Microsoft Word - Donning_A_Gown_DC

DIRECT CARE STAFF COMPETENCY CHECKLIST

Applying Non-Sterile Gloves

Assistance with Infection Control

Cough/Sneeze Etiquette

Donning a Gown

Oral Care

Performing Fingerstick Blood Glucose Specimen

Personal Protective Equipment

Positioning - Shortness of Breath

ROM – Hand and Wrist

ROM - Hip

ROM - Knee

ROM - Shoulder

Side-Lying - Lateral Position

This work is licensed under the Creative Commons Attribution-NoDerivatives 4.0 International License. To view

a copy of this license, visit http://creativecommons.org/licenses/by-nd/4.0/.

_____________________________________________________________________________________________

This policy and procedure is not intended to replace the informed judgment of individual physicians, nurses or

other clinicians nor is it intended as a statement of prevailing community standards or minimum standards of

practice. It is a suggested method and technique for achieving optimal health care, not a minimum standard

below which residents necessarily would be placed at risk.

DIRECTCARESTAFFCOMPETENCYCHECKLIST

ApplyingNon‐SterileGloves

AREAOBSERVED MET NOT

MET

COMMENTS

Gathernecessarysupplies

Washhandsanddrythoroughly.

Selectappropriatesizedgloves

Removeapairofglovesfromtheglovebox

Examineglovesforanydefects/damage

Pullglovesoncarefully

Ifglovetearsorbecomespunctured,removeglove

andbeginagainwithanewglove

Interlacefingerstoremovewrinkles,airpockets

andachieveacomfortablefit

Performresidentcaretasks

Removegloveswithoutcontaminatingthehands

Disposeofglovesperpolicy

Washhandsandexitroom

NAME______________________________________________________DATE______________

EVALUATOR_________________________________________________DATE______________

This work is licensed under the Creative Commons Attribution-NoDerivatives 4.0 International License. To view

a copy of this license, visit http://creativecommons.org/licenses/by-nd/4.0/.

_____________________________________________________________________________________________

This policy and procedure is not intended to replace the informed judgment of individual physicians, nurses or

other clinicians nor is it intended as a statement of prevailing community standards or minimum standards of

practice. It is a suggested method and technique for achieving optimal health care, not a minimum standard

below which residents necessarily would be placed at risk.

Clear Form

DIRECTCARESTAFFCOMPETENCYCHECKLIST

AssistancewithInfectionControl

AREAOBSERVED MET NOT

MET

COMMENTS

Usesconsistentandappropriatehandwashing

procedures

Consistentandappropriateapplication,removal

anddisposalofgloves

Assistsresidentsinapplyingprinciplesofinfection

controlandpreventionduringallactivities

Appliesstandardprecautionsappropriately

Preparessoiledlinenforlaundryinamannerto

preventpersonalcontamination

Identifiescommoninfectiousdiseases

Understandsandappliesprinciplestopreventthe

spreadofinfection