NCM 109

Clinical Nursing Skills Performance Checklist

Performance Checklist
Student’s Name:________________________ Rate: _________________
Section:_______________________________ Signature: _____________ Date:
________________________________

Learning Objectives:
1. Safely administer medications and irrigations for the eye, ear, inhalation, nasal, and vaginal
routes
2. Select the appropriate equipment
3. Calculate correct amount to administer
4. Select appropriate site
5. Modify the procedure to reflect variations across the life span
6. Document actions and observations
7. Recognize and report significant deviations from norms.

A. Administration of Medications Via Other Routes Introduction

Performance Criteria COMPETENCY LEVEL Commen
t
Transdermal Patch Excellent Good Fair Poor Fail
(5) (4) (3) (2) (1)

• Perform hand hygiene

and apply clean
gloves.
• Remove the old patch
(if present).
• Clean the skin with
mild soap and water.
Dry the area
completely.
• Assess the skin for any
breaks or rashes. Do
not use these areas.
• Apply a new patch
wearing gloves. Rotate
application site based
on manufacturer
recommendations. Be
careful not to touch
the medication
surface.
• Press firmly to the
patient’s skin for about
ten seconds.
• Date, time, and initial a
piece of tape and
place
this next to the patch.
• Perform hand hygiene.

Ear Drop

• Perform hand
hygiene. (Put on
gloves, as needed, to
comply with standard
precautions).
• Clean the external ear
of debris.
• Tilt the patient’s head
so the affected ear
is
uppermost.
 • Remove the cap and
keep inside sterile. Do
not touch the dropper.
• Straighten the auditory
canal properly for the
age of the patient:
o Adult: Pinna
pulled up and
back
o Child: Pinna
pulled straight
back
o Infant and
child under
three: Pinna
pulled back
and down
• Squeeze the bottle and
allow drop(s) to fall
on
the side of the
auditory canal.
• Release the pinna and
massage the tragus
to
help with movement
of the drop into the
canal.
• Keep the patient in a
lying position with the
affected ear up for 5
minutes.
• Repeat in the other ear
if ordered.

Eye Drops

• Perform hand
hygiene. (Put on
gloves, as needed, to
comply with standard
precautions).
• Clean the eyes from
the inner canthus to
the outer canthus
using water or normal
saline.
• Tilt the patient’s head
back or have them
lying supine with their
head on a pillow.
• Remove the cap and
keep inside sterile. Do
not touch the dropper.
• Pull the lower
conjunctival sac open.
• Squeeze the ordered
drops into the
conjunctival sac.
• Apply gentle pressure
over the inner
canthus.
• Repeat in the other
eye if ordered.
• Perform hand hygiene.
 Nose Spray

• Perform hand
hygiene. (Put on
gloves, as needed, to
comply with standard
precautions).
• Have the patient blow
their nose.
• Have the patient tilt
their head back.
• Instruct the patient to
inhale with
administration if
necessary.
• Close the opposite
nare.
• Place a bottle or
dropper in the affected
nare.
• Squeeze the bottle or
dropper and have
the
patient inhale.
• Keep the bottle or
dropper compressed
and remove from the
nare.
• Instruct the patient to
hold their breath
for a
few seconds and then
breathe out through
the mouth.
• Repeat in other nare if
ordered.
• Clean tip of bottle with
tissue or cloth.
• Perform hand hygiene.

SCORE

FINAL SCORE

COMMENTS:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Points to Review: (RATIONALE)

Topical and Transdermal Medications

Topical medications are medications that are administered via the skin or mucous membranes for direct
local action, as well as for systemic effects. An inunction is a medication that is massaged or rubbed into
the skin and includes topical creams such as nystatin antifungal cream. The transdermal route of
medication administration includes patches or disks applied to the skin that deliver medication over an
extended period of time. Common types of transdermal medications are analgesics (such as fentanyl),
cardiac medications (such as nitroglycerin), hormones (such as estrogen), and nicotine patches (for
smoking cessation).

Medications delivered transdermally provide a consistent level of the drug in the bloodstream for
distribution. The transdermal route is also helpful for patients who are nauseated or having difficulty
swallowing.
Heat may be applied with the administration of some inunctions. Heat causes vasodilation that
enhances blood flow and improves absorption of some medication. However, heat should never be
applied over patches, such as the fentanyl or nitroglycerin patches, because it increases the release of
the drug and can cause overdose and death. Be sure to reference manufacturer recommendations
regarding the application of heat.[2]

When applying transdermal patches, the nurse should always wear gloves and check the rights of
medication administration as is done with other types of medication. Before applying a new patch, the
old patch should be removed, the skin around the old patch should be assessed, and the site for the
patch cleansed and dried thoroughly. The skin around the patch should be monitored for any irritation
or reaction to the medication or patch adhesive. Patches should not be applied to broken or irritated
skin.

When applying a new patch, the nurse should remove the clear plastic backing and take care to not
touch the medication surface of the patch while placing it on the patient’s skin. Patches should be
placed on an appropriate skin area per manufacturer guidelines, such as the upper arms or on the chest.
The patch should be pressed firmly to the skin for ten seconds to ensure adhesion to the skin. For
documentation purposes, the nurse should initial, date, and time a piece of tape that is applied close to
the patch. If your agency allows you to mark the patch directly, please be sure to use a marking pen in
order to not puncture the patch and render it ineffective. Based on the onset of the medication, the
patient should be evaluated to ensure they are responding appropriately to the therapeutic effects of
the medication and not experiencing any adverse effects.

Patch placement should be routinely assessed for dislodgement per agency policy. For example, for
some opioid patches like fentanyl, the nurse is required to assess and document that the patch is
present during every shift. The nurse should also be aware that patches with aluminum backing can
cause issues with defibrillation and MRI scans, so this type of patch should be removed prior to either of
these actions.

To remove a patch, the nurse should wear gloves and remove the patch carefully so as not to tear the
skin. The patch should be disposed of in the proper waste receptacle per agency policy. For example,
some agencies have specific receptacles for nitroglycerin patches. Additionally, agencies have specific
policies for disposal of fentanyl patches to prevent drug diversion of used patches. Patch removal should
be documented in the patient’s record.

Eye Instillations and Irrigations

Eye Drops

Eye drops are administered for a local effect on the eye. Examples of eye drop medications include
antibiotic drops for conjunctivitis, glaucoma medication to reduce intraocular pressure, and saline drops
to relieve dry eyes. The amount of drops to administer per eye is indicated on the provider order. When
instilling eye drops, the nurse should perform hand hygiene, apply gloves, and check the same rights of
medication administration as done with other types of medication. Prior to administration of eye
medication, the patient’s eyes should be assessed for new or unusual redness or drainage. If discharge is
present, the eyelids should be cleansed with gauze saturated with warm water or normal saline to
remove any dirt or debris that could be carried into the eye during instillation. When cleaning the
eyelids, the nurse should clean from the inner canthus toward the outer canthus so as not to introduce
debris or dirt into the lacrimal ducts that could cause an infection. A new gauze pad is used for each
stroke. The nurse should remove gloves after cleansing, perform hand hygiene, and apply new gloves
prior to medication administration.

When administering the drops, the patient should be instructed to tilt their head backwards or be
positioned in a supine position with their head on a pillow looking up. When the cap of the medication
is removed, it should be placed on a clean surface with care taken to keep the inside of the cap sterile
and to not contaminate the dropper tip. The patient should look up and away while the nurse gently
uses pressure to pull the lower lid down and expose the lower conjunctival sac. By holding the dropper
close to the sac without touching it, the nurse should squeeze the bottle and allow the drop to fall into
the sac, taking care to not touch the dropper to the eye. After the eye drop has been instilled, the
patient should close their eye. The nurse should apply gentle pressure to the inner canthus, when
appropriate, to prevent the medication from entering the lacrimal duct and causing a possible systemic
reaction to the medication. This procedure should be repeated in the other eye as ordered. The patient
should be instructed to not to rub their eye(s). During the procedure, the nurse evaluates the patient’s
tolerance of the medication and the procedure and documents it.

Eye Ointment

Administering eye ointment follows the same procedure as administering eye drops, except that instead
of drops, ½ inch of ointment is placed in the lower conjunctival sac. When applying the ointment, the
nurse should start at the inner canthus and move outward. After application, the patient should be
instructed to close their eyelid and move the eye to spread the ointment, so it is absorbed. They should
be advised they may experience blurry vision for a few minutes until the medication is absorbed.

Eye Irrigations

Eye irrigations are used to flush foreign bodies from the eye, such as debris or chemicals, using large
amounts of saline. The amount of solution and length of time used to irrigate the eye depends on the
contaminant. Follow agency policy when performing eye irrigation. For example, some emergency eye
flush stations provide a 15-minute flush to the eye. Care should be taken to not contaminate the other
eye while removing the debris unless it is necessary to flush both eyes.
Ear Instillations and Irrigations

Medications and fluids may be instilled into the ear for local effect, including antibiotics, analgesics, wax
softeners, and irrigation fluid to remove foreign objects or wax buildup. Medications and fluids are
instilled into the outer ear canal, with the tympanic membrane forming a thin barrier to the middle and
inner ear. However, if the tympanic membrane is ruptured, instillation of ear drops is generally
contraindicated unless a sterile, no-touch technique is used. However, if a patient has a surgical opening
in the tympanic membrane (i.e., tympanostomy tubes have been placed), ear drops may be prescribed
but caution must be taken not to introduce debris into the middle or inner ear.

Ear Drops

When administering ear drops, the nurse should carefully follow the dosage and amount of drops per
ear according to the provider order. The nurse should perform hand hygiene, apply gloves, and check the
same rights of medication administration as is completed with other types of medication. The external
ear should be cleaned of debris prior to drops being instilled. The patient should be positioned so the
affected ear is tilted in the uppermost position. If the patient is lying in bed, position the patient so they
are lying with the unaffected ear against the pillow and the affected ear upward. When removing the
cap of the medication, caution should be used to not touch the dropper or the inside of the cap to avoid
contamination. The pinna of the ear should be grasped and pulled backwards and upwards for an adult.
For children, the pinna should be pulled straight back, and for infants, it should be pulled down and
back. This movement straightens the auditory canal and prepares it for instillation. The nurse should
squeeze the bottle so that the drops of medication fall onto the side of the auditory canal and not
directly onto the tympanic membrane. The medication should run towards the tympanic membrane
after it is instilled. The tragus can be massaged to help move the medication into place. The patient
should remain in this lying position for five minutes. After five minutes, this procedure can be repeated
on the other ear, if ordered. Evaluation of the patient should be performed post administration to assess
if the patient tolerated the procedure and if anticipated therapeutic effects occurred. When instilling
medication or fluids into the ear, monitor for side effects such as dizziness or nausea

Ear Irrigations
Ear irrigations are typically performed to remove wax buildup or foreign bodies from the external ear
canal. Normal saline at room temperature is typically used, although a mixture of saline and hydrogen
peroxide can also be used. A 60-cc needleless syringe is typically used to irrigate the ear, or a spray
bottle with a soft angiocatheter can also be used. Ask the patient to hold an emesis basin under the ear
to catch the expelled irrigant. During and after the irrigation, the patient should be evaluated for side
effects such as dizziness, nausea, or pain.

Nasal Instillation

Medications administered via the nasal passage are typically used to treat allergies, sinus infections, and
nasal congestion. Nasal spray or drops should be administered via the nasal passage using a clean
technique. The nurse should perform hand hygiene, apply gloves, and perform the same rights of
medication administration as is completed with other types of medications. The patient should be given
tissues and asked to blow their nose. Position the patient with their head tilted backwards while sitting
or lying supine looking upwards. The nurse should insert the tip of the spray bottle or the nasal dropper
into one nare while occluding the other nare and then activate the spray as the patient inhales. The
bottle should remain compressed as it is removed from the nose to prevent contamination. The patient
should be instructed to hold their breath for a few seconds and then breathe through their mouth.
Repeat this procedure in the other nare if ordered. Wipe the outside of the bottle with clean tissue
before storing it and advise the patient to avoid blowing their nose for 5-10 minutes after nasal
instillation. Note any unexpected situations such as nosebleeds or increased congestion.[6]
Administration of Medications Via Other Routes Introduction

TRANSDERMAL
STEPS RATIONALE

1. Hand Hygiene(HH) & Clean gloves Ensures hygiene and prevents infection.

2. Remove old patch prevents overdose or interference with new medication.

3. Clean skin w/ mild soap & water. Dry area completely removes residue and enhances absorption

4. Assess skin for breaks/rashes. Do not use them. prevents irritation or adverse reactions

5. Apply a new patch wearing gloves. Rotate avoids direct medication absorption by the nurse.
application site based on manufacturer Rotating sites prevents skin irritation and promotes
recommendations. Be careful not to touch the effectiveness
medication surface

6. Press firmly to the patient’s skin for about 10sec ensures adhesion for proper absorptio

7. Date, time, initial a piece of tape and place this next labeling helps track the patch change schedule
to the patch.

8. HH

EAR DROPS
STEPS RATIONALE

1. HH, clean gloves

2. Clean the external ear of debris. removes debris for better absorption

3. Tilt the patient’s head so the affected ear is allows medication to reach the inner ear
uppermost.

4. Remove the cap and keep inside sterile. Do not touch Maintaining sterility prevents contamination.
the dropper.

5. Straighten the auditory canal properly for the age of Correct pinna positioning ensures optimal delivery to the
the patient: auditory canal.
Adult: Pinna pulled up and back
Child: Pinna pulled straight back
Infant and child under three: Pinna pulled back and
down

6. Squeeze the bottle and allow drop(s) to fall on the Dropping medication on the canal wall avoids direct
side of the auditory canal. tympanic membrane impact.

7. Release the pinna and massage the tragus to help Massaging the tragus aids medication movement.
with movement of the drop into the canal.

8. Keep the patient in a lying position with the affected Keeping the ear upward ensures absorption before
ear up for 5 minutes. drainage

9. Repeat in the other ear if ordered.

EYE DROPS
1. HH, clean gloves

2. Clean the eyes from the inner canthus to the outer removes secretions for effective absorption.
canthus using water or normal saline

3. Tilt the patient’s head back or have them lying supine prevents medication runoff
with their head on a pillow.

4. Remove the cap and keep inside sterile. Do not touch prevents contamination
the dropper.

5. Pull the lower conjunctival sac open. Lower sac application ensures medication reaches the
eye surface.

6. Squeeze the ordered drops into the conjunctival sac

7. Apply gentle pressure over the inner canthus Gentle pressure prevents systemic absorption via the
nasolacrimal duct.

8. Repeat in the other eye if ordered. repeating in both eyes ensures complete treatment.

9. HH

NOSE SPRAY
1. HH, clean gloves

2. Have the patient blow their nose (BLOW) Clearing nasal passages allows better medication
absorption.

3. Have the patient tilt their head back. (TILT) Head tilting directs medication into the nasal cavity.

4. Instruct the patient to inhale with administration if Inhaling during administration enhances effectiveness.
necessary (INHALE)

5. Close the opposite nare. (CLOSE) Closing one nostril focuses medication delivery.

6. Place a bottle or dropper in the affected nare.

7. Squeeze the bottle or dropper and have the patient

inhale.

8. Keep the bottle or dropper compressed and remove Keeping the bottle compressed prevents contamination.
from the nare

9. Instruct the patient to hold their breath for a few Holding breath enhances absorption.
seconds and then breathe out through the mouth.

10. Repeat in other nare if ordered

11. Clean tip of bottle with tissue or cloth. cleaning the bottle prevents cross-contamination.

12. HH
RETDEM #1 RATIONALE

●​ Topical and Transdermal Medications

○​ Topical Medications
■​ Administered via the skin or mucous membranes for direct local action and systemic effects.
■​ Inunction: Medication massaged or rubbed into the skin (e.g., nystatin antifungal cream).
○​ Transdermal Route
■​ Includes patches or disks applied to the skin for extended medication delivery.
■​ Common types of transdermal medications:
■​ Analgesics (e.g., fentanyl)
■​ Cardiac medications (e.g., nitroglycerin)
■​ Hormones (e.g., estrogen)
■​ Nicotine patches (for smoking cessation)
■​ Provides a consistent drug level in the bloodstream.
■​ Beneficial for patients experiencing nausea or difficulty swallowing.
○​ Heat Application
■​ Enhances blood flow (vasodilation) and absorption in some inunctions.
■​ Should never be applied over patches (e.g., fentanyl, nitroglycerin) due to risk of overdose and
death.
■​ Manufacturer recommendations should always be referenced.
○​ Applying Transdermal Patches
■​ Wear gloves and follow medication administration rights.
■​ Remove old patch, assess skin, cleanse, and dry the site thoroughly.
■​ Monitor for irritation or reaction to the medication or adhesive.
■​ Avoid applying to broken or irritated skin.
■​ Remove clear plastic backing without touching the medication surface.
■​ Place on an appropriate skin area per manufacturer guidelines (e.g., upper arms, chest).
■​ Press firmly for ten seconds to ensure adhesion.
■​ Document with initials, date, and time near the patch (or on the patch if permitted).
■​ Evaluate patient response based on medication onset.
○​ Patch Placement and Removal
■​ Routinely assess placement per agency policy (e.g., fentanyl patch checked each shift).
■​ Patches with aluminum backing should be removed before defibrillation or MRI scans.
■​ Wear gloves for patch removal, ensuring no skin damage.
■​ Dispose of patches per agency policy (e.g., specific receptacles for nitroglycerin, fentanyl
disposal policies to prevent drug diversion).
■​ Document patch removal in the patient’s record.
●​ Eye Instillations and Irrigations
○​ Eye Drops
■​ Used for local effects (e.g., antibiotics for conjunctivitis, glaucoma medication, saline for dry
eyes).
■​ Follow provider order for the number of drops per eye.
■​ Perform hand hygiene, wear gloves, and follow medication administration rights.
■​ Assess eyes for redness or drainage before administration.
■​ Clean eyelids from inner to outer canthus using a new gauze pad for each stroke.
■​ Remove gloves, perform hand hygiene, and apply new gloves before instillation.
■​ Position patient with head tilted backward or lying supine looking up.
■​ Avoid contaminating the dropper tip.
■​ Pull lower lid down to expose the conjunctival sac and instill drops without touching the sac.
■​ Apply gentle pressure to the inner canthus when appropriate.
■​ Instruct the patient not to rub their eyes.
■​ Document procedure and evaluate patient response.
○​ Eye Ointment
■​ Same procedure as eye drops but with ½ inch of ointment applied to the conjunctival sac.
■​ Start at the inner canthus and move outward.
■​ Instruct patient to close eyes and move them to spread the ointment.
 ■​ Advise that blurry vision may occur temporarily.
○​ Eye Irrigations
■​ Used to flush debris or chemicals from the eye.
■​ Follow agency policy for irrigation duration and solution type.
■​ Take care not to contaminate the other eye unless both require irrigation.
●​ Ear Instillations and Irrigations
○​ Ear Drops
■​ Used for local effects (e.g., antibiotics, analgesics, wax softeners).
■​ Avoid if tympanic membrane is ruptured unless using a sterile, no-touch technique.
■​ Perform hand hygiene, wear gloves, and follow medication administration rights.
■​ Clean external ear before administration.
■​ Position patient with the affected ear facing upward.
■​ Pull pinna back and up (adults), straight back (children), or down and back (infants).
■​ Instill drops onto the side of the auditory canal.
■​ Massage the tragus to help medication movement.
■​ Keep patient in position for five minutes before treating the other ear (if needed).
■​ Evaluate patient response and monitor for side effects (e.g., dizziness, nausea).
○​ Ear Irrigations
■​ Used for wax removal or foreign body extraction.
■​ Normal saline (or saline with hydrogen peroxide) at room temperature is used.
■​ A 60-cc syringe or spray bottle with soft angiocatheter is used.
■​ Patient holds an emesis basin under the ear to catch expelled fluid.
■​ Monitor for dizziness, nausea, or pain during and after the procedure.
●​ Nasal Instillation
○​ Nasal Sprays and Drops
■​ Used for allergies, sinus infections, and nasal congestion.
■​ Perform hand hygiene, wear gloves, and follow medication administration rights.
■​ Provide tissues and instruct patient to blow their nose before administration.
■​ Position patient with head tilted backward while sitting or lying supine.
■​ Insert spray bottle or dropper into one nare while occluding the other.
■​ Activate spray as patient inhales, keeping the bottle compressed while removing.
■​ Instruct patient to hold breath briefly and then breathe through the mouth.
■​ Repeat in the other nostril if ordered.
■​ Wipe bottle with clean tissue before storage.
■​ Instruct patient to avoid blowing their nose for 5-10 minutes post-administration.
■​ Document any unexpected events (e.g., nosebleeds, increased congestion).