COLLEGE OF NURSING
SKILLS LABORATORY
PERFORMANCE EVALUATION TOOL
NCM 109 – CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS
(ACUTE AND CHRONIC)
PROCEDURE:
WOUND CARE
NAME OF STUDENT :______________________________________ Score:
Block :______ Date:______________
DIRECTIONS:
● The evaluation tool will be discussed by the clinical instructor/s.
● During the discussion, the instructor/s may demonstrate the procedures or may use video viewing for students’
orientation.
● The students should be given sufficient time to prepare for the return demonstration.
● The students will do the return demonstration based on the checklist given.
● The following rating scale shall be used in grading student’s performance:
DONE- able to perform
Perform the procedure safely and accurately in a very consistent and independent manner without
supportive assistance from the instructors.
Perform a difficult action quickly and skillfully
Spends minimal time on task
Focuses on the client while giving care
NOT DONE - unable to perform
Unable to perform the procedure even under close supervision of guidance
Require continuous, supportive, and directive cues
Takes a longer time to complete the procedure.
Performs in an unskilled manner
● At the end of each laboratory session, the instructor/s will give remarks based on the student’s performance per
the procedures indicated.
PROCEDURE DONE NOT DONE
1. Informs the patient and explains the procedure
2. Performs hand hygiene.
3. Prepares needed equipment: sterile gloves, clean gloves, sterile
dressing tray, betadine, 4x4 gauze, micropore, Montgomery ties
or straps or binder as needed, hand sterilizer, antiseptic ointment
as ordered, surgical scissors.
4. Positions the client comfortably and drapes properly to expose
wound site. Instructs client not to touch wound or sterile
supplies.
5. Places disposable bag within reach of work area. Folds top of bag
to make cuff. Puts on clean disposable gloves.
6. Removes tape pulling parallel to skin, toward dressing. Removes
remaining adhesive from skin.
7. Removes dressings with gloved hand. Keeps soiled undersurface
from client’s sight.
GEN-FM-019 Rev 2 Effective Date 24 July 2023
COLLEGE OF NURSING
8. Observes appearance of drainage on dressing. If drains are
present, slowly and carefully removes dressings one layer at a
time. Assesses wound for odor.
9. Describes the appearance of the wound and any indicators of
wound healing to the client.
10. Disposes of soiled dressings in disposable bag. Removes gloves
by pulling them inside out. Disposes of in bag and applies hand
sterilizer.
11. Puts on sterile gloves.
12. Inspects wound for appearance, drains, exudates, and integrity.
Gently palpates wound edges for drainage, bogginess, or client
report of increased pain. Measures wound size such as length,
width, and depth (if indicated). Avoids contact with contaminated
material.
13. Cleanses wound: A. Uses separate swab for each cleansing
stroke.
B. Cleanses from least contaminated area to most contaminated
part (inner to outer).
14. Uses dry gauze to blot in same manner as Step 13 to dry wound.
15. Applies antiseptic ointment if ordered, using same technique as
for cleansing.
16. Applies dry sterile dressings to incision or wound site:
A. Applies loose woven gauze as contact layer.
B. Cuts 4x4 gauze flat to fit around drain if present or uses precut
split drain flat.
C. Applies additional layers of gauze as needed. D. Applies
thicker woven pad (surgi-pad, abdominal dressing).
17. Secures dressing with tape, Montgomery ties or straps (applies
perpendicular to the wound), or binder as needed.
18. Removes gloves and disposes of all supplies.
19. Assists client back to comfortable position.
20. Performs hand hygiene.
TOTAL
***nothing follows***
REMARKS:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
GEN-FM-019 Rev 2 Effective Date 24 July 2023
COLLEGE OF NURSING
EXPECTED LEVEL OF PERFORMANCE:
9 to 11 items done: PASS
8 items below done: Repeat the procedure to PASS
Student’s Signature:_______________
Date:__________
Instructor’ Signature:________________
Date:__________
GEN-FM-019 Rev 2 Effective Date 24 July 2023
