‫جامعة المنوفية‬

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 ‫جامعة المنوفية‬

Procedure checklist of Oral medication:-

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….

Steps Competency

Marks
1 2 3
1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D

1 Wash your hands 1

2 Gather equipment 1
3 Try to know the actions, special 1
nursing considerations, and adverse
effects of medications.
4 Prepare for administration in the 1
medication area.
5 Select the proper medication from 1
the cart and compare with the
order
6 Check the expired date of
medication and perform the 2
necessary calculations by:
a. Place unit dose-packaged
medications in a disposable
cup.
b. Hold liquid medication bottles
with the label against the palm.
c. Use the appropriate measuring
device when pouring liquids.
d. Wipe the lip of the bottle with
a paper towel and discard
excess
7 Recheck each medication package, 1
card.
8 Recheck medications for with the2
medication order. 1
9 Take medication to the client's
bedside 1

10 Identify the client carefully by:- 1

a. Check the name of the

client's identification band.

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 ‫جامعة المنوفية‬

b. Ask the client his or her name.

c. Ask the staff member who
knows the client
11 Complete necessary assessments 1
before administration.
12 Check allergy bracelet or 1
ask client about allergies.
13 Explain the purpose and action of 1
each medication to the client.
14 Assist the client to an 1
upright position.
15 Administer medications: 1

a. Offer cup of water or juice with

medications.
b. Ask the client's preference to
be taken by hand or in a cup.
c.If the capsule or tablet falls
discard it.
d.Record any fluid intake.
16 Remain with the client until each 1
medication is wallowed
17 Wash your hands and dispose any 1
soiled supplies
18 Record each medication given on 1
the medication chart
19 Check on the client within 30 -45 1
minutes to verify response
Total marks 20
1 evaluation Score…………….
st

2nd Evaluation Score……………

3rd Evaluation Score……………..
Average ……………………

Comment

Low A= 0 unable to Basic B=1(limited ability, Proficient C=2(proficient capable Expert D=3 fully
perform needs significant help and experienced needs no capable and
assistance to complete the task experienced
Less than 10 10-14 14-18 18-20

3
 ‫جامعة المنوفية‬

Procedure checklist of Preparing Parenteral Medication

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….

Steps Competency
1 2 3

Marks
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D

1 Hand washing 1
2 Gather equipment. 2
3 Check the label on the medication 1
carefully against the chart
4 Follow the three checks for 2
administrating medication.
5 Open plastic syringe by the correct 2
way and check efficiency.
6 If the drug is in ampoule:
Flick upper stem of ampoule with 2
fingernails several times.
Wrap a sterile gauze or alcohol 2
wipe around ampoule and break
off neck toward from you.
Dispose the top of ampoule in the2
sharps container 2
Use filter needle to withdraw
medication, 1
Remove cap from filter needle and 1
insert needle into the center of the
ampoule.
Replace the filter needle with a 2
regular needle.
Hold the needle upright, inspect 2
the syringe and expel air
Total marks 20
7 If drug is in prefilled vial
Step from 1- 5
8
Rotate vial between palms. 1
Remove plastic cap 1
Clean the rubber cap with alcohol 1
swab.
Using filter needle to withdraw 1
medication, disconnect the regular
needle, leaving its cap on and
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 ‫جامعة المنوفية‬

attach the filter needle to syringe

Remove the cap from the filter 1
needle, then draw up into the
syringe the amount of air equal to
the volume of medication to be
withdraw
Inject air into vial, the bevel is 2
kept above surface of medication
Withdraw the prescribed amount 2
of medication either by holding
vial down or by invert vial
Expel any air bubbles from the 2
syringe.
Replace the filter needle with a 1
regular needle and tighten the cap
at the hub of needle before
injecting the patient.
Total marks 20
8 Mixing medication from one
vial and one ampoule: 8
Follow the same steps 1-8 of
Preparing medication from
ampoules
Remove seal from top of vial and 1
avoid touching rubber stopper.
Clean the rubber cap with 1
alcoholic sponge
Insert the solution in the vial by 2
introducing the needle in the
center of the vial.
Rotate vial between palms to 2
dissolve all the powder after
removing the needle from the vial.
Inject air into vial, the bevel is 1
kept above surface of medication
to prevent air bubbles.
Withdraw the prescribed amount 2
of medication either by holding
vial down or by invert vial.
Replace the filter needle with a 1
regular needle and tighten the cap
at the hub.
Expel any air bubbles from the 2
syringe.
Total marks 20
9 Mixing medication from two
vial

Follow steps from 1-5

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8
Take the syringe and draw up a
volume of air equal to volume of 2
medication to be withdrawn from
both vial A and B

Inject a volume of air equal to 2

volume of medication to be
withdrawn into a vial A. make
sure the needle does not touch the
solution to prevent cross
contamination of medication.
Withdraw the needle from vial A 2
and inject remaining air into vial
B.
Withdraw the required amount of 2
medication from vial B.
Use a newly attached sterile 2
needle, withdraw the required
amount of medication from vial A
Expel air bubbles and change 2
needle
Total marks 20

1st evaluation Score…………….

2nd Evaluation Score……………
3rd Evaluation Score……………..
Average ……………………

Comment

Low A= 0 unable to Basic B=1(limited ability, Proficient C=2(proficient capable Expert D=3 fully
perform needs significant help and experienced needs no capable and
assistance to complete the task experienced
Less than 10 10-14 14-18 18-20

6
 ‫جامعة المنوفية‬

Procedure checklist of Intramuscular injections:-

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date:
…………….

Weight with standing scale:- Competency

1 2 3

Marks
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D

1 Hand washing 0.5

2 Gather equipment. 0.5
3 Check the label on the medication 0.5
carefully against the chart

4 Follow the three checks for 0.5

administrating medication.

5 Prepare the syringe with medication. 1

Wash your hand and wear gloves

6 Go to patient, read the name on the 1

client identification band
7 Greet him and explain procedure to 0.5
him.
8 Select appropriate injection site. 0.5
9 assist patient to comfortable position 0.5
and expose area to be injected
10 Clean it with alcohol in a circular 1
motion. Allow the skin to dry
11 remove the needle cover 0.5
12 Spread the skin ; if patient is thin 1
pinch the muscle before injection
13 Hold the syringe in your dominant 1
hand like a pencil
14 Insert the needle quickly into the 1
tissue at a 90 degree angle
15 Support the syringe your non- 1
dominant.
16 Aspirate gently by pulling back on 1
the plunger.
17 If there is blood withdraw the needle 1
and prepare a new injection.
18 If no blood appears, inject the 1
medication slowly.
19 Remove the needle quickly at the 1
same angle you inserted it
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20 Apply gentle pressure and massage 1

the injection site.
21 Discard the needle: Do not recap the 1
needle use one hand technique.
22 Assist the client to a position of 0.5
comfort
23 Remove your gloves and perform 1
hand hygiene
24 Record the procedure. 1
25 Check the client's response 0.5
TOTAL MARKS :. 20
1 evaluation Score…………….
st

2nd Evaluation Score……………

3rd Evaluation Score……………..
Average ……………………

Comment

Low A= 0 Basic B=1(limited Proficient C=2(proficient capable and Expert D=3 fully
unable to ability, needs experienced needs no assistance to capable and
perform significant help complete the task experienced
Less than 10 10-14 14-18 18-20

8
 ‫جامعة المنوفية‬

Procedure checklist of subcutaneous injections:-

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….
Weight with standing scale:- Competency

Marks
1 2 3
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D
1 Follow steps from 1-10 of 5
intramuscular injection procedure.
2 Bunch the skin at the site or spread it 1
Insert insulin syringe half inch 2
needle at 90 angle.
3 Aspirate gently by pulling back on 2
the plunger.
If there is blood withdraw the needle 1
and prepare a new medication.
4 If no blood appears, inject the 1
medication slowly.
5 Remove the needle quickly at the 1
same angle you inserted it
6 Apply gentle pressure. 1
7 Do not recap the needle by use one 2
hand technique as shown before.
8 Assist the client to a position of 1
comfort.
9 Remove your gloves and perform 1
hand hygiene.
10 Record the medication administered. 1
11 Check the client's response to the 1
medication
TOTAL MARKS :. 20
1 evaluation Score…………….
st

2nd Evaluation Score……………

3rd Evaluation Score……………..
Average ……………………

Comment
Low A= 0 Basic B=1(limited Proficient C=2(proficient capable Expert D=3 fully
unable to ability, needs significant and experienced needs no assistance to capable and
perform help complete the task experienced
Less than 10-14 14-18 18-20
10

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 ‫جامعة المنوفية‬

Procedure checklist of Intradermal injections:-

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….

Weight with standing scale:- Competency

1 2 3

Marks
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D

1 Follow steps from 1-10 of 5

intramuscular injection procedure.
2 Selecting site: Usually (inner) 1
forearm.
3 Place the patient's arm palm up and 1
exposing inner arm area.
4 Clean the site with cotton soaked 1
with alcohol.
5 Remove Needle cover 1
6 Stabilize Injection Site by using non 2
dominant thumb
7 Insert needle, bevel up, just under the
skin at an angle of 15 degrees.
2
8 Inject medication slowly forward
until the medication a wheal appears
at the site of the injection. 2

9 Withdraw needle and dry with sterile 2

small gauze without applying
pressure.
10 Evaluate reaction of medication.
▪ For a tuberculin test, the patient 1
will wait 48 to 72 hours.
▪ If the patient is allergic reaction 1
will take place in a few minutes
20-30 minutes.
▪ Caution patient not to rub, 1
scratch, or wash injection site.
TOTAL MARKS :. 20

1st evaluation Score…………….

2nd Evaluation Score……………
3rd Evaluation Score……………..
Average ……………………

10
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Comment

Low A= 0 Basic B=1(limited Proficient C=2(proficient capable Expert D=3 fully

unable to ability, needs significant and experienced needs no assistance to capable and
perform help complete the task experienced
Less than 10-14 14-18 18-20
10

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Procedure Check List for IV push medication

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….

evaluation Score…………….
IV push medication Competency

Marks
1 2 3
1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D

1 Wash hands. 0.5

2 Explain the procedure to the patient. 0.5
3 Don gloves. 0.5
4 Prepare equipment. 0.5
5 Prepare the medication in the vial or 2
in the ampoule.
6 Assist the patient to suitable position 0.5

7 Select the vein that straight and 1

palpable.

8 Apply the tourniquet above insertion 1

site.
9 Disinfect the selected site with skin 1.5
disinfectant agent and allow drying.
10 Open the syringe and hold it with the 1
bevel upward.
11 Grasp the vein down ward and insert 1
the syringe using 45 degree angle and
then decrease the angle.
12 Observe for "flash back" as blood 1
slowly fills the flash back chamber.
13 Advance the needle approximately 1 1
cm further into the vein.
14 Aspirate blood to make sure that the 1
needle is in the vein.
15 Remove the tourniquet and push the 1
medication in the vein very slowly.
16 With draw the needle and press with 1
dry cotton over the insertion site.
17 Apply adhesive tape over the site. 0.5
18 Cover the syringe using one hand 2
technique.
19 Discard the syringe and remove 0.5
equipment.
20 Reassure the patient and check for 0.5
patient response.
21 Hand washing. 0.5
22 Record medication name ,dose route 1
,time ,patient response and your
signature
12
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2nd Evaluation Score……………

3rd Evaluation Score……………..
Average ……………………

Comment

Low A= 0 unable to Basic B=1(limited ability, Proficient C=2(proficient capable and Expert D=3 fully
perform needs significant help experienced needs no assistance to capable and
complete the task experienced
Less than 10 10-14 14-18 18-20

13
 ‫جامعة المنوفية‬

Procedure Check List for cannula insertion

Student name: ---------------------------- Group: ………………..
1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….

cannula insertion Competency

Marks
1 2 3
1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D

1 Having a signed order for the 0.5

intravenous line insertion.
2 Explain procedure to patient. 0.5
3 Wash hands with antiseptic soap. 0.5

4 Prepare equipment and check for 10 0.5

rights.
5 Don gloves. 0.5

6 Apply the tourniquet above insertion 1

site.
7 Disinfect the selected site with skin 1
disinfectant agent and allow drying.

8 Ensure that the bevel of the cannula is 0.5

facing upwards to facilitate the
piercing of the skin by the bevel.
9 Insert the stylet through the skin and 1
then reduce the angle as you
advance through the vein.
10 Observe for "flash back" as blood 2
slowly fills the flash back chamber.
11 Advance the needle approximately 1 cm 1
further into the vein.
12 Holding the end of the catheter with 1
your thumb and index finger, pull the j 0.5
needle (only) back 1 cm with your
middle finger.
13 Slowly advance the catheter into the 1
vein while keeping tension on the 0.5
vein and skin.
14 Partially withdraw the needle and 1
advance the cannula. 0.5
15 Release the tourniquet. 1
1
16 Secure the hub of the cannula with 1
clean adhesive tape and do not cover 1
the puncture site .
17 Flush the cannula with normal saline to 1
ensure the line is patent and
accessible.
18 Cover the intravenous and surrounding 1
area with a sterile transparent 1 14
dressing.
19 Ensure that the insertion site and the 1
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area proximal to the site are visible 0.5

for inspection purposes.
20 Dispose of equipment safely. 1
1
21 Note the date and time of insertion in 2
the patient’s medical record. 2
22 Always wash hands after placing an IV 1
catheter. 1
23 Evaluate the IV site at the time of new 1
injections and regularly to ensure 1
that no infiltration has occurred.
evaluation Score…………….
2nd Evaluation Score……………
3rd Evaluation Score……………..
Average ……………………

Comment

Low A= 0 unable to Basic B=1(limited ability, Proficient C=2(proficient capable Expert D=3 fully
perform needs significant help and experienced needs no capable and
assistance to complete the task experienced
Less than 10 10-14 14-18 18-20

15
 ‫جامعة المنوفية‬

Procedure Checklist for intravenous infusion

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….

intravenous infusion Competency

Marks
1 2 3
1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D

1 Perform hand hygiene. 0.5

2 Prepare equipment. 0.5
3 Remove the outer plastic covering of 0.5
the container.

4 Check fluid for cloudiness, sediment, 0.5

discoloration and expiry date.
5 Remove the sheath covering the entry 1
channel, without contamination.
6 . Remove the administration set from its 0.5
package.
7 1
Close the flow control clamp.
8 Remove the protective sheath from the 1
trocar of the administration set,
maintaining asepsis.
9 Insert the trocar firmly through the seal 1
of the container’s entry channel until
fluid flows into the first part of the
administration set.
10 Gently squeeze the chamber of the 1
administration set and allow it to
partly fill.
11 Slowly release the flow control clamp 1
and allow the fluid to fill the rest of
the tubing.
12 Close the flow control clamp. 1
13 Perform hand hygiene. 1
14 Explain the procedure to the patient and 0.5
gain patient’s consent.
15 Wear disposable gloves. 0.5
16 Place the infusion fluid on the stand 1
beside the patient, check that it is
running freely.
17 Expose the cannula 0.5
18 Flush the canula with normal saline. 1.5
19 Connect infusion line. 1
20 Regulate the flow rate as prescribed. 1.5
21 Dispose of equipment as per policy. 1
22 Perform hand hygiene. 1
23 Document the procedure, monitor for 1
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after effects and report abnormalities

immediately.
evaluation Score…………….
2nd Evaluation Score……………
3rd Evaluation Score……………..
Average ……………………

Comment

Low A= 0 unable to Basic B=1(limited ability, Proficient C=2(proficient capable Expert D=3 fully
perform needs significant help and experienced needs no capable and
assistance to complete the task experienced
Less than 10 10-14 14-18 18-20

17
 ‫جامعة المنوفية‬

Procedure Checklist for topical medication

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….

Skin application Competency

Marks
1 2 3
1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D

Assessment: 1
1) Check physician order for patient's
name, time and site of application.
2) Check medication action, purpose, 1
side effect and nursing
implications.
Preparation: 1
3) Wash hands and wear gloves.

4) Prepare the equipment 1

5) Greeting the patient and explain 1

procedure to him.
6) Close room curtain or door, place the 1
client to comfortable position and
expose the area.
7) Before applying a dermatologic 1
preparation, clean the area with the
soap and water and dry it with a
pitting motion.
8) Applying topical agent: 2
A- powder:
a) Make sure the skin surface is dry.
b) Spread any skin folds such as
between toes or under axillae.
c) Sprinkle the site until the area is
covered with a fine thin layer.
d) Cover the site with dressing if
ordered.
B- Creams, ointments: 2
a) Place approximately 1 to 2
teaspoons of medication in palm,
warm and soften it in gloved hands.
b) Distribute it over the skin using
long firm strokes that follow the
direction of hair growth.
c) Explain that the skin may feel
greasy after application.
d) Cover the site with dressing if
ordered.
C-Suspension- based lotion: 1.5
a) Shake the container before use.
b) Put a little amount of lotion on a 18
small dressing or pad.
‫جامعة المنوفية‬

c) Apply the lotion to skin using long

firm stroke that follow the direction
of hair growth.
D- Aerosol spray: 2
a) Shake the container before use.
b) Read the container label for
recommended distance (usually 15 to
30 cm).
c) If neck or upper chest are to be
sprayed ask the client to turn the face
away from the spray or cover the
face with towel.
d) Spray the medication over the
affected site.
E- Transdermal patch: 3.5
a) Assess the patient’s skin, site
should be clean, dry and free of hair.
Rotate the application sites.
b) Remove any old transdermal
patches from patient’s skin
c) Gently wash the area where the
old patch was with soap and water
d) Remove the patch from its
protective covering and hold it
without touching the adhesive edges
e) Apply it by pressing firmly with
palm of hand for about 10 seconds.
f) Advise the client to avoid using a
heating pad over the area.
g) Remove the patch at the
appropriate time and folding it so
that the medication side is covered.
9) Recording and reporting: 2
The condition of the skin before
application of topical agent, type of
agent and site of application.
Total 20
evaluation Score…………….
2nd Evaluation Score……………
3rd Evaluation Score……………..
Average ……………………

Comment

Low A= 0 unable to Basic B=1(limited ability, Proficient C=2(proficient capable Expert D=3 fully
perform needs significant help and experienced needs no capable and
assistance to complete the task experienced
Less than 10 10-14 14-18 18-20

19
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Procedure checklist of Applying warm, moist compresses and pack

Student name: ---------------------------- Group:…………………………

1st Clinical evaluator name: ------------------- Date:……………………….
2nd Clinical evaluator name: ------------------- Date:……………………….
3rd Clinical evaluator name: ----------------- Date:……………………….

Competency
marks 1 2 3
Steps
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D
1 Explain the procedure to the client 1

2 Give the client an opportunity to 1

use urinal or bedpan before the
bath
3 Take the client’s temperature and 2
record it
4 Use hot pack machine set at the 2
proper temperature. Immerse the
compress or pack in hot tap water
5 Apply petroleum jelly to the 2
client’s skin before applying pack
6 Wring the compress or pack with 2
forceps or wringer. Clamp one
forceps onto each end of pack
7 Shack the pack lightly and apply it 2
to area gently then gradually
pressing it against patient’s skin
8 Cover the moist compress or pack 1
with dry pack and moisture proof
cover
9 Provide client with blanket during 1
and after treatment
10 Assess condition of client’s skin 1
every 10 minutes
11 Continue treatment for prescribed 2
period and then remove
application
12 Dry the skin and cover it 2

13 Hand washing 1
Total marks 20

1st evaluation Score ………………….

2nd Evaluation Score…………………..
3rd Evaluation Score……………….
Average ……………………….
Comment

20
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Administering a tub soak to arm or leg

Student name: ---------------------------- Group:…………………………
1st Clinical evaluator name: ------------------- Date:……………………….
2nd Clinical evaluator name: ------------------- Date:……………………….
3rd Clinical evaluator name: ----------------- Date:……………………….
Mark Competency
Steps s 1 2 3

1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D

1 Explain the procedure to the 1

client
2 Give the client an opportunity to 1
use urinal or bedpan before the
bath
3 Take the client’s temperature 2
and record it
4 Cover the tub with a bath towel 2

5 Cover the client with a 2

protective sheet or bath blanket
6 Prepare water in tub (37.8- 2
40.6). always use thermometer
7 Wear gloves if the client has an 2
open wound or rash. Remove
dressing if present.
8 Gradually lower client’s 2
affected body part into the water
9 Adjust padding on the edge of 2
tub for knee or elbow
10 Remove client’s arm or leg from 2
bath in 15 to 20 minutes and dry
client skin
11 Apply sterile dressing to wound 1
12 Wash hand 1

Total Score 20
1st evaluation Score……………….
2nd Evaluation Score…………………
3rd Evaluation Score………………..
Average …………………
Comment
Low A= 0 unable Basic B=1(limited Proficient C=2(proficient Expert D=3
to perform ability, needs capable and experienced fully capable
significant help needs no assistance to and
complete the task experienced

21
 ‫جامعة المنوفية‬

Less than 19 10-14 14-18 18-20

Applying cold compresses

Student name: ---------------------------- Group:…………………………
1st Clinical evaluator name: ------------------- Date:……………………….
2nd Clinical evaluator name: ------------------- Date:……………………….
3rd Clinical evaluator name: ----------------- Date:……………………….

Competency
marks 1 2 3
Steps
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D
1 Wash hands 2

2 Explain procedure to the client 2

3 Prepare equipment 3

4 Close door 2

5 Immersed wash cloth or gauze in 3

basin that contain pieces of ice
and small amount of water

22
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6 Squeeze compresses before its 2

applied
7 7- The application should be 3
continued for 20 minutes. and
repeated every 2 hours
8 Assess condition of skin and 3
client response to cold
compresses at frequent interval
Total marks 20
Steps Competency

1st evaluation Score……………….

2nd Evaluation Score…………………
3rd Evaluation Score………………..
Average ………………… …….

Comment

Low A= 0 unable to Basic B=1(limited ability, Proficient C=2(proficient capable and Expert D=3 fully
perform needs significant help experienced needs no assistance to capable and
complete the task experienced
Less than 19 10-14 14-18 18-20

Applying Tepid sponge bath to reduce body temperature

Student name: ---------------------------- Group:…………………………
1st Clinical evaluator name: ------------------- Date:……………………….
2nd Clinical evaluator name: ------------------- Date:……………………….
3rd Clinical evaluator name: ----------------- Date:……………………….

23
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marks 1 2 3
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D
1 Explain the procedure to the 1
client
2 Give the client an opportunity to 1
use urinal or bedpan before the
bath
3 Take the client’s temperature and 2
record it
4 Note whether the client’s has an 1
antipyretic such as aspirin to
reduce fever
5 Add tepid water to the bath basin. 2
Use bath thermometer
6 Place moist, cool cloths- wrung 2
out just enough to prevent
dripping- in the client axilla and
the groin
7 Be aware that the client’s first 2
reaction to a tepid sponge bath is a
sensation of chilliness, which
disappears as the body adjusts to
the water temperature. Therefore,
continue the bath long enough to
allow for this adjustment (at least
25-30 min). monitor client’s body
temperature throughout the
procedure.
8 Sponge each limb for at least 5 2
min and the back and the buttocks
for at least 10-15 min
9 Stop the procedure if the client 2
becomes very chilled or begin to
shiver
10 Top sponging as soon as the 2
client’s temperature approaches
the normal range. Give the client
bath blanket
11 Wash the hands and document 1
the treatment on the client’s chart
12 Take the client temperature 30 2
min after you complete the bath
Total marks 20

1st evaluation Score……………….

2nd Evaluation Score…………………
3rd Evaluation Score………………..
Average ………………… …….

24
‫جامعة المنوفية‬

Comment

Low A= 0 unable Basic B=1(limited Proficient C=2(proficient Expert D=3 fully

to perform ability, needs capable and experienced needs capable and
significant help no assistance to complete the experienced
task
Less than 19 10-14 14-18 18-20

Alcohol or cold sponge bath:

Student name: ---------------------------- Group:…………………………
1st Clinical evaluator name: ------------------- Date:……………………….
2nd Clinical evaluator name: ------------------- Date:……………………….
3rd Clinical evaluator name: ----------------- Date:……………………….

25
 ‫جامعة المنوفية‬

1st evaluation Score……………….

2nd Evaluation Score…………………
3rd Evaluation Score………………..
Average ………………… …….
Comment

Competency
marks 1 2 3
Steps
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D
1 Prepare a water and alcohol 3
solution at 29.5.c
2 Protect the client bed by place 3
rubber sheet under patient
3 Prepare several ice bags one is 2
placed on the
4 Others ice bag placed in the groin 2
auxiliary-areas

5 Sponge face, neck, arms and legs 3

for 3-5 minutes and back for 15
minutes then cover the clients
6 Check the client to color, pulse 3
during j F the client becomes pale
or if pulse bath increase or
irregular discontinue the bath
7 Don't dry the client after bath 2
8 Check the clients body 2
temperature about 30 minute after
the bath
Total marks 20
Low A= 0 unable to Basic B=1(limited ability, Proficient C=2(proficient capable and Expert D=3 fully
perform needs significant help experienced needs no assistance to capable and
complete the task experienced
Less than 19 10-14 14-18 18-20

Procedure checklist of applying Bandage (circular,spiral,spiral reverse)

Student name: ---------------------------- Group:…………………………
1st Clinical evaluator name: ------------------- Date:……………………….
2nd Clinical evaluator name: ------------------- Date:……………………….
3rd Clinical evaluator name: ----------------- Date:……………………….

26
‫جامعة المنوفية‬

1- Circular Turns: Competency

marks

27
 ‫جامعة المنوفية‬

1 2 3
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D
1 Hold the bandage in your 1
dominant hand
2 Keep the roll uppermost, and 1
unroll the bandage about 8 cm
3 Apply the end of the bandage to 1
the part of the body
4 Hold the end down with the 1
thumb of the other hand.
5 Encircle the body part a few 1
times or as often as needed.
6 Secure the end of the bandage 1
with tape or a safety pin

2- Spiral Turns:
1 Make two circular turns. Two 1
circular turns anchor the bandage.
2 Continue spiral turns at about a 2
30- degree angle.
3 Terminate the bandage with two 1
circular turns

4 Secure the end of the bandage with 1

tape or a safety pin
3- Spiral Reverse Turns:
1 Anchor the bandage with two 1
circular turns
2 Bring the bandage upward at 1
about a 30-degree angle.
3 Place the thumb of your free hand 1
on the upper edge of the bandage
4 Unroll the bandage about 15 cm. 1
5 Turn your hand so that the 1
bandage falls over itself.
6 Continue the bandage around the 1
limb.
7 Make each bandage turn at the 1
same position on the limb
8 Terminate the bandage with two 1
circular turns
9 secure the end 1
Total marks 20

28
‫جامعة المنوفية‬

1st evaluation Score ………………….

2nd Evaluation Score…………………..
3rd Evaluation Score……………….
Average ……………………….

Comment

Low A= 0 unable to Basic B=1(limited Proficient C=2(proficient capable Expert D=3

perform ability, needs significant and experienced needs no fully capable
help assistance to complete the task and experienced

Less than 10 10-14 14-18 18-20

Procedure checklist of applying Bandage (recurrent, figure of eight)

29
 ‫جامعة المنوفية‬

Student name: ---------------------------- Group:…………………………

1st Clinical evaluator name: ------------------- Date:……………………….
2nd Clinical evaluator name: ------------------- Date:……………………….
3rd Clinical evaluator name: ----------------- Date:……………………….
4 - Recurrent Turns:. Mark Competency
s 1 2 3
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3.
3.C
A B C D A B C D A B D
1 Anchor the bandage with two 1
circular turns.

2 Fold the bandage back on itself, 1

3 Bring it centrally over the distal 1
end to be bandaged.
4 Holding it with the other hand, 2
bring the bandage back
5 Bring the bandage back on the 2
lift side
6 Overlapping the first turns by 1
two- third
7 Continue this pattern of 2
alternating
8 Terminate the bandage with 1
two circular turns
9 Secure the end appropriately. 1
5- Figure- Eight Turns:

1 Anchor the bandage with two 2

circular turns.
2 Carry the bandage above the 2
joint, around it, and then below
3 Continue above and below the 2
joint
4 Terminate the bandage with 2
two circular turns
Total Score 20

1st evaluation Score……………….

30
‫جامعة المنوفية‬

2nd Evaluation Score…………………

3rd Evaluation Score………………..
Average …………………

Comment

Low A= 0 unable to Basic B=1(limited Proficient C=2(proficient capable Expert D=3

perform ability, needs significant and experienced needs no fully capable
help assistance to complete the task and experienced

Less than 19 10-14 14-18 18-20

31
 ‫جامعة المنوفية‬

Procedure checklist of applying Binder:-

Student name: ---------------------------- Group:…………………………

1st Clinical evaluator name: ------------------- Date:……………………….
2nd Clinical evaluator name: ------------------- Date:……………………….
3rd Clinical evaluator name: ----------------- Date:……………………….

Triangular Arm Sling: Marks Competency

1 2 3
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3.
3.C
A B C D A B C D A B D
1 Ask the client to flex the 3
elbow to an 80- degree angle
or less, depending on the
purpose.
2 Place one end of the unfolded 2
triangular binder over the
shoulder of the uninjured side
3 Take the upper corner, and 2
carry it around the neck
4 Bring the lower corner of the 2
binder up over the arm
5 Using a square knot, secure 2
this corner to the upper corner
6 Tying knot at the side of the 2
neck
7 Make sure the wrist is 2
supported
8 Fold the sling neatly at the 1
elbow
9 Secure it with safety pins or 2
tape.
10 Remove the sling periodically 2
to inspect the skin
Total Score 20
st
evaluation Score……………….
2 Evaluation Score…………………
nd

3rd Evaluation Score………………..

Average …………………
Comment
Low A= 0 unable to Basic B=1(limited Proficient C=2(proficient capable Expert D=3
perform ability, needs significant and experienced needs no fully capable
help assistance to complete the task and experienced
Less than 19 10-14 14-18 18-20

32
 ‫جامعة المنوفية‬

Procedure checklist of Weighting the patient with standing scale:-

Student name: ---------------------------- Group: ………………..
1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….

Weight with standing scale:- Competency

1 2 3

Marks
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D

1 Hand washing and wear gloves 2

2 Greating patient and explain 2
procedure to him
3 Have client to void before 2
weighing if possible.
4 The client should wear the same 2
clothes for each weight
measurement and should remove
shoes before measurement.
Other helpful measures include
using the same scale and
measuring weight at the same time
of day preferred morning.
5 Place protective paper or clothe 2
on scale.
6 Check that scale registers zero 2
immediately before use
7 Assist client onto scale, client must 2
stand in center of platform and not
hold onto support.
8 Read digital display to 2
determine client's weight.
9 Assist client from scale and record 2
weight in the client's record.
10 Dispose of protector sheet. 2
TOTAL MARKS :. 20
1 evaluation Score…………….
st

2nd Evaluation Score……………

3rd Evaluation Score……………..
Average ……………………
Comment
Low A= 0 unable to Basic B=1(limited ability, Proficient C=2(proficient capable Expert D=3 fully
perform needs significant help and experienced needs no capable and
assistance to complete the task experienced
Less than 10 10-14 14-18 18-20

33
 ‫جامعة المنوفية‬

Procedure checklist of Weighting the patient with chair scale:-

Student name: ---------------------------- Group: ………………..
1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….
Weight with chair scale:- Competency

Marks
1 2 3
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D
1 Hand washing and wear gloves 2
2 Greating patient and explain 2
procedure to him
3 Have client to void before 2
weighing if possible.
4 The client should wear the same 2
clothes for each weight
measurement and should remove
shoes before measurement.
Other helpful measures include
using the same scale and
measuring weight at the same time
of day preferred morning.
5 Place protective paper or clothe 2
on scale.
6 Check that scale registers zero 2
immediately before use
7 place scale beside client and lock 2
wheels
8 Transfer client onto chair. If arm of 2
chair is removable unlock and
remove before transfer. Lock back
into place after transfer.
Some scales allow wheel chairs to
be wheeled onto scale.
9 Read digital display to 2
determine client's weight.
10 Transfer client back to bed or 2
wheel chair.
TOTAL MARKS :. 20
1st evaluation Score…………….
2nd Evaluation Score……………
3rd Evaluation Score……………..
Average ……………………

Comment

34
 ‫جامعة المنوفية‬

Procedure checklist of Weighting the patient with bed scale:-

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….

Weight with bed scale:- Competency

Marks
1 2 3
1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D

1 Hand washing and wear gloves 1

2 Greating patient and explain procedure to 1
him
3 Have client to void before weighing if 1
possible.

4 The client should wear the same 1

clothes for each weight measurement
and should remove shoes before
measurement.
Other helpful measures include using
the same scale and measuring weight
at the same time of day preferred
morning.
5 Place protective paper or clothe on 1
scale.
6 Check that scale registers zero 1
immediately before use
7 Elevate client's bed to level of 2
stretcher scale.
8 With one or two assistants turn client 1
on the side with back toward the
scale.
9 Roll scale toward the bed. Lock wheels 1
in place.
10 Position folded stretcher under 1
client, Roll client onto stretcher.
11 Attach stretcher arms to stretcher 1
and gradually elevate stretcher about
2 inches above mattress surface.
12 Inform client before elevating. 1
13 Determine that stretcher isn't 1
touching any equipment.
14 Read digital display for client's Weight. 1
15 Gradually lower stretcher to bed. 1
Remove stretcher arms and transfer
client off stretcher and remove
stretcher.

35
 ‫جامعة المنوفية‬

16 Unlock bed scale wheels and move 1

away from bed.
17 Assist client to comfortable 1
position.
18 clean stretcher and scale and return it 1
in it's place
19 Record weight and note any extra 1
linen or equipment weighed with the
client
TOTAL MARKS :. 20

1st evaluation Score…………….

2nd Evaluation Score……………
3rd Evaluation Score……………..
Average ……………………

Comment

Low A= 0 unable to Basic B=1(limited ability, Proficient C=2(proficient capable Expert D=3 fully
perform needs significant help and experienced needs no capable and
assistance to complete the task experienced
Less than 10 10-14 14-18 18-20

36
 ‫جامعة المنوفية‬

Procedure checklist of measuring the height of the patient:-

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….

Competency
Weight Bearing Height:- (When

Marks
1 2 3
client is able to stand) 1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D

1 Ask client to remove shoes and paper 2

towel is placed on scale platform
2 Raise L shaped sliding arm on the 2
measuring device attached to the
scale somewhat higher than the
client's approximate height.
3 Ask client to step on the platform of 3
the scale and stand erect with the
back to the measuring device and the
heels together.
4 Lower the L shaped sliding arm until it 2
rests on the top of the client's head.
5 Read the height in inches and record 2
it.
6 Ask the client to step down from the 2
platform.
Non Weight Bearing Height:- Such
as an infant
1 The nurse place infant in supine 2
position on a firm surface.
2 The legs are extended straight with 3
the soles of the feet supported
upright.
3 The nurse places a tape measure 2
from the soles of the feet to the
vertex of the head to measure
recumbent length.
TOTAL MARKS :. 20
1 evaluation Score…………….
st

2nd Evaluation Score……………

3rd Evaluation Score……………..
Average ……………………
Comment
Low A= 0 unable to Basic B=1(limited ability, Proficient C=2(proficient capable and Expert D=3 fully
perform needs significant help experienced needs no assistance to capable and
complete the task experienced
Less than 10 10-14 14-18 18-20

37
 ‫جامعة المنوفية‬

Procedure checklist of Cardiopulmonary Resuscitation (adult):-

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….

Competency

Marks
1 2 3
1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D

1 Check scene for danger 1

2 Put victim on flat firm surface 1
3 Check responsiveness (shake 2
victim and shout for help)
4 Ask for calling EMS 1

5 Check breathing and pulse (carotid 2

or brachial artery) for 10 seconds
6 Begin with heart compression:- 3
Identify the last rib Put 2 fingers at
the end of the sternum Put heel of
the 2 hands interlacing with each
other above it. Give 30
compression if one or two rescuer.
7 Depth of adult chest compression 1
is 2 inches
8 Opening airway bye:- Head-tilt 2
chin-lift Jaw- thrust
9 Put barrier over victim mouth 1
10 Giving 2 mouth to mouth breath:- 2
Rescuer take deep breath and hold it
Pinch victim nose
Expel the expiration into victim
mouth and rescuer mouth should be
seal with victim one.
11 Continue CPR for 5 cycle about 2 2
minutes
Reassessment for the victim 1
After regained pulse and breath put 1
victim in recovery position
TOTAL MARKS :. 20
1st evaluation Score…………….
2nd Evaluation Score……………
3rd Evaluation Score……………..
Average ……………………

38
 ‫جامعة المنوفية‬

Procedure checklist of Cardiopulmonary Resuscitation (child):-

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….
Competency

Marks
1 2 3
1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D

1 Check scene for danger 1

2 Put victim on flat firm surface 1
3 Check responsiveness (shake 2
victim and shout for help)
4 Ask for calling EMS 2

5 Check breathing and pulse (carotid 2

or brachial artery) for 10 seconds
6 Begin with heart compression:- 3
Identify the last rib Put 2 fingers at
the end of the sternum Put heel of
the one hand above it. Give 30
compression if one rescuer and 15
compression if two rescuer.
7 Depth of child chest compression 2
is 2 inches
8 airway bye:- Head-tilt chin-lift 2
Jaw- thrust
9 Put barrier over victim mouth 1
10 Giving 2 mouth to mouth breath:- 2
Rescuer take deep breath and hold
it Pinch victim nose Expel the
expiration into victim mouth and
rescuer mouth should be seal with
victim one.
11 Continue CPR for 5 cycle about 2 2
minutes
TOTAL MARKS :. 20

1st evaluation Score…………….

2nd Evaluation Score……………
3rd Evaluation Score……………..
Average ……………………

Comment

39
 ‫جامعة المنوفية‬

procedure checklist of Cardiopulmonary Resuscitation (infant):-

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….
Competency

Marks
1 2 3
1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D

1 Check scene for danger 1

2 Put victim on flat firm surface 1
3 Check responsiveness (shake 2
victim and shout for help)
4 Ask for calling EMS 2

5 Check breathing and pulse (carotid 2

or brachial artery) for 10 seconds
6 Begin with heart compression:- 3
Imagine line between infant nipples
Put 3 fingers(index, middle and
ring finger) at the centre of this line
Remove index and give
compression bye middle and ring
finger Give 30 compressions if one
rescuer and 15 compressions if two
rescuer .
7 Depth of infant chest compression 2
is 1,5 inches
8 Opening airway bye:- Slightly 2
head-tilt chin-lift Jaw- thrust
9 Put barrier over victim mouth 1
10 Giving 2 mouth to nose and mouth 2
breath:- Rescuer take deep breath
and hold it Expel the expiration
into victim mouth and rescuer
mouth should be seal with victim
mouth and nose. Use gentle force
while giving breath
11 Continue CPR for 5 cycle about 2 2
minutes
TOTAL MARKS :. 20
1 evaluation Score…………….
st

2nd Evaluation Score……………

3rd Evaluation Score……………..
Average ……………………

Comment
40
 ‫جامعة المنوفية‬

Procedure checklist of Heimlich maneuver

Student name: ---------------------------- Group: ………………..

1st Clinical evaluator name: ------------------- Date: …………….
2nd Clinical evaluator name: ------------------- Date: …………….
3rd Clinical evaluator name--------------------- Date: …………….

Competency
1 2 3

Marks
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D

1 Sub diaphragmatic abdominal

thrusts for standing or sitting
conscious patient:
- Stand behind the patient,
wrap your arms around the 1
patient’s waist.
- Make a fist with one hand
- Grasp the fist with the other 1
hand. 1
- Press your fist into the
patient’s abdomen with a 1
quick inward and upward
thrust..
2 For patient Lying Down
(Unconscious)
1. Position patient on the back. 1
2. Kneel astride the patient’s 1
thighs, facing the head.
3. Place the heel of one hand 2
against the patient’s abdomen,
in the midline slightly above
the umbilicus and well below
the tip of the xiphoid; place
the second hand directly on
top of the first.
4. Press into the abdomen with a 1
quick upward thrust.

41
 ‫جامعة المنوفية‬

3 Finger Sweep
1. Open the adult patient’s mouth
by tongue-jaw lift. 1
2. If a foreign body is visible in
the mouth, insert the index finger of
the other hand down along the 1
inside of the cheek and scrape
across the back of the throat.
3. Use a hooking action to
dislodge the foreign body. 1
Chest Thrusts with Conscious
Patient Standing or Sitting
1. Stand behind the patient with
your arms under the patient’s 1
axillae to encircle the patient’s
chest.
2. Place the thumb side of your fist
on the middle of the patient’s
sternum.
3. Grasp your fist with the other 2
hand and perform backward thrusts
until the foreign body is expelled
or the patient becomes
unconscious..
2
4 Chest Thrust With Patient Lying
(Unconscious)
1. Place the patient on the back.
2. Place the heel of your hand 1
on the lower half of the sternum.
3. Deliver each chest thrust 1
slowly and distinctly.

1
TOTAL MARKS :. 20
1st evaluation Score…………….
2nd Evaluation Score……………
3rd Evaluation Score……………..
Average ……………………
Comment
Low A= 0 unable to Basic B=1(limited ability, Proficient C=2(proficient capable Expert D=3 fully
perform needs significant help and experienced needs no capable and
assistance to complete the task experienced
Less than 10 10-14 14-18 18-20

42
‫جامعة المنوفية‬

Procedure checklist of Administering an Enema

Student name: ------------------------ Group:………………….

1st Clinical evaluator name: ------------------- Date:……………….
2nd Clinical evaluator name: -------------------Date:………………..
3rd Clinical evaluator name: --------------------Date:…………….

43
 ‫جامعة المنوفية‬

Competency
marks 1 2 3
Steps
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D
1 Prepare the needed equipment in 0.5
one place.
2 Check temperature of solution by 1
pouring some over your inner
wrist
3 Fill enema bag with 750 to 1000 1
mL lukewarm solution .
4 Open clamp on tubing and allow 1
solution to flow through tubing to
remove the air then, reclamp
tubing.
5 Provide privacy by closing 1
curtains or room door
6 Identify client Position client on 2
left side (Sims’ position) with
right knee flexed .
7 Cover client with bath 0.5
blanket, exposing only the rectum
8 Put on disposable gloves and 1
Place waterproof pad under
client’s buttocks .
9 Lubricate 2 to 3 inches of the tip 1
of the rectal tube with water-
soluble lubricant
10 Separate the buttocks to visualize 1
the anus. Observe for external
hemorrhoids
11 Ask client to take a slow, deep 2
breath. Gently insert the tube,
directing the tip toward the
umbilicus
12 open the clamp and allow solution 1
to slowly enter the client
13 Raise container 18 inches above 2
the anus, allowing solution to
flow slowly 44
Over 5 to 10 minutes
14 Reclamp tubing when desired 1
amount of solution has infused .
 ‫جامعة المنوفية‬

15 Have client retain solution as long 1

as possible.
16 Assist client to bathroom. Provide 1
privacy until all of the solution
has been expelled
17 Assist client into comfortable 1
position.
18 Remove gloves and wash hands. 1
Total marks 20

1st evaluation Score

2nd Evaluation Score
3rd Evaluation Score
Average
Comment

Low A= 0 unable to Basic B=1(limited Proficient C=2(proficient capable Expert D=3

perform ability, needs significant and experienced needs no assistance fully capable
help to complete the task and experienced
Less than 10 10-14 14-18 18-20

45
 ‫جامعة المنوفية‬

Procedure checklist of female catheterization

Student name: ---------------------------- Group:……………………….
1st Clinical evaluator name: -------------------Date:……………..
2nd Clinical evaluator name: ------------------- Date:……………..

Female catheterization Competency

1 2 3

Marks
Steps 1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D

1 Review the patient’s chart 0.5

2 Prepare the equipment. 0.5
3 Greeting, Introduce yourself and 0.5
Identify Patient.
4 Explain procedure to patient and 0.5
check allergy
5 Close curtains around the bed and 0.5
close the door of the room.
6 Perform hand washing and wear 0.5
gloves
7 Assemble equipment on the over bed 0.5
table within reach.
8 Adjust bed to comfortable height , 0.5
Provide good lighting,
9 Explain procedure to patient 0.5

10 Close curtains around the bed and 0.5

close the door of the room.
11 Perform hand washing and wear 0.5
gloves
12 Assemble equipment on the over bed 0.5
table within reach.
14 Assist patient to a dorsal recumbent 0.5
Drape the patient,.
Slide a water proof pad under the 0.5
patient
15 . Clean perineal area. Remove 0.5
gloves. Perform hand washing.
16 open sterile catheter tray on a clean 0.5
over bed table using a sterile
technique
wear sterile gloves. 0.5
Ask patient to lift her buttocks and 1
slide sterile drape under her with
gloves.
Place the fenestrated sterile drape 1
over the perineal area.
46
‫جامعة المنوفية‬

Open all supplies, open package of 1

antiseptic swab,
Lubricate 1 to 2 inches of catheter 1
tip, With thumb and one finger of
your nondominant hand, spread the
labia
Clean perinael area 1
Ensure that the clamp on the 1
drainage bag is closed.
Insert catheter slowly into urethra. 1
Advance the catheter until there is
return of urine approximately 2-3
inches
inflate catheter balloon by injecting 0.5
sterile water
Pull gently on the catheter after 0.5
balloon is inflated to feel resistance
Attach catheter to drainage 0.5
system if not pre attached
Remove equipment and dispose 0.5
it
Remove gloves and secure 0.5
catheter tubing to the patient’s inner
thigh .
Assist patient to comfortable position 0.5
Secure the drainage bag below 0.5
the level of bladder.
Obtain urine specimen 0.5
immediately, if needed,
Remove gloves and perform hand 0.5
washing
Total score:

1st evaluation Score

2nd Evaluation Score

3rd Evaluation Score

Average
Comment:
Low A= 0 unable to Basic B=1(limited Proficient C=2(proficient capable Expert D=3
perform ability, needs significant and experienced needs no assistance fully capable
help to complete the task and experienced
Less than 10 10-14 14-18 18-20

47
 ‫جامعة المنوفية‬

Procedure checklist of male catheterization

Student name: ---------------------------- Group:……………………….
st
1 Clinical evaluator name: -------------------Date:……………..
2nd Clinical evaluator name: ------------------- Date:……………..
3rd Clinical evaluator name--------------------- Date:……………..

Male catheterization Competency

Marks
1 2 3
Steps 1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D

1 Follow previous steps from 1 to 8 4

2 Position the patient on his back with 1

thighs slightly apart.

3 Wear clean gloves. Clean the 1

genital area
4 Remove gloves and wash hands 1
6 Follow previous steps from 10 to 2
15
7 Lift the penis with your non 1
dominant hand. Retract the foreskin
in the uncircumcised patient
9 Gently insert the tip of syringe with 1
lubricant into the urethra
10 Ask patient to bear dawn . Insert 1
catheter into meatus, ask patient to
take deep breathing
. If there is resistance ask patient to 1
breathe deeply and rotate catheter
slightly.
11 follow steps from 20 to 28 7
12 Total score
st
1 evaluation Score
2nd Evaluation Score
3rd Evaluation Score
Average
Comment:
Low A= 0 unable to perform Basic B=1(limited ability, needs Proficient C=2(proficient capable and Expert D=3 fully
significant help experienced needs no assistance to complete the capable and
task experienced
Less than 10 10-14 14-18 18-20
48
 ‫جامعة المنوفية‬

Procedure checklist of specimen collection (collecting 24- hour urine

specimen)

Student name: ------------------------ Group:………………….

1st Clinical evaluator name: ------------------- Date:……………….
2nd Clinical evaluator name: -------------------Date:………………..
3rd Clinical evaluator name: --------------------Date:…………….
Competency
Steps marks 1 2 3
1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D
1 Label specimen before the client 2
void

2 the client should wash the genital 2

area with soap and water
immediately before collection of
specimen
3 Give bedpan, specimen hat or 2
urinal to client and instruct him to
void. Discard this urine and record
time on client chart and on
collection bottle
4 Measure each specimen of urine 4
voided and pour into collecting
bottle that is placed into ice
5 Keep the collecting bottle opening 4
covered Urine decomposes into
ammonia when exposed to air
6 Transport specimen to laboratory 2

7 Wash hand before and after 4

procedure and instruct client to do
Total marks 20
st
1 evaluation Score
2nd Evaluation Score
3rd Evaluation Score
Average
Comment

Low A= 0 unable to perform Basic B=1(limited ability, needs Proficient C=2(proficient capable and Expert D=3 fully
significant help experienced needs no assistance to complete the capable and
task experienced
Less than 10 10-14 14-18 18-20

49
 ‫جامعة المنوفية‬

Procedure checklist of Blood glucose monitoring

Student name: ------------------------ Group:………………….
1st Clinical evaluator name: ------------------- Date:……………….
2nd Clinical evaluator name: -------------------Date:………………..
3rd Clinical evaluator name: --------------------Date:…………….

Competency
marks 1 2 3
Steps
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D
1 Wash hands and wear gloves 2
2 Explain the procedure to the 1
patient
3 Remove a test strip from the 1
container. Turn on the meter.
4 The code number on the strip 2
matches the code number that
appears initially on the
monitor screen (or follow the
manufacturer's instructions).
5 Prepare the lancet by twisting 2
off the cap. Arm the
automatic device by pushing
back the plunger until it
clicks. Attach the lancet.
6 Select the site on the patient's 2
finger for puncture. Gently
massage the finger toward the
intended puncture site.
7 Clean the site with alcohol 1
and allow the area to dry
thoroughly. (Patients may
omit this step at home).
8 Prick the side of the patient's 1
finger with a lancet and
squeeze gently. Use to obtain
blood cotton ball to wipe
away the first drop of blood if
recommended for the
particular meter.
9 Gently touch the drop of 2
blood to the strip's target area
or use a pipette as instructed.
Have the patient hold a clean
cotton ball to the puncture site

50
 ‫جامعة المنوفية‬

for a few seconds.

10 Insert the strip as far as it will 2
go into the meter with the
target area facing the red dot
on the meter
11 Read test results in 15 to 60 2
seconds on the meter face.
Remove the strip and turn off
the meter.
12 Dispose of equipment 2
properly. Remove gloves and
wash your hands.
Total marks 20
st
1 evaluation Score
2nd Evaluation Score
3rd Evaluation Score
Average
Comment

Low A= 0 unable to perform Basic B=1(limited ability, needs Proficient C=2(proficient capable and Expert D=3 fully
significant help experienced needs no assistance to complete the capable and
task experienced
Less than 10 10-14 14-18 18-20

51
 ‫جامعة المنوفية‬

Procedure checklist of Sputum Specimen

Student name: ------------------------ Group:………………….
1st Clinical evaluator name: ------------------- Date:……………….
2nd Clinical evaluator name: -------------------Date:………………..
3rd Clinical evaluator name: --------------------Date:…………….

Competency
marks 1 2 3
Steps
1. 1. 1. 1. 2. 2. 2. 2. 3. 3. 3. 3.
A B C D A B C D A B C D
1 label container 3

2 Hand washing and wear 3

gloves
3 Instruct pt. to take several 4
deep breaths and cough up
secretion from deep
respiratory passage
4 have the patient expectorate 4
directly on sterile container

5 Cover specimen immediately 3

and send it to lab
6 remove gloves and wash 3
hands
Total marks 20
1st evaluation Score
2nd Evaluation Score
3rd Evaluation Score
Average
Comment

Low A= 0 unable to perform Basic B=1(limited ability, needs Proficient C=2(proficient capable and Expert D=3 fully
significant help experienced needs no assistance to complete the capable and
task experienced
Less than 10 10-14 14-18 18-20

52
 ‫جامعة المنوفية‬

Procedure checklist of Obtaining a urine specimen from indwelling catheter:

Student name: ------------------------ Group:………………….
1st Clinical evaluator name: ------------------- Date:……………….
2nd Clinical evaluator name: -------------------Date:………………..
3rd Clinical evaluator name: --------------------Date:…………….

Competency
Steps mark 1 2 3
s
1.A 1.B 1.C 1.D 2.A 2.B 2.C 2.D 3.A 3.B 3.C 3.D
1 Wash hands and wear gloves 1
2 Explain procedure to the patient. 1
3 Drape the patient 1
4 Wipe the area where needle will be 2
inserted with a disinfectant swab.
5 Occlude or kink the drainage tubing a 1
minimum of three inches below the
sample port until urine is
visible under the access site
6 When urine is visible under the sample 2
port, swab the surface of the
sampling port with an antiseptic wipe
7 Using aseptic technique, position the 2
luer lock or slip tip syringe in the center
of the sampling port
8 Hold syringe perpendicular to the 2
surface of the sampling port, press
firmly and twist gently.
9 Slowly aspirate the desired volume of 2
urine into the syringe and remove the
syringe from the sample port when
complete
10 Transfer the specimen into a specimen 2
container, label according to hospital
protocol and place in a transport pouch
11 Allow hospital specimen handling 2
guidelines and send
specimen to the laboratory immediately
or refrigerate
until transported
12 Discard syringe, remove gloves, and 2
perform hand hygiene following hospital
protocol
Total marks 20
st
1 evaluation Score
2nd Evaluation Score
3rd Evaluation Score
Average
Comment
Low A= 0 unable to perform Basic B=1(limited ability, Proficient C=2(proficient capable and experienced Expert D=3 fully
needs significant help needs no assistance to complete the task capable and experienced

Less than 10 10-14 14-18 18-20

53