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FACULTY OF NURSING AND ALLIED HEALTH SCIENCES
Bachelor of Science in Nursing
Guang-guang, Dahican, City of Mati, Davao Oriental
Modified Observe Structure Clinical Examination (OSCE) Checklist
Name:___________________________________________________ Grade:
Year and Section:__________________________________________
Date:__________________________________________
Performance Rubrics
Score Qualitative Description Criteria
4 Excellent Demonstrates accuracy and integrates knowledge and
skills appropriately. Clearly stated the steps of every
procedure and profoundly demonstrate with rationale
3 Good Demonstrate moderately with assistance in integrating
knowledge and skills. Clearly stated the steps of every
procedure and properly demonstrated; however, failed
to state the complete rationale.
PERFORMED
2 Acceptable Demonstrates average performance integrating the
knowledge and skills. Clearly stated the steps of every
procedure and properly demonstrated but fail to state
the rationale. Consequently, failed to answer pertinent
queries appropriately.
1 Needs Demonstrate the gaps in the necessary knowledge and
Improvement requires frequent and utmost assistance that lacks the
skills. Partially stated the steps of every procedure,
incorrectly demonstrated without rationale, or stated the
rationale but failed to perform the procedure or vice
versa.
0 Not Performed Frequently lacks knowledge and skills and is unable to
perform and state every procedure and rationale.
OR and Instrument Pack Preparation and Setting-up Surgical Instruments in the Sterile
Mayo Tray
Purpose/s
• Preparation for surgical procedures
• Create a barrier between sterile and unsterile areas.
• Permit the handling of sterile supplies prior to the start of any surgical procedures.
Material and Equipment
• Mayo Tray
• Sterile OR Pack
• Sterile Instrument Pack (CS Set)
• Sharp Instruments Soaked in Soaking Solution
• Add on instruments in a sterile pack
• OR grade Blade
• OR grade Needles
• Sterile Square Packs
• Sterile Surgical Gloves
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Timeframe: 3-6 minutes
Instruction: Mark check (✓) for box which the student was able to perform with competence
and (x) for not.
Not
No. Nursing Management Performed Remarks
Performed
1. Assessment
Check availability and the sterility of all OR
1.1. supplies. If you are in doubt of the sterility of the
surgical pack request for new one.
1.2. Check expiration date of the supply packaging.
2. Planning
2.1. Determined the location of scrubbing area with
water supply and surgical scrub solution or
scrubbing pack.
2.2. Identify the availability of OR sterile field table and
mayo tray
2.3. Gathers all needed supplies
3. Implementation
Opening of OR and Instrument pack
3.1. Done medical hand washing
3.2. Placed the sterile OR pack at the center of the
sterile field table with the outward flap facing the
scrub room.
3.3. Using one hand opened OR pack carefully
following the direction of the folded flap while the
none working hand secured at the back.
3.4. Get a sterile pick-up forceps (optional: from a
sterile wrapper or soaked in the soaking solution.
Follow institutional guidelines.)
3.5. Opened the inner OR pack cover using a sterile
pick-up forceps, the same manner as in step 3.3.
3.6. Put back the pick-up forceps in the soaking
solution making sure that the tip is always
pointing downward.
3.7. Get the sterile instrument pack and put it in the
mayo tray.
3.8. Following the technique in step 3.3 opened sterile
instrument pack outer cover carefully following
the direction of the folded flap.
3.9. Dropped sterile gloves in the newly established
sterile field table. Using banana peel technique or
pick-up forceps.
Allow circulating nurse to keep the opened sterile
3.10.
items in his/her field of view at all times.
3.11. Done Propper Surgical Scrubbing
3.12. Performed Propper Sterile gowning (allows the
circulating nurse to assist in securing sterile gown
ties)
3.13. Performed Propper Close Gloving
3.14. Bring the instrument pack to the sterile field table
holding only the inner cover.
Setting-up Surgical Instruments in the Sterile Mayo Tray
3.15. Picked up the sterile mayo cover and inserts the
gloved hand in its cuff while maintaining the
bottom part of the mayo cover at the waist level
above the hips.
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3.16. Slipped the mayo cover over the mayo stray
frame while supporting its stand with your
dominant foot.
3.17. Unfold the mayo cover cuff extending towards the
opposite edge of the mayo tray keeping the
gloved hands above the level of the mayo tray
corner.
3.18. Get a sterile towel from the sterile field table to
cover the mayo tray.
3.19. Request sterile square pack from you circulating
nurse or get it from the sterile field table if it is
already dropped by your circulating nurse.
3.20. Rolled the square pack and put it on the preferred
side of the mayo tray
3.21. Opened the instrument pack carefully
3.22. Unlocked the towel clip and slowly pulled out the
Babcock from the ring of the instrument.
3.23. Place and arrange the instruments on the top of
the mayo tray per institutional guidelines.
3.24. Arrange the instruments according to the order of
use. Instrument that is use first will be placed
nearest to the scrub nurse.
3.25. Allowed circulated nurse to dropped add-on
instruments (sharps, suction tip and tubes,
special instruments, addition sterile basins, ATRs
and sponges).
3.26. Arrange add-on instruments following institutional
guidelines.
3.27. Mounted the blade safely on the appropriate
blade holder size.
3.28. Informed the circulating nurse he/she is ready for
the initial counting.
3.29. Picked up one of the tissue forceps and uses the
tip of the handle in counting the instrument or
hold instrument directly by hand. (Follow
institutional guidelines).
Start counting following SIN Mnemonics
(Sponges, Instruments, and needles).
CS set
a. Square packs (at least 4)
b. OS (if available or per surgeon
preference)
c. Knife (1)
d. Metz scissors (1)
e. Bandage scissors (1)
f. Mayo Scissors (1)
g. Tissue Forceps (1)
h. Thumb Forceps (1)
i. Kelly or Richardson’s Retractor if available
(1)
j. Army Navy R. (1)
k. Kelly Straight (1)
l. Mosquito Curve (1)
m. Kelly Curve (4)
n. Ochsner/Kocher (2)
o. Babcock (2)
p. Allis (4)
q. Needle holder (1)
r. Towel Clips (5)
s. Bowl (1)
t. ATRs (Preferably 5)
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3.30. Waited for the surgeon to signal the start of the
draping procedure of the patient.
4. Evaluation
Maintains good body mechanics throughout the
4.1. performance of the procedure.
Manifest neatness in the performance of the
4.2.
procedure.
4.3. Receptive to criticisms.
4.4. Observed courtesy.
4.5. Show calmness while performing the procedure.
4.6. Show mastery of the procedure.
(Student’s
a. Total Number of Items Performed
Signature)
Comments/Suggestion for Further Improvements
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Name and Signature of Supervising Faculty
