Ministry of Education

Taif university
Faculty of Applied Medical Sciences
Nursing Department

PEDIATRIC NURSING
Skill Code B1
Performance Evaluation Checklist
Category B Skills Name: Health Assessment

Steps

Independent

Dependent
Supervised

Marginal
Assisted
1. General appearance
 Posture
 Facial expression
 Hygiene
 Nutrient status
 Level of child activity
 Child reaction to stress
2. SKIN
 Colour
 Palpate texture
 Palpate turgor
 Lymph nodes .inspect &palpate
 Size
 Temperature
 Tenderness
 Any abnormality
3. Head
 Shape
 Control
 Fontanal
4. Scalp
 Cleanliness
 Trauma
 Lesions
 Hair texture
 Hair loss
 Hair discolaration
Face
 Symmetry
 Facial expression

5 Neck
 Size
 Trachea
 Thyroid
 Carotid arteries
 Thyroid gland
6. Eyes
 Test visual activity
 Placement
 Conjunctiva
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 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

7. Ears:
 Pinna
 External canal
8. Nose &sinuses
 Shape
 Nasal mucosa
 Nasal septum
 Palpate -sinuses for tenderness
9. Mouth &and throut
 Lips
 Tongue.
 Gums
 Teeth
 Colour
 Tonsils
10. Chest:
 Inspect chest
 Palpate chest
 Percuss chest
 Auscultate the chest
11. Nails
 Colour and shape
 Lesions
12. Nails
 Colour and shape
 Lesions
13. Heart:
 Inspect heart
 Palpate for pulse
 Auscultate for heart sound
14. Abdominal assessment :
 Inspection
 Auscultation
 Percussion
 Palpitation
15. Back:
 Colour
 Symmetry
 Lesions
16. Genitalia :
 Male:
 Penis
 Scrotum
 Tests
 Urethral meatus
 Female:
 Labias
 Urethral meatus
17. Anus :
 Opening
 Skin condition
18. Upper and lower extremities:
 Range of motion
 Colour

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 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

 Symmetry
 Lesions
 Oedema
19. Neuromuscular system
 Level of consciousness
 Reflexes
 Activity
 Mobility
 Sensation
20. Documentation of findings

Comments :
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………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
Evaluator Signature Student Signature
Date: Date:

3
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

PEDIATRIC NURSING

Skill Code B2
Performance Evaluation Checklist
Skills Name: GROWTH MEASUREMENTS
Category B

1. LENGTH

Dependent
Independent

Supervised

Assisted

Marginal
NO STEPS

- Identify the patient .

- Introduce yourself .
- Explain the procedure to the family, why it is
necessary .
- Gather the equipment :
o Measuring board for infant .
o Measuring tape .
- Perform hand wash .
Provide privacy .
* By using measuring board :
1 Place the towel on the board .
2 Remove the infant clothing .
Place infant on centre of board firmly in supine position .
3
4 Hold the head against headboard firmly .
5 Grasp the knees together gently .
Push down in knees until the legs are fully extended and
6
hold the legs firmly .
Bring the headboard against the soles of
7
heals firmly .
8 Read and record .
* By using measuring tape :
Place the infant on a proper covered hard surface.
1
Push down the knees and head against a
2
firm surface.
Make points of the top of the head and heel of the feet by
3
a point.
4 Remove infant from his place.
5 Measure between these two points .
6 Record.
- Final assessment / Total :
1
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

Standing height measurement evaluation

Procedure steps No

Independen
t
Greet the mother & child , introduced your self 1
Explain procedure to child 2
Balance the scale by setting it at zero
Perform hand rub. 3
Remove shoes 4
Ask the child stand as tall as possible, back straight, head in 5
midline, and eyes looking straight ahead, Check for flexion of
knees, slumping shoulders raising of heels, Still keeping the
head in position ,use your other hand to pull down the
headboard to rest firmly on top of the head and compress
the hair .*
Measure from top of head to standing surface and record the 6
child `s height to the nearest 0.1cm , if the child less than 2
years old add 0.7 cm to height and record it percentile chart
Record height and plot on percentile chart 7

Comments :
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………
Evaluator Signature Student Signature
Date: Date:

2
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

2. WEIGHT

Supervised
Independent

Assisted

Marginal

Dependent
NO STEPS

- Keep parents informed about what you are

doing .
- Explain the procedure and why it is necessary .
- Gather the equipment :
o An infant weighing scale.
Disposable sterile drape .
1 Drape the scale .
2 Balance the scale by setting it at zero .
3 Remove the infant clothes .
Gently left the infant from his crib, and place him on the
4
scale .
Hold one hand over the body of the infant
5
(not touching him) for reasons of safety .
6 Return the infant to the crib .
7 Dress the infant quickly .
Take an accurate reading of the weight and record it .
8

Measure to the nearest 10gm for the infant

9
& 100 gm for children .
10 Remove and discard the drape .
11 Record .
- Final assessment / Total :

1
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

Standing weight measurement

Procedure steps No

Independent
Greet the mother & child , introduced your self 1
Explain procedure to child 2
Balance the scale by setting it at zero
Perform hand rub. 3
Remove shoes and outer clothing , If the child has 4
braids or hair ornaments that will interfere with
length/height measurements, remove them before
weighing
Ask the child to stand in the middle of the scale, feet 5
slightly apart (on the footprints, if marked), and to
remain still until the weight appears on the display

Record the child’s weight to the nearest 0.1 kg and plot 6

on percentile chart.

Comments :
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………
Evaluator Signature Student Signature
Date: Date:

2
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

3. HEAD CIRCUMFERENCE

Supervised
Independent

Dependent
NO STEPS

Marginal
Assisted
- Keep parents informed about what you are
doing .
- Explain the procedure and why it is necessary .
- Gather the equipment :
o Measuring tape .

III. Implementation:
Measure head at its greatest circumference, usually
slightly above the eyebrows and pinna of the ears of
1 ears and around the occipital prominence at the
back of the skull .

2 Record .
- Final assessment / Total :

4. CHEST CIRCUMFERENCE Independent

Supervised

Marginal

Dependent
NO STEPS
Assisted

- Keep parents informed about what you are

doing .
- Explain the procedure and why it is necessary .
- Gather the equipment :
o Measuring tape .

III. Implementation:
1 Remove infant's clothes of upper half .
2 Place on a flat table in supine position .
3 Place tape across the nipple line .
Measure midway between inspiration and expiration .
4
5 Record .
- Final assessment / Total :

1
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

PEDIATRIC NURSING

Skill Code B3
Performance Evaluation Checklist
Skills Name: Assessment of Consciousness using Glasgow Coma Scale
Category B

STEPS

Independent

Assisted

Marginal

Dependent
Supervised
Equipment’s:
Glasgow Coma Scale Sheet
Knee hammer, pen and
flashlight
3 Implementation
. 1. Explain and reassure the parents and child and inform them how to cooperate.
2. Keep patient in comfortable position.
3. Score responses in Glasgow Coma Scale sheets.
4. Add total score at bottom of sheet during each assessment.
5. Assess pupils, limb movement and vital signs for completion of procedure.
6. Document accurately and report changes if any.
7.Assessment guide to Glasgow Coma Scale
Category of Appropriate Response Score
response stimulus
Eye opening -Approach to bedside -Spontaneous response 4
-Verbal command -Opening of eyes to name or command 3
-Pain -Lack of opening of eyes to previous stimuli 2
-Lack of opening of eyes to any stimulus 1
Untestable U
Verbal response -Verbal questioning -Appropriate orientation, conversant, correct 5
With maximum arousal identification of self, place, year and month
-Confusion, conversant but disorientation in 4
one or more spheres.
-Inappropriate or disorganized use of words, 3
lack of sustained conversation.
-Incomprehensive words, sounds 2
-Lack of sound, even with painful stimuli 1
-Untestable U
Best motor -Verbal command -Obedience of command 6
response
-Pain (pressure on -Localization of pain, lack of obedience but 5
proximal nail bed) presence of attempts to remove offending
stimulus.
-Flexion withdrawal, flexion of arm in 4
response to pain without abnormal flexion
posture.
-Abnormal flexion, flexing of arm at elbow 3
and pronation making a fist.
-Abnormal extension, extension of arm at 2
elbow usually with adduction and internal
rotation of arm at shoulder.
Lack of response 1
Untestable U
Minimum score- 3
Maximum score-15 for fully alert person
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

Score less than 8 indicates coma

Comments :
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………

Evaluator Signature Student Signature

Date: Date:
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

PEDIATRIC NURSING

Skill Code A1
Performance Evaluation Checklist
Skills Name: ADMINISTERING OXYGEN
Category A

STEPS

Supervised
Independent

Assisted

Marginal

Dependent
Equipment’s: Method of O2 administration Oxygen source
-Nasal Cannula, Mistent, Venturi Humidifier with distilled
Mask water Flow meter
-Simple facemask Gauze pads
-Hood (head box) “No smoking” signs
-by Incubator
Implementation
1. Explain and reassure the parents and child and explain about 02 therapy and inform
them how to cooperate.
2. Check physicians order for rate, device used, concentration, etc.
3. Perform an assessment of vital signs, level of consciousness, lab. Values etc and
record.
. 4. Post “No smoking” signs in the patient’s door in view of patient and visitors and
explain to
them the dangers of smoking when oxygen is on flow.
5. Wash hands
6. Set up oxygen equipment and humidifier
a. Fill humidifier up to the level marked on it with sterile water.
b. Attach flow meter to source, set flow meter in OFF position.
c. Attach humidifier to base of flow meter.
d. Attach tubing and method of O2 administration (Cannula, facemask etc.) to
humidifier.
e. Regulate flow meter to prescribed level.
f. Ensure proper functioning by checking for bubbles in humidifier or feeling
oxygen at the outlet.
7. Place cannula or facemask to patients and adjust straps.
8. Inspect patient equipment frequently for flow rate, clinical condition Level
of water in humidifier etc.
Flo O2
w Concentrati
Rate on
1L 24 TO 25%
2L 27 TO 29%
3L 30 TO 33%
4L 33 TO 37%
5L 36 TO 41%
6L 39 TO 45%

9. Ensure that safety precautions are followed.

10. Wash hands
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

11. Remove and clean the facemask or cannula with soap and water, dry and replace
every 8
hours. Assess nares at least every 8 hours.
12. Evaluation .
- Perform follow-up based on findings that deviated from expected or normal for
client.
- Relate findings to previous data if available (O2 saturation, ABG etc.)
- Report significant deviations from normal to the primary care provider.
13. Document time, flow rate and observations made on patient.
Record the procedure in Nurses record. Document the baby’s/ child’s condition before
and after procedure.

Comments :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………

Evaluator Signature Student Signature

Date: Date:
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

PEDIATRIC NURSING

Skill Code A2
Performance Evaluation Checklist
Skills Name: ADMINISTERING NEBULIZER
NOCategory A STEPS

Independent

Supervised

Marginal
Assisted
1. Equipment’s: Air compressor or Oxygen source if indicated
2 Nebulizer set(connecting tube, facemask,
nebulizer)
Medication and saline solution
Sputum cup(specimen)
Kidney tray
2. Identify patient and check physician’s instructions and nursing
3 care plan.
Monitor heart rate before and after the treatment for patients
using bronchodilators drugs.
4. Explain the procedure to the mother.
5. Ask the mother to cuddle the child and place the child
comfortable position in upright .
6. Add the prescribed amount of medication and saline or sterile
water to the nebulizer.
7. Connect the tubing to the compressor or oxygen source if
indicated. A fine mist from the device should be visible.
8. Place mask on patient’s face to cover his mouth and nose.
9. Observe patient for any adverse reaction to the treatment.
10. Record medication used and description of secretion
expectorated.
11. Disassemble and clear nebulizer after each use and keep the
equipment In patient room. The tubing is changed every 24
hours.
12. Wash hands
13. Re-evaluates patient respiratory status and relieve of dyspnoea
14. Document the procedure in Nurses record. & child’s condition
before and after procedure.

Comments :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………

Evaluator Signature Student Signature

Date: Date:
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

PEDIATRIC NURSING

Skill Code A3
Performance Evaluation Checklist

Category A Skills Name:

Endotracheal Tube: Open Suctioning (Neonatal)

Procedure 

Independent

Supervised

Dependent
Marginal
Assisted
Supplies
 Sterile gloves
 Bag and mask (appropriate size) connected to oxygen source
 Oxygen saturation and cardiopulmonary monitors
 Specimen trap (optional for obtaining specimen for culture)
 Sterile normal saline
 Stethoscope
 Suction canister with vacuum to wall suction and connecting
tubing
 Suction catheter (appropriate size)
1. Performed hand hygiene before patient contact.  

2. Verified the correct neonate using two identifiers.  

3. Assessed signs and symptoms of airway secretions and

 
inadequate oxygenation and ventilation.
4. Using one of the following methods, chose the proper size
suction catheter:
a) Selected a recommended suction catheter size.
 
b) Calculated suction catheter size by doubling the ET tube size
and choosing the suction catheter size closest to the
calculation.
5. Prepared open suction system.
a) Set suction control at 60 to 100 mm Hg. Used the least amount
of negative pressure necessary to remove secretions.
b) Prepared sterile saline for rinsing the catheter.  
c) If a specimen for culture was required, placed specimen trap
in-line between the suction catheter and the suction tubing that
connect to the wall-mounted suction regulator.
6. Ensured that an appropriate-size bag and mask were connected
to an oxygen source at the bedside. Ensured that the oxygen
 
source had the capability of being blended to provide a sufficient
variety of concentrations of oxygen to meet the neonate's needs.
7. Ensured that the ET tube was secure.  
a) Ensured minimal tube movement.
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

b) Ensured tape or securement device integrity.

8. Performed hand hygiene.  

9. Provided developmentally appropriate containment for comfort

 
during the procedure.
10. Reassessed the neonate's lung sounds before suctioning.  

11. Increased FIO2 by no more than 10% if needed to maintain

 
target oxygen saturation levels.
12. Determined the proper catheter length for suctioning by
measuring the length of the tube plus the adapter. Correlated the
 
desired (measured) suction catheter length with the matching
measurements on the ET tube.
13. Opened the suction catheter package using sterile technique.  

14. Poured a small amount of sterile normal saline in the sterile

 
container.
15. Prepared the sterile suction catheter.
a) Performed hand hygiene and donned sterile gloves. Kept one
hand sterile to handle the catheter. Kept the other hand clean.  
b) With the clean hand, grasped the tubing coming from the
vacuum source and connected it to the suction catheter.
16. Suctioned a small amount of the normal saline from the
 
container.
17. As an assistant stabilized the ET tube, maintained sterile
technique while inserting and advancing the catheter to the
 
predetermined length without applying suction,unless the
neonate was ventilated with a high-frequency jet ventilator.
18. Suctioned secretions by depressing the control valve while
withdrawing the catheter from the ET tube. Ensured that the
neonate's head remained in a midline position and ET tube  
remained stabilized. Did not apply suction for longer than 10 to
15 seconds.
19. Reassessed breath sounds.  

20. After each pass, allowed the neonate time to recover (as
indicated by oximetry and the cardiopulmonary monitor) by  
providing positive pressure ventilatory support.
21. Noted the color, amount, and consistency of secretions removed.  

22. As needed, flushed and rinsed the catheter with normal saline.  

23. Weaned oxygen to pre procedure level, as tolerated.  

24. Monitored oxygenation levels before, during, and after  

suctioning and adjusted support to prevent extremes of
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

oxygenation.
25. Monitored cardiac and respiratory stability during suctioning  

26. Assessed breath sounds and chest excursion before, during, and
 
after each suctioning
27. Reconfirmed security and position of ET tube.  

28. Suctioned the ET tube as needed.  

29. Monitored the neonate's tolerance of the procedure.  

30. Assessed, treated, and reassessed pain.  

31. Discarded supplies, removed gloves, and performed hand

 
hygiene.
32. Documented the procedure in the neonate's record.  

Comments :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………

Evaluator Signature Student Signature

Date: Date:
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

PEDIATRIC NURSING

Skill Code A4
Performance Evaluation Checklist

Category A Skills Name:

Performing Neonatal Resuscitation-Chest Compressions

Independent

Supervised
Assisted
Marginal

Dependent
STEPS

Trained Code Blue Responder

Implementation
1. Compress the chest by placing the hands around the newborn’s chest with the
fingers under the back to support and the thumbs over the lower third of the
sternum (just above the xiphoid process) Or Use 2 fingers of one hand to
compress the chest and place the other hand under the
back to provide support.
2. Compress the sternum to a depth of approximately one third of the anteroposterior
diameter of the chest and with sufficient force to cause a palpable pulse. The
fingers should remain in
contact with the chest between compressions.
3. Use three compressions(about 1/3 to ½ the depth of the chest) followed by one
ventilation for a combined rate of compressions and ventilations of 120 each
minute. This provides 90 compressions and 30 ventilations each minute. Pause
for ½ second after every third compression of ventilation.
Compression to Ventilation ratio:
One rescuer: 30: 2 Two rescuer: 15:2
4. Check the heart rate after 30 seconds. If it is 60 bpm or more, discontinue
compressions but continue ventilation until the heartrate is more than 100 bpm
and spontaneous breathing
begins.
Evaluation: .
-Have other outcome measures for the goal of maintaining adequate cardiac output?
-Are there additional factors that are placing stress on the heart?
-Are prescribed medications being taken/administered as ordered?
-Is there a balance between factors that affect cardiac output, such as preload and after
load?
-Are there signs of fluid overload such as weight gain?
Documentation:
Record the procedure in Nurses record. Document the baby’s condition before and after
procedure.
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

Performing Child CPR-Chest

Compressions

STEPS

Independent

Supervised

Dependent
Marginal
Assisted
Trained Code Blue Responder
Implementation
1. Determine unresponsiveness by gently shaking shoulders and calling Out
the child loudly.
2. Place the victim on his/her back on a firm flat surface.
3- Open the airway and check for breathing. To open the airway use head tilt-
chin lift maneuver.
For suspected cervical spine injury Use the jaw thrust instead.
4. Assess if the victim is breathing by keeping your cheek against the
a. Victim’s nose and look at the chest for rise and fall and listen and
b. Feel for exhaled breath against your cheek.
5. If no breathing is detected, give 2 breaths that make the chest rise.
a. Deliver each rescue breath in 1 second and ensure chest rise with
each breath.
6. Assess for circulation
7. Infants: Check brachial pulse
8. Children: Check carotid or femoral pulse
a. Note: Pulse check should not take more than 10 seconds.
9. If the pulse is absent. Initiate cardiac
compressions
a. -Compress at a rate of 100 times per
minute
b. -Push hard and push fast
c. -In children ( ages 1-8 years)- 1/3 to ½ the depth of the chest.
Use the heel of one or two hands on the lower half of the
sternum.
10. Perform rescue breathing
a. Follow compression to ventilation ratio:
b. 2 Rescuer - 15 to 2
c. 1 Rescuer – 30 to 2
d. -Insert an oropharyngeal or nasopharyngeal airway
e. -Use bag- valve-mask and higher flow oxygen
f. Deliver Each breath over 1 second with enough volume to cause
chest to rise.
-
11. Continue CPR until advance cardiac life support is available.
Evaluation:
-Have other outcome measures for the goal of maintaining adequate cardiac
output?
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

-Are there additional factors that are placing stress on the heart?
-Are prescribed medications being taken/administered as ordered?
-Is there a balance between factors that affect cardiac output, such as preload and
after load?
-Are there signs of fluid overload such as
weight gain?
Documentation:
Record the procedure in Nurses record. Document the child’s condition before
and after procedure.

Comments :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………

Evaluator Signature Student Signature

Date: Date:
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

PEDIATRIC NURSING

Skill Code A5
Performance Evaluation Checklist

Category A Skills Name: GAVAGE FEEDING

nt
Independe

Supervised

Assisted

Marginal

Dependent
STEPS

- Identify the patient .

1
- Introduce yourself .
- Explain the procedure to the family, why it is necessary .
- Gather the equipment :
o Oral feeding syringes 60 cc with Catheter tip .
o The formula .
o Water for flush .
o Clear adhesive dressing
o Anti-reflux valve
- Perform hand wash .
- Assess the type ,amount , concentration, frequency
and warmth of the prescribed formula .
2 Positioned the patient in semi setting or upright if he/she can .
3 Unclamped gavage tube .
4 Checked for formula left in stomach from last feeding (residuals )
by attaching a syringe to the tube and pulling back on
plunger.
5 Removed the plunger from the syringe.
6 Put the syringe in to the open end of the gavage tube.

7 Pinched tube closed.

8 Hold syringe upright.
9 Poured the determined amount of formula in to syringe.
10 Released the tube and left feeding begin to
flow.
11 Administer feeding flow by gravity slowly.
12 Flushed tube with 3-5 cc of tap water to clear it of formula .
13 - Clamped the tube
- Retuned equipment
- Document procedure
Final assessment / Total :

Comments :

………………………………………………………………………………………………………

………………………………………………………………………………………………………
………………………………………………………………………………………………………

Evaluator Signature Student Signature

Date: Date:
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

PEDIATRIC NURSING

Skill Code A6
Performance Evaluation Checklist

Category A Skills Name: Care of baby under phototherapy

Procedure steps No

Independent

Supervised
Washed hands 1.

The lamp should be 5-8cm over incubator 2.

Shield baby eye & genitalia 3.

Oily lubricants should be avoided to prevent tanning /burning 4.

Change position frequently ( every tow hour). 5.

Continue feeding to prevent dehydration . 6.

Increased fluid intake to prevent dehydration. 7.

Weight infant daily to detect any sign of dehydration 8.

Check vital signs (mainly temperature) 9.

Billirubin level be checked every 6 to 12 hours after photo therapy start then 10.
every day .

Washed hands &document 11.

Comments :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………

Evaluator Signature Student Signature

Date: Date:
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

PEDIATRIC NURSING

Skill Code C
Performance Evaluation Checklist

Category C1 Skills Name: care of incubator

Procedure steps No

Independent
Performed hand hygiene and wear gloves . 1.
Replenish humidity tank up to the black line with distilled H2O 2.
Wiped down the inside wall with disinfectant according to hospital policy while 3.
changing sheet and having infant on scale.
Wiped the plastic cover mattress with disinfectant 4.
Clean the mattresses with warm water using a clean towel or paper tissues then dry it. 5.
Wiped the outside wall every 8 h with disinfectant. 6.
Changed bed sheet daily and whenever needed. 7.
Monitored O2 flow rate and concentration as prescribed. 8.
Check that temperature is set between 28-35C. 9.
Checked that humidity is between 55-65%. 10.
Washed hands & document 11.
Comments :
……………………………………………………………………………………………………
……………………………………………………………………………………………………
………………………………………………………………………………………………
Evaluator Signature Student Signature
Date: Date:
 PEDIATRIC NURSING

Skill Code A7
Performance Evaluation Checklist

Category A Skills Name: MEDICATION ADMINSTERATIN

Independent

Supervised

Assisted

Marginal

Dependent
STEPS

* Prepare equipment
* Wash hands
* Identify the patient
* Introduce yourself
* Explain the procedure

10 rights of giving medication

Dropper.
*Wash hands.
*Hold the infant in the cradle position and stabilize the head against your body.
Hold infant's arm with your free arm. Press on the infant's chin to open mouth.
Squirt the medication to the back and side of the mouth in small amount
Syringe.
Hold the infant or toddler in the cradle position, supporting the head and holding the
arms. place the syringe to the back and side of the mouth and give the medication
slowly , allowing the child to swallow
Nipple.
*Hold the infant in the cradle position, squirting the medication from the syringe
into the nipple pour the medication from a cup into the nipple.
* Allow the infant to suck the medication from the nipple
* Follow the medication with 2-3 ml of water
Medicine cup.
*A cup can be used for the older infant , toddler , preschooler , school age child
& adolescent
* For the younger patient , a patient , apparent or child may hold the cup
* Stay with the child until the entire dose is swallowed
* A spoon is an effective alternative to the medicine cup.
* Disguise a disagreeable taste in a small amount of food like applesauce
* Syrup is also good for mixing medications that do not dissolve in water
* Dilute alcohol –based elixirs with water before administering
 Capsules
Older children may enjoy swallowing a capsule
* Place the capsule on the back of the tongue and have them swallow a lot of
fluid.
* Stay with child until all the medicine is swallowed
* Some capsules may also be opened & the contents sprinkled on a spoonful of
food.
* Check with the pharmacist to see which capsules can be opened
Nose drops
*Hold the infant in the cradle position, stabilizing the head with your arm , and
tilting it back slightly
* Squeeze the drops into each nostril as you try to comfort & hold the
infant in this position for at least 1 minute
* Place a toddler's head over a pillow
* Squeeze the drops into each nostril
* The school age child and adolescent may give themselves their own
medication since they can sniff the medication into the nasal passage
Ear drops
* Position infants & toddlers on their sides.
*The pinna of the ear is to be pulled down and back.
* Instill warm drops into the external canal and gently massage the area anterior
to the ear
* For children over 3 years , pull the pinna upwards and back
* After instillation, the child should maintain the position for 5-10 minutes.
A cotton pledged placed into the ear canal can prevent the medication from
leaking out , however , it must be loose enough to allow discharge to drain from
the ear canal
Eye drops or ointment
* Place the child in a supine position
* Restraining him or her as necessary to safely instil the medication
* Pull the lower eyelid down and out to form cup.
* Drop the solution into cup
* The medicine will enter the conjunctiva
* Close the eye gently and attempt to keep it closed for a few moments
* Ointments are applied along the inner canthus in outward direction
Avoid touching the tip of the dropper or ointment tube to the body part
Rectal medications
* Place the child in aside –lying or prone position.
* Lubricate the suppository with a water soluble gel
* Using a finger cot , gently insert the suppository into the rectum
* Do not insert your finger more than 1/2 inch.
* The buttocks should be held tightly together for 5-10 minutes.
Co
mments :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
…………………………………………………………………………………………………
Evaluator Signature Student Signature
Date: Date:
 Administering Intramuscular Injection(Vastus lateralis) Checklist

Steps

Independent

Supervised
No

Marginal
Assisted
1 Greet the child`s parent or caregiver & introduce your self
2 Check physician's order and identify patient.
3 Confirm the patient , medication and dosage .
4 Explain procedure to the parent or caregiver (the purpose of
medication and the site of injection).
5 Wash hands and wear the gloves.
6 Prepare medication from ampoule/vial.
7 Keep needle outside of child’s visual field
Secure child before giving IM injection.

7 Position patient:
• put the child on a supine position .
8 Chose the outer middle third of the thigh and clean it .

9
Inject the medication:
a. Give 1 ml or less to infants. And 2 ml or less to
Toddlers.
b. Grasp and pinch the area surrounding the injection site about 10
seconds.
c. Hold the syringe between the thumb and forefinger in a pen- and
inject at a 90 degree angle
d. Aspirate and pulling the medication .

10 Withdraw the needle slowly apply gentle pressure at the site

11 Discard the needle and syringe into appropriate receptacle.
12 Remove gloves, wash hands.
Record procedure , name , dose, site , time and signature

Comments :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………
Evaluator Signature Student Signature
Date: Date:

PEDIATRIC NURSING
Skill Code A8
Performance Evaluation Checklist

Category A Skills Name: HEEL STICK (NEONATAL)

 PROCEDURE

Dependent
Independe

Supervise

Marginal
Assisted
nt

d
Supplies:
 Gloves

 Approved commercial heel warmer

 Approved skin disinfectant

 Sterile saline swabs

 Appropriate-size lancet device with retractable blade

 Blood collection tube

 Appropriate laboratory requisition forms

 Specimen labels containing two neonate identifiers

 2 × 2-inch (5 × 5-cm) gauze pads

 Cotton ball or cotton roll with tape, or bandage

 Swaddling blanket (optional)

 Sucrose solution for pain reduction

 Pacifier for use with sucrose solution

1. Performed hand hygiene before patient contact.  

2. Verified the correct neonate using two identifiers.  

3. Ascertained a history of previous similar procedures.

 

4. Assessed and documented the neonate’s heel skin integrity before  

 the procedure.

5. Verified the practitioner’s order.  

6. Selected the appropriate site on the lateral or medial aspect of the

neonate’s heel.  

7. Activated an approved commercial heel warmer per the

manufacturer’s instructions. Applied the warmer to the selected  
area for 3 to 5 minutes, or as recommended by the manufacturer.

8. Cleansed the area with an approved disinfectant for neonates.

Allowed skin to air dry, then wiped the area with a sterile saline  
swab.

9. Immobilized the neonate using developmentally appropriate

containment. Used non pharmacologic techniques as appropriate  
for pain reduction.

10. Held the neonate supine with foot in a dependent position.  

11. Using the lancet, punctured the skin on the most medial or lateral
portion of the heel.  

12. Wiped away the first drop of blood using a sterile 2 × 2-inch (5 ×
5-cm) gauze pad.  

13. Obtained the blood sample from the puncture site by allowing
another drop of blood to form on the skin and dropping the blood  
freely into the appropriate blood-collection tube.

14. After collecting the sample, applied gentle pressure to the puncture
site with a sterile 2 × 2-inch gauze pad until bleeding stopped.  
Included the family in this step, if desired.

15. Removed the capillary collection piece of the collection tube, and
capped the specimen.  

16. Labeled specimens at the bedside, and completed laboratory

paperwork per the organization’s practice. Sent specimens to the  
laboratory as soon as possible to avoid clotting in specimen.
 17. Covered the puncture site per the organization’s practice when
hemostasis was achieved.  

18. Discarded the lancet in a sharps container at the neonate’s bedside.  

19. Assessed, treated, and reassessed pain.  

20. Discarded supplies, removed gloves, and performed hand hygiene.  

21. Documented the procedure in the neonate’s record.  

Comments :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………

Evaluator Signature Student Signature

Date: Date:
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

PEDIATRIC NURSING

Skill Code Performance Evaluation Checklist

A9 Skills Name: URINE SAMPLE COLLECTION
Category A

Independen

Supervised

Dependent
Marginal
Assisted
Procedure

t
Supplies:
 Bladder catheterization kit

 Gloves

 Sterile gloves

 Closed drainage system for indwelling catheter, if needed

 If bladder catheterization kit is not available, sterile urine

catheter of appropriate size (3.5, 5, 6.5, or 8 Fr); sterile towels
for draping

 Water-soluble lubricant

 Antiseptic solution to cleanse skin

 Sterile container for urine culture specimen; appropriate

container for urinalysis or other laboratory studies

 Labels for specimen container

Performed hand hygiene before neonate contact.  

Verified the correct neonate using two identifiers per institution

 
policy.
Verified practitioner’s order for procedure along with ordered
laboratory tests to make sure necessary laboratory containers were  
available.
Verified the neonate’s gestational age and weight to select correct
 
catheter size and appropriate insertion length.
Obtained additional assistance from another health care provider to
provide oral sucrose via a pacifier (as appropriate) and positioning  
support.
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

Performed hand hygiene.  

Swaddled neonate’s chest and arms (or provided other

 
developmental positioning).
Placed the neonate supine in frog-leg position, removed diaper, and
 
cleansed surrounding area with mild soap and water.
Opened all necessary supplies in a sterile manner on a sterile field.
Ensured lubricant was on field and was easily accessible to lubricate  
tip of catheter.
Performed hand hygiene and donned sterile gloves. Prepared
equipment on sterile field, including lubricating tip of appropriate-  
size urinary catheter.
With help from assistant, draped sterile towel(s) across the neonate’s
 
lower abdomen and legs.
Female:
 Using nondominant hand, grasped the labia and carefully
retracted them to reveal urinary meatus, rendering
nondominant hand unsterile.
 Cleansed area from urinary meatus to vaginal opening with
downward strokes. Obtained new antiseptic solution
applicator with each new downward stroke. Repeated
cleansing three times.
 Identified the urinary meatus.
 
Male:
 Using nondominant hand, grasped the penis and carefully
and gently retracted foreskin to reveal urinary meatus,
rendering nondominant hand unsterile.
 Cleansed tip of penis with antiseptic solution using circular
motion starting from meatus and ending at proximal penile
shaft. Performed three times, using new antiseptic solution
applicator with each cleansing.

Maintaining sterile technique, inserted lubricated catheter into

urethra to predetermined length or just until urine was observed,  
whichever occurred first.
If insertion to recommended length did not yield urine, left catheter
 
in place and waited for urine to appear.
Collected required urine sample quantity, noticing color and clarity
 
of urine.
Remove the catheter carefully.  
 Ministry of Education
Taif university
Faculty of Applied Medical Sciences
Nursing Department

During procedure, monitored the neonate for tolerance to it.  

Cleansed area with mild soap and water to remove skin antiseptic
 
and lubricant.
Diapered and repositioned neonate.  

Assessed, treated, and reassessed pain according to institution

 
standard.
Discarded supplies, removed gloves, and performed hand hygiene.  

Documented the procedure in the neonate’s record.  

Comments :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
……………………………………………………………………………
Evaluator Signature Student Signature
Date: Date:
Faculty of Applied Medical Sciences
Nursing Department

STEPS

Independent

Supervised

Marginal
Assisted
1. Equipment’s:
Suction machine as needed, Gown or blanket
Container or Tissue, Oral care kit , Water
2. CPT in Children
1. Introduce yourself and explain procedure to the parent or care giver
2. Perform hand washing
3. Position child in an upright position with his back towards you.
4. Keep the infant or child covered with a gown or blanket.
5. Follow the previous techniques of chest physiotherapy (percussion, vibration,
coughing and deep breathing exercise, postural drainage, positive expiratory
pressure mask and flutter). Bronchial drainage positions for the main segments
of all lobes.
6. After percussion and vibration, have the child set up, take a deep breath, and
cough up out the mucus into a container or tissue.
7. If child is intubated or unable to generate an effective cough, perform suctioning
as indicated.
8. Reposition child in alternate position and repeat percussion/vibration/cough
therapy. Modification may be necessary based on child’s tolerance and
condition.
9. Allow child to rest if needed between positions.
10. Upon completion of therapy assess child’s respiratory status.
11. Return child to position of comfort, with side rails up.
12. Assist child to brush teeth or rinse out mouth as needed.
13. Return equipment to appropriate area.
14. Perform hand washing
15. Reevaluates patient respiratory status and relieve of dyspnea. .
CPT in Infant/Neonate
1. Check chart for orders , wash hand
2. Ascultate lungs before and after procedure.
3. Perform procedure prior to feeding and oral medication.
4. Perform percussion and vibration in position best for particular premature
infants, depending on which part of lung is affected.
5. Monitor O2 saturation throughout procedure not to exceed 10 min .
6. Suction gently.
7. Place in position of comfort.
8. Return equipment.
9. Wash hands.
3. Documentation:
-Findings from respiratory assessment of child before and after procedure.
-Adjunctive treatments given.
- Education provided to parent.
-Child’s response to therapy.
Faculty of Applied Medical Sciences
Nursing Department

Skill Code B4 Category B Course Title: PEDIATRIC NURSING

Skills Name: Performing Chest Physiotherapy