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Level 2 Checklist 1st Sem

This document is a performance evaluation checklist for the donning and doffing of sterile gloves using the open method. It outlines the procedure steps, expected outcomes, and provides a rating system for student performance. The checklist includes sections for planning, implementation, and documentation, along with space for remarks and signatures.

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Jodemae Aquino
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17 views3 pages

Level 2 Checklist 1st Sem

This document is a performance evaluation checklist for the donning and doffing of sterile gloves using the open method. It outlines the procedure steps, expected outcomes, and provides a rating system for student performance. The checklist includes sections for planning, implementation, and documentation, along with space for remarks and signatures.

Uploaded by

Jodemae Aquino
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NAME OF STUDENT: ____________________________________________

LEVEL & BLOCK: SCHOOL YEAR & TERM:


_____________________________ ___________________________ OVERALL RATING

DONNING AND DOFFING OF STERILE GLOVES (OPEN METHOD)


PERFORMANCE EVALUATION CHECKLIST
PROCEDURE PERFORMED PERFORMED UNABLE
INDEPENDENTLY WITH TO REMARKS
ASSISTANCE PERFORM
4-5 2-3 0-1
1.
PLANNING
2. Expected outcomes following completion
of procedure:
• Patient does not develop signs or
symptoms of infection after
procedure.
• Patient does not develop latex
sensitivity or latex allergy
reaction

IMPLEMENTATION
1. Wash hands.

2. Remove outer wrapper carefully by


separating and peeling apart sides and
lay it on clean, flat surface.

3. Open inner wrapper and touching only


the outside, secure both flaps in open
position.

4. Identify right and left glove. Each glove


has cuff approximately 5 cm and 2 inches
wide. Glove dominant hand.

5. With thumb and first two fingers of non-


dominant hand, grasp the inner fold of
the cuff. Lift the glove, holding away
from the body. Slip dominant hand
touching only the inner surface of the
glove.
6. With gloved dominant hand, slip four
fingers underneath second glove cuff. Lift
the glove away from the body.
7. Carefully pull second glove over
nondominant hand and adjust fingers of
both gloves using gloved hand.

8. After second glove is on, interlock hands


together above waist level. The cuffs
usually fall down after application. Be
sure to touch only sterile sides

9. Grasp outside of one cuff with other


gloved hand, avoid touching the wrists.

10. Pull glove off, turning it inside out.

11. Take fingers of bare hand and tuck inside


remaining glove cuff Peel glove off inside
out and over previously removed glove.
Discard both gloves in receptacle

DOCUMENTATION
12. Record the specific procedure performed
and patient’s response and status.
REMARKS:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
________________________________________________________

_______________________ ______________________
CONFORME: STUDENTS SIGNATURE CLINICAL INSTRUCTOR

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