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Procedure Checklist With Rating Form Donning and Removing Sterile Gloves

The document is a procedure checklist and rating form for donning and removing sterile gloves used at the School of Nursing of Centro Escolar University. It contains 19 criteria for properly donning and removing sterile gloves, including assessing the need for gloves, selecting the correct size and type, performing hand hygiene, opening the sterile packaging carefully, and putting on and removing the gloves without contamination. Students are rated on a scale of 5 to 1 for each criterion, with their total score converted to an equivalent numeric grade and interpretation. The form is used to evaluate students' technique and ensure patients' safety from potential infection.

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Rachel Villanueva
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231 views4 pages

Procedure Checklist With Rating Form Donning and Removing Sterile Gloves

The document is a procedure checklist and rating form for donning and removing sterile gloves used at the School of Nursing of Centro Escolar University. It contains 19 criteria for properly donning and removing sterile gloves, including assessing the need for gloves, selecting the correct size and type, performing hand hygiene, opening the sterile packaging carefully, and putting on and removing the gloves without contamination. Students are rated on a scale of 5 to 1 for each criterion, with their total score converted to an equivalent numeric grade and interpretation. The form is used to evaluate students' technique and ensure patients' safety from potential infection.

Uploaded by

Rachel Villanueva
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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CENTRO ESCOLAR UNIVERSITY

Manila * Makati * Malolos

SCHOOL OF NURSING

PROCEDURE CHECKLIST WITH RATING FORM


Donning and Removing Sterile Gloves
Name of Student Score

Year/Section/Group/Number

Rate the student's performance by checking the appropriate box using the following criteria:
5 - Excellent (Carries out procedures efficiently, systematically and independently/Personality trait is observed at all times)
4 - Very Satisfactory (Carries out procedures efficiently and systematically but requires minimal guidance and supervision/Personality trait is
observed at all times)
3 - Satisfactory (Carries out the procedures efficiently and systematically but requires moderate guidance and supervision/Personality trait is
observed at all times)
2 - Fair (Carries out the procedures efficiently and systematically but requires close guidance and supervision/Personality trait is observed at
all times)
1 - Poor (Carries out the procedures inefficiently, unsystematically even under close guidance and supervision/Personality trait is observed at
all times)
0 - Not done

Criteria 5 4 3 2 1 0
ASSESSMENT
1. Assess the situation to determine the necessity for sterile gloves. Consider
the type of procedure to be performed and consult institutional policy on the
use of sterile gloves.
2. Check the patient’s medical record for information about a possible latex
allergy. Question the patient about any history of allergy, including latex
allergy or sensitivity, and signs and symptoms that have occurred. If the
patient has a latex allergy, anticipate the need for latex-free gloves.
PLANNING
3. Select correct size and type of glove.
4. Select a clean, dry work surface above waist level.
5. Complete all priority care tasks before beginning procedure. Rationale:
Sterile field should be prepared as close as possible to time of use.
6. Check that the sterile glove package is dry and unopened. Also note
expiration date, making sure that the date is still valid. Rationale: Moisture
contaminates a sterile package. Expiration date indicates the period that the
package remains sterile.
IMPLEMENTATION
Donning Sterile Gloves
7. Perform hand hygiene and put on PPE, if indicated
8. Peel open the outer pack from the corners and lay it on the surface.
9. Open the inner glove wrapper exposing the cuffed gloves with palms facing
up.
10. Pick up the first glove by the cuff, touching only the inside portion of the
cuff.
11. While holding the cuff in one hand, slip your other hand into the glove.
(Pointing the glove towards the floor will keep the fingers open).
12. Pick up the second glove by sliding the fingers of the gloved hand under the
cuff of the second glove.
13. Put the second glove on the ungloved hand by maintaining a steady pull on
the cuff. Adjust the glove fingers until the gloves fit comfortably.
Removing
14. Using the dominant hand with gloves, grasp the other glove near the cuff end
and remove by inverting it, keeping the contaminated area on the inside.

Donning and Removing Sterile Gloves


Rev. September , 2018
Page 1 of 2
Continue to hold the glove.

Criteria 5 4 3 2 1 0
15. Slide fingers of hand without glove inside the remaining glove. Grasp glove
in the inside by turning inside out over hand and the other glove.
16. Discard glove in appropriate container and wash hands.
EVALUATION
17. Gloves are applied and removed without contamination.
18. Patient remains free of exposure to potential infection-causing
microorganisms.
19. Patient does not exhibit signs and symptoms of a latex-allergy response.

Total Score:

Comments/Suggestions:

Computation: Total Score divided by 19 (number of items) x 20 (factor) = _________________

*Total points shall be transmuted using the table for 100 pts. Passing cut-off point is 65.

Equivalent Numeric Grade: _______________

Interpretation: __________________________

Evaluator: Conforme:

Donning and Removing Sterile Gloves


Rev. September , 2018
Page 2 of 2
Clinical Instructor's Student’s Signature Date:
Printed Name & Signature

Donning and Removing Sterile Gloves


Rev. September , 2018
Page 3 of 2

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