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Student's Name: ____________________

Grade (circle one):

P = achieved 3 or above in all categories

F = achieved 2 or below in one or more categories

The following scale is utilized:

ACTION	S	G	SA	U	F
Gather the supplies	5	4	3	2	1
Place the supplies on the patient's overbed table	5	4	3	2	1
Explain the procedure to the patient	5	4	3	2	1
Wash and dry hands carefully	5	4	3	2	1
Draw the curtain around the bed for privacy	5	4	3	2	1
Move the patient's overbed table to the head of one side of the bed	5	4	3	2	1
Go to and stand as close as possible at the head of the side of the bed you moved the patient's overbed table to, in line with the patient's waistline	5	4	3	2	1
Lock the wheels of the bed	5	4	3	2	1
Raise the bed to waist level and lower the head of the bed to a horizontal position or as low as the patient can tolerate	5	4	3	2	1
Lower the siderail closest to you	5	4	3	2	1
Assist the patient in assuming a comfortable position in which his/her abdominal dressing can be readily exposed	5	4	3	2	1
Make a cuff on a moisture proof bag	5	4	3	2	1
Tape the moisture proof bag to the patient's overbed table	5	4	3	2	1
Don a gown, face mask, and protective eye gear, if necessary	5	4	3	2	1
Spread a bath blanket over the top sheet and the patient	5	4	3	2	1
Have the patient grasp the top edge of the bath blanket or tuck the bath blanket under his/her shoulders	5	4	3	2	1
Pull the top sheet down and out from under the patient's abdominal dressing	5	4	3	2	1
Pull the bath blanket down below the patient's abdominal dressing	5	4	3	2	1
Pull the patient's gown up above his/her abdominal dressing	5	4	3	2	1
Loosen all the adhesive tape on the soiled abdominal dressing by holding the patient's skin down and pulling all the tape gently, but firmly, toward his/her wound	5	4	3	2	1
Don clean gloves	5	4	3	2	1
Lift up and carefully remove the outer abdominal surgipad from the patient's wound with the underside facing away from his/her face	5	4	3	2	1
Assess the location, type (color, consistency), odor, and diameter of the wound drainage collected on the outer abdominal surgipad	5	4	3	2	1
Discard the outer abdominal surgipad in the moisture proof bag taped to the patient's overbed table without touching the outside of the bag	5	4	3	2	1
Lift up and carefully remove all the inner dressings from the patient's wound with the undersides facing away from his/her face	5	4	3	2	1
Assess the location, type (color, consistency), odor, and diameter of the wound drainage collected on all the inner dressings	5	4	3	2	1
Discard all the inner dressings in the moisture proof bag taped to the patient's overbed table without touching the outside of the bag	5	4	3	2	1
Remove the clean gloves	5	4	3	2	1
Discard the used clean gloves in the moisture proof bag taped to the patient's overbed table without touching the outside of the bag	5	4	3	2	1
Open a package containing sterile 4 x 4's, being sure not to touch the inside of the sterile package since you will be using it as a sterile field, and place it on the patient's overbed table	5	4	3	2	1
Open a package containing a sterile abdominal surgipad, being sure not to touch the inside of the sterile package since you will be using it as a sterile field, and place it on the patient's overbed table	5	4	3	2	1
Open a package containing sterile soft-wick drain sponges, being sure not to touch the inside of the sterile package since you will be using it as a sterile field, and place it on the patient's overbed table	5	4	3	2	1
Open a package containing sterile betadine swab sticks, being sure not to touch the inside of the sterile package since you will be using it as a sterile field, and place it on the patient's overbed table	5	4	3	2	1
Cut three strips of tape that are wide enough to cover the abdominal surgipad and several inches of skin on each side of the abdominal surgipad and adhere them so that they hang down from the patient's overbed table	5	4	3	2	1
Don sterile gloves	5	4	3	2	1
Swab down the patient's incision line from top to bottom with one betadine swab stick	5	4	3	2	1
Discard the used betadine swab stick in the moisture proof bag taped to the patient's overbed table without touching the outside of the bag	5	4	3	2	1
Swab down one side of the patient's incision line from top to bottom with a second betadine swab stick	5	4	3	2	1
Discard the used betadine swab stick in the moisture proof bag taped to the patient's overbed table without touching the outside of the bag	5	4	3	2	1
Swab down the other side of the patient's incision line from top to bottom with a third betadine swab stick	5	4	3	2	1
Discard the used betadine swab stick in the moisture proof bag taped to the patient's overbed table without touching the outside of the bag	5	4	3	2	1
Support and hold the patient's surgical drain erect with your left hand	5	4	3	2	1
Swab closely around the patient's surgical drain in a full circle with a betadine swab stick	5	4	3	2	1
Discard the used betadine swab stick in the moisture proof bag taped to the patient's overbed table without touching the outside of the bag	5	4	3	2	1
Swab further away from the patient's surgical drain in a full circle with a second betadine swab stick	5	4	3	2	1
Discard the used betadine swab stick in the moisture proof bag taped to the patient's overbed table without touching the outside of the bag	5	4	3	2	1
Swab even further away from the patient's surgical drain in a full circle with a third second betadine swab stick	5	4	3	2	1
Discard the used betadine swab stick in the moisture proof bag taped to the patient's overbed table without touching the outside of the bag	5	4	3	2	1
Place the soft-wick drain sponge around the patient's surgical drain site	5	4	3	2	1
Apply a 4 x 4 gauze sponge on top of the soft-wick drain sponge placed around the patient's surgical drain site	5	4	3	2	1
Place a 4 x 4 gauze sponge over the patient's incision line	5	4	3	2	1
Place an abdominal surgipad over the previously applied dressings	5	4	3	2	1
Remove the used sterile gloves	5	4	3	2	1
Discard the used sterile gloves in the moisture proof bag taped to the patient's overbed table without touching the outside of the bag	5	4	3	2	1
Secure the top part of the abdominal surgipad with tape	5	4	3	2	1
Secure the middle part of the abdominal surgipad with tape	5	4	3	2	1
Secure the bottom part of the abdominal surgipad with tape	5	4	3	2	1
Unfold the top linens over the patient	5	4	3	2	1
Lower the bed to the lowest level	5	4	3	2	1
Raise the siderail nearest you	5	4	3	2	1
Assure that the patient's call light is readily available	5	4	3	2	1
Wash and dry hands carefully	5	4	3	2	1
Document cleaning the abdominal wound and applying a dry sterile abdominal dressing per agency policy	5	4	3	2	1
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