply sterile gloves.
12. Place the fenestrated drape over the client’s perineal area with
the penis extending through the opening.
13. If inserting a retention catheter, attach the syringe filled
with sterile water to the Luer-Lock tail of catheter. Inflate
and deflate the retention balloon. Detach the water-filled
syringe.
14. Attach the catheter to the urine drainage bag.
15. Coat the distal portion of catheter with water-soluble, sterile
lubricant.
16. With one hand, gently grasp the penis & retract the foreskin (if
present). With your other hand, cleanse the glans penis with
antimicrobial cleanser.
17. Hold the penis perpendicular to the body & gently pull it up.
18. Inject 10ml sterile, water-soluble lubricant into the urethra.
19. Steadily insert the catheter about 8 inches, until urine is noted.

20. If the catheter will be removed right away, insert the

catheter another inch, place the penis in a comfortable
 position & hold the catheter in place as the bladder drains into
a sterile receptacle.
21. If the catheter will be indwelling with a retention balloon,
continue inserting until the hub of the catheter is met.
22. Reattach the water-filled syringe to the inflation port.
23. Inflate the retention balloon.
24. If the client experiences pain during balloon inflation,
deflate the balloon and insert the catheter farther into the
bladder. If the pain continues, with the balloon inflation,
remove the catheter and notify the client’s physician.
25. Once the balloon has been inflated, gently pull the catheter
until the retention balloon is resting against the bladder
neck.
26. Secure the catheter to either the client’s thigh or abdomen.
27. Place the drainage bag below the level of the bladder,
Secure the drainage tubing to prevent pulling.
28. Remove gloves, dispose equipment, and wash hands.
29. Help client adjust position. Lower the bed.
30. Wash hands.
31. Assess and document properties of client’s urine.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: INSERTING AN INDWELLING CATHETER: FEMALE

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Assess the following:
● Need for catheterization & the type ordered
● Need for peritoneal care prior to catheterization
● Urinary meatus & ask for any history of urinary
difficulty
● Client’s ability to assist in procedure
● Allergy to povidone-iodine
● Indications of distress or embarrassment

Planning/Expected Outcomes:
1. The catheter will be inserted without trauma to the client.
2. The client’s bladder will be emptied without complication.
3. The ruse will maintain the sterility of the catheter during
insertion.
Implementation:
1. Gather the equipment needed.
2. Provide for privacy and explain the procedure.
3. Set the bed to a comfortable height to work, and raise the
opposite side of rail.
4. Assist the client to a supine position with legs slightly
spread or to a side-lying position with upper leg flexed.
5. Drape the client’s abdomen and thighs for warmth, if
needed.
6. Ensure adequate lighting of perineal area.
7. Wash hands and apply disposable gloves.
8. Wash perineal area.
9. Remove gloves & wash hands.
10. Open the catheteriz ati on kit. Use the wrapper to establish a
sterile field.
11. Add the catheter or any other items needed using sterile
technique.
12. Apply sterile gloves.
13. If inserting a retention catheter, attach the syringe filled
with sterile water to the Luer-Lock tail of catheter. Inflate
and deflate the retention balloon. Detach the water-filled
syringe.
14. Attach the catheter to the urine drainage bag.
15. Coat the distal portion of catheter with water-s ol ubl e, sterile
lubricant.
16. Place the fenestrated drape over the client’s perineal area
with the labia visible through the opening.
17. Gently spread the labia minora with your fingers and
visualize the urinary meatus.
18. Holding the labia apart, use the forceps to pick up a cotton
ball soaked in povidone-iodine and cleanse the periurethral
mucosa using one downward stroke for each cotton ball, then
dispose.
19. Steadily insert the catheter into the meatus until urine is
noted.
20. If the catheter will be removed right away, insert the
catheter another inch, place the penis in a comfortable
 position & hold the catheter in place as the bladder drains
into a sterile receptacle.
21. If the catheter will be indwelling with a retention balloon,
continue inserting another 1 to 3 inches.
22. Reattach the water-filled syringe to the inflation port.
23. Inflate the retenti on balloon.
24. If the client experienc es pain during balloon inflation,
deflate the balloon and insert the catheter farther into the
bladder. If the pain continues, with the balloon inflation, remove
the catheter and notify the client’s physician.
25. Once the balloon has been inflated, gently pull the catheter
until the retention balloon is resting against the bladder
neck.
26. Tape the catheter to the abdomen or thigh with enough
slack so it will not pull on the bladder.
27. Place the drainage bag below the level of the bladder .
Secure the drainage tubing to prevent pulling.
28. Remov e gloves, dispose equipment, and wash hands.
29. Help client adjust position. Lower the bed.
30. Wash hands.
31. Assess and document properti es of client’s urine.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: COLLECTION OF STOOL SPECIMEN

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1

1. Perform personal hygiene.

2. Assemble equipment (gloves, sterile container with cover.) and

place on bedside.
3. Explain procedure to the patient.

▪ The first stool in the morning is usually preferred.

▪ Fresh warm, non-formed stools are usually required for
protozoan screening.
▪ Examination for helminths can be done with formed stool.

4. Assist the client to a sitting position on the bedpan,

commode or toilet.

5. Fill each container aseptically at least 1/3 full, or add enough

feces to bring to the fill line if present. DO NOT
overfill.
6. To prevent the spread of infection wear gloves when filling the
collection cup or whenever in contact with the stool and wash
hands at least in beginning and with patient contact.
7. For maximum detection of parasites, three non-formed stools
should be collected over a five-day period, every
other day (stool series).

8. Label the sample container with the patient’s name, type of test,
form number, physician’s name and the date and time.

9. Document observations in the chart of the patient.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ADMINISTERING AN ENEMA

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Assess the following:
● Type of enema & rationale of the ordered enema
● Physical condition of the client
● Client’s mental state
Planning/Expected Outcomes:
1. The client’s rectum will be free of feces & flatus.
2. The client will experience a minimum of trauma and
embarrassment.
Implementation: Large Volume, Cleansing Enema
1. Wash hands.
2. Assess understanding of procedure. Provide privacy.
3. Apply gloves.
4. Prepare equipment.
5. Place absorbent pad on bed under client. Assist client into
left lateral position.
6. Heat solution to desired temperature.
7. Pour solution into the bag or bucket. Open clamp or prime
tubing.
8. Lubricate 5cm of the rectal tube unless the tube is pre-
lubricated.
9. Hold the enema container level with the rectum. Have the
client take a deep breath. Simultaneously insert rectal tube 7
to 10 cm into rectum.
10. Raise the container to the appropriate height (12 to 18
inches) and open clamp.
11. Slowly administer the fluid.
12. When the solution has been administered or the client
cannot hold more fluid, clamp and remove the rectal tube,
disposing it properly.
13. Clean lubricant, solution, and any feces from the anus with
the toilet tissue.
14. Have the client continue to lie on the left side for the
prescribed length of time.
15. When the enema has been retained the prescribed
amount of time, assist to the bedside commode, toilet, or
bedpan. Instruct client not to flush the toilet.
16. When finished, assist to clean the perineal area.
17. Return the client to a comfortable position with a protective
pad in place.
18. Observe feces.
19. Remove gloves and wash hands.
20. Document the procedure and results.
Implementation: Small Volume, Pre-packaged Enema
21. Wash hands.
22. Remove pre-packaged enema from packaging. Warm the
fluid prior to use.
23. Apply gloves.
24. Place absorbent pad under client. Assist client into left
lateral position.
25. Remove protective cap from nozzle. Lubricate as needed.
26. Squeeze container to remove any air & prime the nozzle.
 27. Have the client take a deep breath. Insert the enema
nozzle into the anus.
28. Squeeze the container until all the solution is instilled.
29. Remove the nozzle from the anus & dispose the container
appropriately.
30. Clean lubricant, solution, & feces with toilet tissue.
31. Have the client continue to lie on the left side for the
prescribed length of time.
32. After the prescribed amount of time, assist to the bedside
commode, toilet, or bedpan. Instruct client not to flush the
toilet.
33. When the client is finished, assist to clean the perineal
area.
34. Return the client to a comfortable position with a protective
pad in place.
35. Observe feces.
36. Remove gloves and wash hands.
37. Document the procedure and results.
Implementation: Return-Flow Enema
38. Wash hands.
39. Assess understanding of procedure. Provide privacy.
40. Apply gloves.
41. Place absorbent pad on bed under client. Assist client into
left lateral position.
42. Heat solution to desired temperature.
43. Pour solution into the bag or bucket. Open clamp or prime
tubing. Clamp tubing when primed.
44. Lubricate 5cm of the rectal tube unless the tube is pre-
lubricated.
45. Hold the enema container level with the rectum. Have the
client take a deep breath. Simultaneously insert rectal tube into
the rectum, approximately 10 to 20 cm (4-6 inches).
46. Raise container to the appropriate height and open clamp.
47. Slowly administer approximately 200 cc of the solution.
48. Clamp the tubing and lower the enema container 12 to 18
inches below the client’s rectum. Open the clamp.
49. Observe the solution container for air bubbles and fecal
particles as the solution returns.
50. When no further solution is returned, clamp the tubing and
raise the enema container as before. Open the clamp and
instill approximately 200 cc of fluid.
51. Repeat until no further flatus is seen or the institutional
guidelines have been met.
52. After the final return, clamp the tubing and remove the
tubing. Clean the anus with tissue.
53. If the client needs to empty rectum, assist to bedpan,
bathroom, or commode. Instruct not to flush the toilet.
54. When the client is finished, assist to clean perineal area.
55. Return to a comfortable position on a protective pad.
56. Observe any expelled solution.
57. Remove gloves and wash hands.
58. Document the results of the enema.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: COLLECTION OF SPUTUM SPECIMEN

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1

1. Explain the procedure to the patient.

2. Make sure the patient can expectorate the sputum

directly into the sputum cup. Leave the container with
patient if assistance is not required. If the patient need
assistance, wear the gloves and mask.
3. Ask the patient to sit and to breathe deeply thrice and
cough up 1-2 tbsp. or depending on the specified
amount.
4. Advise the patient to hold the sputum cough (or hold it) and
expectorate into it, making sure that the sputum does
not come in contact with the outside of the container.

5. Cover the container immediately after the collection.

6. Determine the respiration rate and any abnormalities or

difficulty in breathing.
7. Assess the color of the patient’s skin especially any
cyanosis.
8. Wipe the outside of the container with a disinfectant if the
sputum has contacted the outside surface.
9. Place the completed label on the container, (name, room
no., purpose, specimen, series no.)

10. Provide the patient with water to rinse the mouth.

11. Together with laboratory requisition slip, send the

specimen to the laboratory within 20minutes.
12. Document collection of the sputum specimen on the
patient’s chart. Include the color, consistency, amount and
odor of the sputum. Chart any discomfort
experienced by the patient.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ADMINISTERING OXYGEN BY CANNULA, FACEMASK, OR FACE TENT

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Perform
Assistance
3 1
2
1. Assess breathing patterns, chest movements, chest wall
configurations, and lung sounds.
2. Determine the vital signs especially pulse rate and
respiratory rate, rhythm, and depth.
3. Assemble the equipment:

Cannula:
● Oxygen supply with a flow meter & adapter
● Humidifier with distilled water or tap water, according
to agency protocol
● Nasal cannula & tubing
● Tape
● Padding for the elastic band

Facemask:
● Oxygen supply with a flow meter & adapter
● Humidifier with distilled water or tap water, according
to agency protocol
● Prescribed face mask of the appropriate size
● Padding for the elastic band

Face Tent:
● Oxygen supply with a flow meter & adapter
● Humidifier with distilled water or tap water, according
to agency protocol
● Face tent of the appropriate size

4. Determine the need for oxygen therapy & verify order.

5. Assist the client to a semi-Fowler’s position, if possible.

6. Explain the oxygen is not dangerous when safety precautions
are observed. Inform the client and support people about the
safety precautions connected with
oxygen use.
Procedure:
7. Introduce self 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.
8. Perform hand hygiene & observe other appropriate
infection control procedures.
9. Provide for privacy.
10. Set up the oxygen equipment & the humidifier.
● Attach the flow meter to the wall outlet or tank. The
flow meter should be in the OFF position.
● If needed, fill the humidifier bottle.
● Attach the humidifier bottle to the base of the flow
meter.
● Attach the prescribed oxygen tubing & delivery
device to the humidifier.
 11. Turn on the oxygen at the prescribed rate, and ensure
proper functioning.
● Check that the oxygen is flowing freely through the
tubing. There should be no kinks in the tubing, and the
connections should be airtight. There should be
bubbles in the humidifier as the oxygen flows through.
You should feel the oxygen at the outlets of the
cannula, mask, or tent.
● Set the oxygen at the flow rate ordered.
12. Apply the appropriate oxygen delivery device.

Cannula:
● Put the cannula over the client’s face with the outlet
prongs fitting into the nares & the elastic band around
the head.
● If the cannula will not stay in place, tape it at the
sides of the face.
● Pad the tubing & band over the ears & cheekbones
as needed.

Facemask:
● Guide the mask toward the client’s face & apply it
from the nose downward.
● Fit the mask to the contours of the client’s face.
● Secure the elastic band around the client’s head so
that the mask is comfortable but snug.
● Pad the band behind the ears and over bony
prominences.

Face Tent:
● Place the tent over the client’s face, and secure the
ties around the head.

13. Assess the client regularly.

Cannula:
● Assess the client’s nares for encrustations and
irritation. Apply a water-soluble lubricant as required
to soothe the mucous membranes.
● Assess the top of the client’s ears for any sign of
irritation from the cannula strap. If irritation is present,
padding with a gauze pad helps relieve discomfort.

Facemask or Face Tent:

● Inspect the facial skin frequently for dampness or
chafing, and dry and treat it as needed.

14. Inspect the equipment on a regular basis.

15. Document findings in the client record.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: INSERTING A NASOGASTRIC TUBE

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Perform
Assistance
3 1
2
1. Assess:
● History of nasal surgery or deviated septum
● Patency of nares
● Presence of gag reflex
● Mental status or ability to cooperate with procedure
2. Determine:
● Size of tube to the inserted
● Whether the tube is to be attached to suction
3. Assemble equipment and supplies:
● Large- or small-bore tube
● Non-allergenic adhesive tape, 2.5cm (1 inch) wide
● Clean gloves
● Water-soluble lubricant
● Facial tissues
● Glass of water and drinking straw
● 20-50ml syringe with an adapter
● Basin
● pH test strips or meter
● Stethoscope
● Disposable pad or towel
● Clamp or plug
● Safety pin and elastic band

4. Assist the client to a high-Fowler’s position, if the health

condition permits, and support head on a pillow. Place a
towel or disposable pad across client’s chest.
Procedure:
1. Introduce self 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.
2. Perform hand hygiene and observe other appropriate
infection control procedures.

3. Provide for client privacy.

4. Assess the client’s nares.

5. Prepare the tube.
● If a small-bore tube is being used, ensure the stylet or
guide wire is secured in position.
6. Determine how far to insert the tube.
● Use the tube to mark off the distance from the top of the
client’s nose to the top of the ear lobe and then from the
top of the earlobe to the top of the xyphoid.
● Mark this length with adhesive tape, if the tube does not
have markings.
7. Insert the tube.
● Put on gloves.
● Lubricate the top of the tube well to ease insertion.
● Insert the tube, with tis natural curve toward the client,
into the selected nostril. Ask the client to hyperextend
 the neck, and gently advance the tube toward the
nasopharynx.
● Direct the tube along the floor of the nostril and toward
the ear on that side.
● Slight pressure is sometimes required to pass the tube
into the nasopharynx, and some client’s eyes may water
at this point. Provide the client with tissues, as needed.
● If the tube meets resistance, withdraw it, re-lubricate it,
and insert it in the other nostril.
● Once the tube reaches the oropharynx, the client will feel
the tube in the throat, and may gag and retch. Ask the
client to tilt the head forward and encourage the client to
drink and swallow.
● If the client gags, stop passing the tube momentarily.
Have the client rest, take a few breaths, and take sips of
water to calm the gag reflex.
● If cooperation with the client, pass the tube 5 to 10 cm
(2-4 inches) with each swallow, until the indicated length
is inserted.
● If the client continues to gag, and the tube does not
advance with each swallow, withdraw it slightly, and inspect
the throat by looking through the mouth.

8. Ascertain correct placement of the tube.

● Aspirate stomach contents, and check the pH.
● X-ray as per agency policy. If a small-bore tube is used,
leave the stylet in place until the correct position is
verified.
● Place a stethoscope over the epigastrium and inject 10 to
30 ml of air into the tube while listening for a whooshing
sound.
● If the signs do not indicate placement in the stomach,
advance the tube 5 cm (2 inches) and repeat the tests.
9. Secure the tube by taping it to the bridge of the nose.
● If the client has oily skin, wipe the nose first with
alcohol.
● Cut 7.5 cm (3 inches) of tape, and split it lengthwise at
tone end, leaving a 2.5 cm (1 inch) tab at the end.
● Place the tape over the bridge of the nose, and bring
the split ends either under and around the tubing, or under
the tubing and back up over the nose.
10. Attach the tube to a suction source or feeding apparatus,
as ordered, or clamp the end of the tubing.
11. Secure the tube to the client’s gown.
● Loop an elastic band around the end of tubing, and attach
the elastic band to the gown with a safety pin; or,
● Attach a piece of adhesive tape to the tube and pin the
tape to the gown. If a Salem sump pump is used, attach
the anti-reflux valve to the vent port.

12. Document relevant information.

13. Establish a plan for providing daily nasogastric tube care.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: OROPHARYNGEAL & NASOPHARYNGEAL SUCTIONING

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Assistance Perform
3 2 1
1. Assess for clinical signs indicating the need for
suctioning.
2. Assemble the equipment:

● Towel or moisture-resistant pad

● Portable or wall suction machine with tubing,
collection receptacle, & suction pressure gauge
● Sterile, disposable container for fluids
● Sterile normal saline or water
● Sterile gloves
● Goggles or face shield, if appropriate
● Moisture-resistant disposal bag
● Sputum trap, if specimen is to be collected

Oral & Oropharyngeal Suctioning:

● Yankauer suction catheter kit
● Clean gloves

Nasopharyngeal Suctioning:
● Sterile gloves
● Sterile suction catheter kit
● Water-soluble lubricant
● Y-connector

Procedure:
1. Introduce self 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.
2. Perform hand hygiene & observe other appropriate
infection control procedures.
3. Provide for privacy.
4. Prepare the client.

● Position a conscious person who has a functional

gag reflex in the semi-Fowler’s position, with head
turned to one side for oral suctioning or with neck
hyperextended for nasal suctioning.
● Position an unconscious client in the lateral position,
facing you.
● Place the towel or moisture-resistant pad over the
pillow or under chin.
5. Prepare the equipment.

● Set the pressure on suction gauge, and turn on the

suction.
● Open the lubricant (if performing nasopharyngeal
suctioning)

Oral & Oropharyngeal Suctioning:

● Moisten the tip of the Yankauer suction catheter with
the sterile water or saline.
● Pull tongue forward, if necessary, using gauze.
 ● Do not apply suction (leave your finger off the port)
during the insertion.
● Advance the catheter about 10-15 cm (4-6 inches)
along one side of the mouth into the oropharynx.
● It may be necessary during oropharyngeal suctioning to
apply suction to secretions that collect in the vestibule
of the mouth and beneath the tongue.

Nasopharyngeal Suctioning:
● Open the lubricant.
● Open the sterile suction package:
o Set up the cup or container, touching only the
outside.
o Pour sterile water or saline into the container.
o Put on the sterile gloves, or put on a non-sterile
glove on the non-dominant hand & then a sterile
glove on the dominant hand.
o With your sterile-gloved hand, pick up the
catheter, and attach it to the suction unit.

6. Make an appointment measure of the depth for the

insertion of the catheter, and test the equipment.

● Measure the distance between the tip of the client’s

nose and the earlobe.
● Mark the position on the tube with the fingers of the
sterile-gloved hand.
● Test the pressure of the suction and patency of the
catheter by applying your sterile-gloved finger or
thumb to the port or open branch of the Y-connector
(the suction control) to create suction.
● If needed, increase supplemental oxygen.
7. Lubricate & introduce the catheter.

● Lubricate the catheter tip with sterile water, saline, or

water-soluble lubricant.
● Remove oxygen with your non-dominant hand, if
appropriate.
● Without applying suction, insert the catheter the
premeasured or recommended distance into either
naris, and advance it along the floor of the nasal
cavity.
● Never force the catheter against the obstruction. If
one nostril is obstructed, try the other.
8. Perform suctioning.

● Apply your finger to the suction control port to start

suction, and gently rotate the catheter.
● Apply suction for 5 to 10 seconds while slowly
withdrawing the catheter, then remove your finger
from the control and remove the catheter.
● A suction attempt should last only 10-15 seconds.
● During this time, the catheter is inserted, the suction
applied and discontinued, and the catheter removed.
9. Rinse the catheter, and repeat suctioning as above.

● Rinse & flush the catheter & tubing with sterile water
or saline.
● Re-lubricate the catheter & repeat suctioning until the
air passage is clear.
● Allow sufficient time between each suction, & limit
suctioning to 5 minutes in total.
 ● Encourage the client to breathe deeply & to cough
between suctions.
10. Obtain a specimen, if required. Use a sputum trap.
11. Promote client comfort.
12. Dispose of equipment and ensure availability for the
next suction.
13. Assess the effectiveness of suctioning.
14. Document relevant data.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: CAPILLARY BLOOD GLUCOSE (MONITORING THE BLOOD GLUCOSE LEVEL)

Name:
Date:

Able to
Able to Unable to
ASSESSMENT Perform w/
Perform Perform
Assistance
3 1
2
1. Check physician’s order for monitoring schedule.

2. Gather equipment.

3. Explain procedure to patient.

4. Perform hand hygiene. Don disposable gloves.

5. Prepare lancet.
6. Remove test strip from vial and recap container
immediately. Turn monitor on and check that code
number on strip matches code number on monitor
strip.
7. Massage side of finger for adult (or heel for child)
toward puncture site.
8. Have patient wash hands with soap and warm water
or cleanse area with alcohol. Dry thoroughly.
9. With finger in dependent position, hold lancet
perpendicular to skin and prick site with lancet.

10. Wipe away first drop of blood with cotton ball.

11. Lightly squeeze or milk puncture site until a hanging
drop of blood has formed. (Check instructions for
monitor.)
12. Gently touch drop of blood to pad on test strip
without smearing it.
13. Insert strip into meter according to directions for that
specific device. Some devices require that the drop of
blood be applied to a test strip already inserted in
monitor
14. Press timer if directed by manufacturer.
15. Apply pressure to puncture site. Do not use alcohol
wipes.
16. Read blood glucose results and document
appropriately at bedside. Inform patient of test result.
17. Turn off meter. Dispose of supplies appropriately.
Place lancet in sharps container.
18. Remove gloves and perform hand hygiene.

19. Record blood glucose on chart or medication record.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature