Grade

UNIVERSITY OF PERPETUAL HELP-GMA

Brgy. San Gabriel, General Mariano Alvarez, Cavite
PERFORMANCE CHECKLIST IN ORAL CARE, HAIR SHAMPOOING, BED BATH
AND BACK MASSAGE

Name:_______________________________ Date:___________________
Yr. & Sec ____________________________ Group # ________________

ORAL HYGIENE ( INDEPENDENT)

3 2 1 Remarks
1. Assess:
 The extent of the client’s self-care abilities.
 The client’s usual mouth care practices.
 Inspect lips, gums, oral mucosa, and tongue for deviations from normal.
 For presence of oral problems such as tooth caries, halitosis,
gingivitis, or loose or broken teeth.
2. Assemble equipment needed for Oral care, shampooing and bed bath :
 1 Face towel, 2 bath towels, 1 linen, 1 bath blanket
 2 pairs disposable gloves, tissue, gauze to cover tongue depressors,
 6 tongue depressors, micropore tape, lip moisturizer
 Curved basin (emesis basin), hospital gown
 Toothbrush, toothpaste, mouthwash, container for mouthwash
 Tepid water, bar soap/liquid soap, soap dish
 1 sachet Shampoo w/conditioner, comb
 M clip/safety pin
 2 basins, 1 water dipper/pitcher, small pail
3. Introduce yourself and verify the client’s identity. Explain to the client
what you are going to do, why it is necessary, and how the client can
cooperate.
4. Offer a urinal/bedpan to prevent interruptions in the performance of
procedure..
5. Perform hand hygiene.
6. Provide for client privacy by drawing the curtains or closing the door.
7. Adjust bed to a comfortable working height to prevent back strain.
8.Put down siderails and remove unnecessary articles on the bed.
9. Put patient in fowler’s position.
10. Place a towel on the patient’s chest.
11. Put on gloves to reduce transmission of microorganisms and exposure
to body fluids.
12. Moisten the bristles of the toothbrush with tepid water, and apply the
dentifrice to the toothbrush.
13. Place or hold the curved basin under the client’s chin, fitting the small
curve around chin or neck.
14. Hand the toothbrush to the client, or brush the client’s teeth as follows:
 Hold the brush against the teeth with the bristles at a 45-degree angle.
The tips of the outer bristles should rest against and penetrate under the
gingival sulcus.
 Move the bristles up and down, using a vibrating or jiggling motion
from the sulcus to the crowns of the teeth.
 Repeat until all outer and inner surfaces of the teeth and sulci of the
gums are cleaned.
Clean the biting surfaces by moving the brush back and forth over them
in short strokes. Brush the tongue gently with the toothbrush.
15. Give a cup of water or mouthwash to rinse mouth vigorously. Then ask
the client to spit the water and excess dentifrice into the basin.
16. Repeat the preceding steps until the mouth is free of dentifrice and food
particles.
17. Remove the curved basin and help the client wipe mouth.
18. Document assessment of the teeth, tongue, gums, and oral mucosa.

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 2 1 0 Remarks
ORAL HYGIENE (Dependent)
1. From a supine position, place the patient on his side with his head over
the edge of the pillow to prevent aspiration.
2. Put pillow behind client’s back to prevent patient from rolling supine.
3. Place a towel on his chest with kidney basin touching his cheeks.
4. Put a towel under the kidney basin to prevent bed from getting soiled.
5. Use a padded tongue depressor to open the mouth of a patient .
6. Use a solution such as bactidol and water to cleanse mouth and lips.
Moisten the gauze, but do not make it so wet. Clean also the tongue.
7. Apply a lip moisturizer to maintain skin integrity of the lips.
8. Dispose any contaminated items in the appropriate receptacle.
HAIR SHAMPOOING
1. Unfasten the gown straps at the nape and behind patient’s back .
2. Drape towel on the patient's shoulder and secure it with safety pin. This
is to prepare the patient for hair shampooing.
3. Place patient in supine position.
4. Change gloves and proceed to the next procedure.
5. Position patient diagonally across the bed to make patient’s hair more
accessible when shampooing. Lift and position first the head part, then the
upper trunk, lower trunk and the legs.
6. Remove patient’s head pillow and place a protective device under the
head such as a kelly pad or improvised trough.At the end of it, put a kick
bucket.
7. Gently put cottonballs on the patient's ears and place a towel on the
forehead/eyes to avoid water & shampoo from getting into the ears and into
the eyes .
8. Brush/comb the hair first to stimulate the scalp and undo tangled
hair.Work from the ends toward the scalp to remove tangles easily.
9. Dilute shampoo by mixing it with water.
10. Wet the hair thoroughly then gently apply the mixed shampoo;
Massage the scalp well.
11. Rinse the hair thoroughly; gently squeeze the hair.
12. Put a towel over the head pillow and position it near the patient.
13. Cover the hair with the towel wrapped on the shoulders and remove
kelly pad..
14. Put pillow under head of patient.
15.Dry patient's hair and comb hair according to patient's preference.
16. Allow the patient to rest.
REMOVING AN IV GOWN WITH SOLID SLEEVES
1. With the bath blanket covering the patient, remove the gown from the
arm without IV access. Slide gown to the IV access side. This allows the
gown to be removed without pulling on the client’s other arm.
2. Determine if client can tolerate a brief interruption in the IV infusion.
Some infusions can’t be interrupted without endangering the client.
3. If IV can be shut off briefly or slowed, clamp the IV tubing. If the IV is
regulated by a pump, shut off the IV pump and remove the tubing from the
pump. This frees the IV line and botle to be passed through the sleeve of the
gown. Clamping the tubing prevents free flow of the IV fluids into the
client. If the IV can’t be slowed or clamped, proceed to the next step.
4. Remove the IV bottle from the IV stand. This facilitates changing of the
gown. DO NOT HOLD IV BOTTLE BELOW THE IV ACCESS SITE TO
PREVENT BLOOD BACKFLOW INTO THE IV TUBING.
5. While holding the IV bottle in the dominant hand, use the other hand to
slide the gown off the arm with IV access, over the IV tubing, over the IV
bottle, and onto the non-dominant hand. This allows removal of the gown
without disrupting IV access.
6. Take IV bottle in the dominant hand and remove the client’s gown from
the nondominant hand. Dispose of the gown appropriately.
BEDBATH
1. Place bath blanket over top sheet. Then gently pull down top sheet. This
is to protect patient from chills.
2. Fold the linen if to be used again and drape them over the back of the
chair.
3. Fill washbasin two-thirds full. Ask client to check water temperature to
prevent accidental burns or chills.

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 2 1 0 Remarks
4. Water should be changed when soap film develops or water becomes
soiled.
Wash the face.
1. Make a bath mitt with the washcloth. This prevents end of washcloth
from dragging across skin. This promotes friction during bath.
2. Wash the client’s eyes with water only, and dry them well. Use a
separate corner of the washcloth for each eye. Wipe from the inner to the
outer canthus.
3. Ask whether the client wants soap used on her face. Clean face using
figure of 8 technique.
4. Using one side of the mitt, clean ear from inner to outer in circular
motion . Then clean neck with one sweeping stroke. Do the same on the
other ear. Clean again the neck in one sweeping stroke.
5. Pat dry the ears and neck. Patting the areas dry reduces skin irritation &
drying.
Wash the arms and hands.
1. Place towel under the near arm. Bathe, rinse and dry the arm and axilla
using four sections of the mitt.
2. Place patient's hand in bath basin. Let it soak while washing and rinsing
the arm.
3. Start washing from the posterior part of arm to sides, then anterior going
to the axilla in long firm strokes. Strokes are directed from distal to
proximal to promotes venous return.
4. With your gloved hand clean and wash hands. Be sure to clean the nails
and in between fingers. Get water using the dipper and pour over the hands.
5. Dry patient’s' hands.
Wash the legs and feet.
1. Place towel under the near leg. Put a towel also under the basin.
2. Flex the knee and soak the foot in the basin to loosen dirt.
3. Wash, rinse and dry the near leg. Start from lower to upper leg paying
attention to the groin. Use 4 sections of the mitt.
4. Wash the feet, clean the toenails and in between toes. Pour water from
the dipper onto the foot. Rinse and dry.
5. Put siderails up and go to the other side of the bed.
6. Do the same procedure in the other arm and leg. Use a new towel for the
arm and leg. Use the old towel for the foot.
7. Put siderails up and go to other side of the bed.
6. Obtain fresh, warm bath water now or when necessary.
Wash the chest .
1. Put siderails down. Place a bath towel crosswise over chest and fold the
bath blanket down to the client’s pubic area.
2. For the male patient: Lift the bath towel off chest, and bathe chest and
abdomen with your mitted hand. Wash, rinse and dry using long, firm,
downward strokes. Rinse and dry well. Long strokes promote circulation.
3. For the female: In cleaning the breast part, start from the inner to outer in
circular motion, paying attention to underneath the breast. Start from
proximal to distal. Wash, rinse and pat dry.
Wash the abdomen.
1 Start from the inner to outer in circular motion paying particular to the
umbilicus.
2. Wash, rinse and dry.
Wash the back and then the perineum.
1. Assist the client into a prone or side-lying position facing away from
you. Place the bath towel lengthwise alongside the back and buttocks while
keeping the client covered with the bath blanket as much as possible.
2. Wash and dry the client’s back, moving from the shoulders to the
buttocks.
3. Assist the client to the supine position and determine whether the client
can wash the perineal area independently. If the client cannot do so, drape
the client and wash the area.
BACK RUB
1. Place patient in prone position.
1 Then do back rubbing:
2. Squeeze a small amount of lotion or oil into palm of hand to warm before
applying to patient. Cold lotion or oil can cause patient discomfort.

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 2 1 0 Remarks
3. To promote relaxation and stimulate circulation, begin with light to
medium effluerage at lower back and continue upward. Avoid the spine and
spinous process to prevent damage to internal structures.The whole hand is
use and firm, even pressure strokes are applied toward the heart to assist in
blood return. Lighter pressure is used when moving away from the heart.
4. Move hands up toward the base of the neck. Continue outward over the
trapezius muscles with circular motions over and around the shoulders,
upper arms, laterally over the latissimus dorsi to the upper gluteals. Use
slow rhythmic movements keeping hands in contact with skin at all times.
5. Continue using petrissage. Do pressing, squeezing, kneading and rolling
movement to enhance deep circulation. The C- shaped motions stimulate
the muscles and promote relaxation.
6. Do tapotement. Apply brisk, vigorous, rhythmic, percussive movements.
Palms, fingertips and knuckles are used to tap, cup and slap muscles. This
technique invigorates and stimulates tired muscles.
7. Finish treatment with effleurage. This gives a sense of completion.
8. Wipe any excess lotion or oil from skin with towel . This promotes and
maintains skin integrity.
9. Assist patient in supine position.
PUTTING AN IV GOWN WITH SOLID SLEEVES
1 With the bath blanket still covering the patient, help the client put on a
clean gown. With the IV bottle in the dominant hand, place the
nondominant hand through the sleeve of the clean gown, from distal end of
the sleeve toward the proximal end of the sleeve.
2. Place the IV bottle in the nondominant hand with the clean gown on it.
Use the dominant hand to slide the sleeve of the clean gown over the IV
bottle, down the IV tubing and over the client’s arm. This is to allow
placement of the clean gown without disrupting IV access.
3.Put back IV bottle on the IV stand. Reinsert the IV tubing into the IV
pump and open the clamp on the IV tubing to resume the infusion.
4. Slide the gown sleeve over the client’s free arm.
5. Fasten the clients gown in back. Straighten the bed clothes and cover the
patient with a new blanket.
6.Check the IV flow rate to ensure that it is still at the ordered rate. Check
the IV access site to ensure that the IV is still intact and patent. This ensures
proper infusion of IV fluids without injury to client.
7. Wash hands.
8. Document comfort measures done, client’s response, and mouth, hair
and skin assessment data.
9. The nurse may now proceed with bedmaking.
CI’s signature _______________________________________
Student’s Signature __________________________________
PERFORMANCE GRADING SYSTEM
GRADE CRITERIA
2  Performs/ recites procedure correctly, in sequence
1  Performs procedure incorrectly, partly recites the procedure in
sequence, no rationalization.
 Performs procedure incorrectly, without reciting the procedure, not in
sequence , no rationalization
0  Procedure neither performed nor mentioned.
Computation:
1. Grade each step of the procedure.
2. Sum up the grade.
3. Get the perfect score by multiplying 2 with the no. of steps in the procedure.
4. To get the percentage , divide the total grade to the perfect score, multiply by 60 then add 40.

90 and above Excellent

85.89 Very Satisfactory
80.84 Satisfactory
75-79 Fair
74 and below Needs Improvement
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