Nursing Skills (NCM 100) and 4th Year Eval Tool

Pamantasan ng Lungsod ng Marikina
College of Nursing
Revised as of A.Y. : 2012-2013
Student's Performance Evaluation Tool

HEALTH ASSESSMENT
Skill: COMPREHENSIVE HEALTH HISTORY
Name of Student:_____________________________________ Date:___________________ Rating:_____________
Rate the students's performance by checking the appropriate box using the following criteria.
5 - Demonstrates produre properly, explains the correct rationale behind action. 1.00 (96-100) 2.25 (81-83)
4 - Demonstrates produre properly, rationale not thoroughly explained.
1.25 (93-95) 2.50 (78-80)
3 - Demonstrates produre properly, wrong rationale stated.
1.50 (90-92) 2.75 (76-77)
2 - Procedure not completely and accurately done, rationale not thoroughly explained.
1 - Procedure not completely and accurately done, wrong rationale stated. 1.75 3.00 (75)
(87-89)
0 - Procedure not done/not mentioned.
2.00 (84-86) 5.00 (below 75)
* The grade shall be computed: Score divided by total number of items, multiplied by 60, plus 40. Passing cut-off
score is 60%
CRITERIA 5 4 3 2 1 0
ATTITUDE 10% TOTAL POINTS:
1 Reports on time
2 Wears complete uniform
3 Neat and well groomed
4 Observes proper decorum
5 Acknowledges criticism/suggestion openly
6 Shows mastery of the activity
Total:
KNOWLEDGE 10% TOTAL POINTS:
1 States the objective/purpose of the activity
2 Uses of the appropriate terms
3 States steps of the procedure in correct order
4 Explain rationale of every step
Total:
PROCEDURE 60% TOTAL POINTS:
1 Read the patient's chart
2 Wash hands and observe appropriate infection control procedures
3 Greet and identify the client.
4 Introduce yourself
5 Explain plan and procedure
6 Provide privacy for the client.
7 Assess the environment, resources and the client's medical condition on
how to systematically complete the procedure.
8 IDENTIFYING DATA: Demographic Information
a. Name
b. Age
c. Gender
d. Marital Status
e. Address
f. Date of birth
g. Religion
h. Occupation
i. Type of health plan
9 SOURCE AND RELIABILITY OF HISTORY
10 CHIEF COMPLAINT
11 Client's perception of their health status
12 HISTORY OF PRESENT ILLNESS
a. Onset of th eproblem
b. Setting in which it has developed
c. Manifestation
d. Treatment
13 Principal symptom
a. Location
b. Quality
c. Quantity or Severity
d. Timing (Onset, Duration and Frequency)
e. Setting in which it occur
f. Aggravating factor and relieving factors
g. Associated manifestations
14 Medications (Prescription, over-the-counter, herbal preparations)
a. Name
b. Dose
c. Route
d. Action
e. Frequency
15 Allergies (Drug, Food, Insects &Environmental factors)
a. Name of the allergen
b. Type of reaction
c. Remedy taken
16 Cigarette or Tobacco Use
a. Type
b. Quantity
c. Frequency
17 Alcohol and Drug Use
a. Type
b. Quantity
c. Frequency
18 PAST HISTORY
a. Childhood Illness
b. Adullt Illness
(Medical, Surgical, Obstetric/Gynecologic and Psychiatric)
c. Health Maintenance (Immunization - Screening Tests)
19 FAMILY HISTORY
a. Acute & Chronic Illness
(Medical, Surgical, Obstetric/Gynecologic and Psychiatric)
b. Age, Cause, Health and Relation
20 PERSONAL AND SOCIAL HISTORY (A.D.L.)
a. Personal History (Personality, Interests, Sources of Support, coping style,
strengths, Fears, job history, Religion and Spiritual beliefs)
b. Exercise (Type & Frequency)
c. Diet (Usual Food Intake, Supplements & Frequency)
21 REVIEW OF SYSTEMS
a. General
b. Skin
c. Head, Eyes, Ears, Nose, Throat (HEENT)
d. Neck
e. Breasts
f. Respiratory
g. Cardiovascular
h. Gastrointestinal
i. Urinary
j. Genital (Male)
(Female)
k. Peripheral Vascular
l. Muskuloskeletal
m. Neurologic
n. Hematologic
o. Endocrine
p. Psychiatric
Total:
CRITERIA 100% SCORE TOTAL

ATTITUDE 10%
KNOWLEDGE 10%
SKILLS COMPETENCY 20%
PROCEDURE 60%
TOTAL SCORE
Evaluator's Comment/s:
Conforme: Evaluated by:
__________________________________ __________________________________
Student's Signature Clinical Instructor's Signature
College of Nursing

BSN Level:
Skill: MEDICAL HANDWASHING
Name of Student:_____________________________________ Date:___________________ Rating:_____________
4 - Demonstrates produre properly, rationale not thoroughly explained.
1.25 (93- 2.50 (78-80)
3 - Demonstrates produre properly, wrong rationale stated. 95)
2.75 (76-77)
2 - Procedure not completely and accurately done, rationale not thoroughly explained. 1.50 (90-92)
1 - Procedure not completely and accurately done, wrong rationale stated. 3.00 (75)
1.75
0 - Procedure not done/not mentioned. (87-89) 5.00
(below 75)
2.00 (84-86)
* The grade shall be computed: Score divided by total number of items, multiplied by 60, plus 40. Passing cut-off
score is 60%
1 Reports on time
Total:
Total:
SKILL COMPETENCY PREPARATION 20% TOTAL POINTS:
1 Checks for breaks/cuts in the skin
2 Removes all jewelry
3 Nails should be kept short
Total:
1 Roles sleeves above wrists
2 Stands in front of the sink, keeping the uniform and hands away from the sink
throughout the acitivity
3 Turns on the water and adjusts its flow and temperature

4 Wet hands thoroughly by holding them under the running water
5 Leaves the water running during the entire procedure
6 Applies soaps to the hands and wrists
A. if the soap is liquid, apply 2 to 4 ml
B. if is bar soap, granules or sheets, rub them firmly between hands
7 Washes hands and wrists for at least 15 seconds

Uses firm, rubbing, and circular movements to wash the palm, back, and wrists
8 of each hand, including the heel of the hand
9 Interlace the fingers and thumbs, and move the hands back and forth
10 Rubs the fingertips against the palm of the opposite hand
11 Rinses the hands starting from the wrists down to the fingers
12 Pats dry the hands and arms thoroughly from fingers to forearms
13 Turns off the faucet using a dry paper towel
14 Discards the paper towel in the appropriate container
Total:
CRITERIA 100% SCORE TOTAL

ATTITUDE 10%
KNOWLEDGE 10%
PROCEDURE 60%
TOTAL SCORE

__________________________________ _________________________________
College of Nursing

Concept: Acute Biological Crisis
Area: EMERGENCY ROOM
Name of Student:_______________________________ Date:___________________ Rating:__________
4 - Demonstrates produre properly, rationale not thoroughly explained. 1.25 (93-95) 2.50 (78-80)
1.50 2.75 (76-77)
2 - Procedure not completely and accurately done, rationale not thoroughly explained. (90-92)
3.00 (75)
1 - Procedure not completely and accurately done, wrong rationale stated. 1.75 (87-89)
* 0The
- Procedure not done/not
grade shall mentioned. Score divided by total number of items, multiplied by
be computed: 2.0060, plus 5.00
40. (below
Passing75)
cut-off score is 60% (84-86)
1 Reports on time

Total:
ASSESSMENT 20% TOTAL POINTS:
Assess different manifestations that are related to Acute Biological Crisis
through the different methods used in physical and appropriate data
1 gathering
2 Performs physical examinations correctly and with confidence
Identifies and differentiates between normal and abnormal findings in Acute
3 Biological Cases
Determines the significance of laboratory and diagnostic findings to the
4 emergent problems
Picks out critical and essential data in nursing history relevant to the current
5 situations
Total:
PLANNING 20% TOTAL POINTS:
Knowledge in setting goals and prioritization of patient's needs with Acute
1 Biologic Crisis in the emergency room
Identify changes in patient's needs and nursing problems as they occur and
2 make necessary adjustments in nursing measures
Total:
INTERVENTIONS 20% TOTAL POINTS:
Assess the capability needed by the client for selfmanagement in the
1 emergency room.
Ensures safety, comfort and privacy in rendering care of patients with acute
2 biological crisis.
3 Provides necessary curative measures.
Provides immediate restorative/rehabilitative measures during temporary
4 stay in the ER.
5 Utilizes available physical and professional resources.
6 Makes referrals to appropriate health professionals, as needed.
7 Shows commitment to the welfare of the client.
8 Implements the plan of care jointly with the client.
9 Performs nursing procedures/activities: 9.1 with ease and confidence
9.2 correctly
9.3 systematically
9.4 practices bioethical principles in care
9.5 provides after care
9.6 demonstrate situational flexibility and adaptability.
Total:
EVALUATION 20% TOTAL POINTS:

1 Evaluates plan of care of client using the outcome criteria and performs
appropriate documentation and recording of changes in the client's
evident status after the interventions.
2 Displays critical thinking in the analysis of the current management
being employed and modifications that has to be done as needed.
3 Discusses with the appropriate health team results of interventions
4 Accepts suggestions, constructive criticisms and employ appropriate
modifications in the plan of care.
Total:
Performance Checklist: 70% = ______________ = _____________
Requirements: 20% = ______________ = _____________
Pre and Pre Exam: 10% = ______________ = _____________
__________________________________ ___________________________
College of Nursing
INTRA-OPERATIVE CARE
Name of Student:___________________________________ Date:_________________Rating:__________
4 - Demonstrates produre properly, rationale not thoroughly explained. 1.25 (93- 2.50 (78-80)
2.75 (76-77)
2 - Procedure not completely and accurately done, rationale not thoroughly explained. 1.50 (90-92)
3.00 (75)
1 - Procedure not completely and accurately done, wrong rationale stated. 1.75
(87-89) 5.00 (below
* 0The
grade shall mentioned. Score divided by total number of items, multiplied by 60, plus75)
be computed: 40. Passing cut-
off score is 60% 2.00 (84-86)
1 Reports on time
Total:
TOTAL POINTS:
I. SAFE AND QUALITY NURSING CARE
1 Utilizes the nursing process in the care of OR client
a. Obtains comprehensive a client's information by checking complete
accomplishment of the operative checklist/client's chart.
b. Identifies priority needs of the client at the Operating Room.
c. Provides needed nursing interventions based on identified needs.
d. Monitors client's responses to surgery.
2 Promotes safety and comfort off patients inside the OR
3 Performs the function of the scrub nurse
a. Performs surgical scrub correctly
b. Wears sterile gowns and gloves aseptically
c. Performs surgical instruments, sponges, sutures and other supplies
in functional arrangement
d. Hands, instruments, sponges, sutures and other needed
materials according to surgeon's preference.
e. Performs surgical count accurately.
4 Performs functions of the circulating nurse
a. Anticipates the needs of the surgical team
b. Sets up the operating rom and needed equipment
c. Receives client for surgery/endorses client post-operatively
d. Assists in skin preparation and draping of client.
5 Administer medications and other health therapeutics safely.
II. MANAGEMENT OF RESOURCES AND ENVIRONMENT
1 Organizes work load to facilitate timely patient care.
2 Utilizes adequate and appropriate esources to support the OR team
3 Ensures functionally of OR resources.
4 Maintains a safe environment at the OR by observing the principles
of asepsis.
III. HEALTH EDUCATION
1 Implements appropriate health education activities to client based
on needs assessment
IV. LEGAL RESPONSIBILITIES
1 Adheres to legal and institutional protocols regarding informed
consent
V. ETHICO-MORAL RESPONSIBILITIES
1 Respects the rights of the OR client
2 Accepts responsibility and accountability for own decisions and
actions as an OR nurse
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT
1 Performs OR functions according to professional standards
2 Possesses positive attitude towards learning surgical and OR related
knowledge and skills.
VII. QUALITY IMPROVEMENT
1 Participates in quality improvement activities related to infection
control and successful OR operations
2 Identifies and reports variances in sterility and other OR activities
VIII. RESEARCH
1 Disseminates results of OR find related research finding to clinical
group and other members of the OR team as appropriate.
IX. RECORDS AND MANAGEMENT
1 Maintains accurate and updated documentation of patient care
2 Uses appropriate information mechanisms to facilitate
communication inside the OR and with other departments in the
hospital.
X. COLLABORATION AND TEAMWORK
1 Collaborates plan of care with other members of the health team.
Total:
CRITERIA SCORE TOTAL
ATTITUDE 10%
KNOWLEDGE 20%
TOTAL SCORE
__________________________________ ___________________________
College of Nursing

NEWBORN CARE
Name of Student:_______________________________ Date:_____________ Rating:_____________
1.00 (96-100) 2.25 (81-83)
5- Demonstrates produre properly, explains the correct rationale behind action.
1.25 2.50 (78-80)
4- Demonstrates produre properly, rationale not thoroughly explained. (93-95)
2.75 (76-77)
3- Demonstrates produre properly, wrong rationale stated. 1.50 (90-
92) 3.00 (75)
2- Procedure not completely and accurately done, rationale not thoroughly explained.
1.75 (87-89)
1- Procedure not completely and accurately done, wrong rationale stated. 5.00 (below 75)
*0 The
- Procedure 2.00 (84-86)
grade not done/not
shall mentioned. Score divided by total number of items, multiplied
be computed: by 60, plus 40.
Passing cut-off score is 60%
1 Reports on time
Total:
TOTAL POINTS:
1 Do hand hygiene and scrubbing
2 Organize all needed materials
3 Provide privacy
4 Assist the obstetrician/registered midwife in delivering the baby.
5 Glove hands
6 Place a drape on the mother's abdomen
7 Note the time of delivery
8 Rest the newborn baby on the mother's abdomen
9 Allow the mother to hold the baby while on the mother's abdomen
10 Use the first blanket to dry the baby. Careful not to wipe off the vernix
caseosa. Bathing is not done on the first 6 hours of life of the newborn.
11 Put on the bonnet.
12 Check the cord and wait for the pulsation to stop. DO NOT milk the cord
13 Do the rapid newborn assessment (1st minute APGAR score)
14 Clamp the cord 2cm away to the baby, then use kelly forcep to clamp
5cm away from the first.
15 Assess for the completionof blood vessel.
16 Employ early skin to skin contact of the baby and the mother.
17 Remove the 1st blanket and lay out the 2nd linen on the baby.
18 Perform the 2nd APGAR scoring
19 Assist the mother in early breastfeeding to get the colostrum
20 Administer IM injection 10 IU of oxytoccin to the mother's deltoid to
prevent uterine atony.
21 Apply erythromycin ointment from inner canthus to outer canthus of the
baby's eye. (crede's prophylaxix)
22 Render the following IM injection (vastus lateralis) to the baby
1. 0.5mg Aquamephyton or vitamin K
2. 0.5mg Hepatitis B vaccine
23 Do the rapid anthropologic measurements
24 Perform proper and complete documentation on the entire procedure.
Total:
ATTITUDE 10%
KNOWLEDGE 10%
PROCEDURE 60%
TOTAL SCORE
__________________________________ __________________________
College of Nursing

PRENATAL ASSESSMENT/LEOPOLD'S MANUEVER
Name of Student:_______________________________ Date:________________ Rating:________
1.00 (96-100) 2.25 (81-83)
1.25 (93- 2.50 (78-80)
4- Demonstrates produre properly, rationale not thoroughly explained. 95)
2.75 (76-77)
1.50 (90-92)
3- Demonstrates produre properly, wrong rationale stated. 3.00 (75)
1.75
2- Procedure not completely and accurately done, rationale not thoroughly explained. (87-89)
5.00 (below 75)
2.00 (84-86)
1- Procedure not completely and accurately done, wrong rationale stated.
0- Procedure not done/not mentioned.
* The grade shall be computed: Score divided by total number of items, multiplied by 60, plus 40.
1 Reports on time
Total:
PREPARATION TOTAL POINTS:
1 Wash hands before the procedure.
2 Explain the procedure to be done.
3 Instruct woman to empty her bladder first.
Total:
SKILLS PROPER TOTAL POINTS:
1 Place woman in dorsal recumbent position, supine with kness flexed to
relax abdominal muscles. Place a small pillow under the head for
comfort.
2 Drape properly to maintain privacy.
3 Assess the skin for integrity.
4 Warm hands by rubbing together. (Cold hands can stimulate uterine
contractions). Use the palm for palpation not the fingers.
5 First Manuever: Fundal Grip
Using both hands, feel for the fetal part lying in the fundus.
6 Get the fundic height.
7 Second Manuever: Umbilical Grip
One hand is used to steady the uterus on one side of the abdomen
while the other hand moves slightly on a circular motion from top to
the lower segment of the uterus to feel for the fetal back and small
fetal parts. Use gentle but deep pressure.
8 Get the Fetal Heart Tone (FHT)
9 Third Manuever: Pawlick's Grip
Using thumb and finger, grasp the lower portion of the abdomen
above symphisis pubis, press in slughtly and make gentle
movements from side to side.
10 Fourth Manuever: Pelvic Grip
Facing foot part of the woman, palpate fetal head pressing downward
about 2 inches above the inguinal ligament. Use both hands.
11 Note if there is contraction or any untoward reaction while doing the
procedure.
12 Perform proper documentation.
13 Do hand hygiene.
Total:

ATTITUDE
KNOWLEDGE
SKILLS COMPETENCY
PROCEDURE
TOTAL SCORE
__________________________________ _______________________
(81-83)
50 (78-80)
2.75 (76-77)
3.00 (75)
(below 75)
College of Nursing

WARD
Name of Student:__________________________________ Date:______________ Rating:________
1.00 (96-100) 2.25 (81-83)
1.25 (93- 2.50 (78-
4- Demonstrates produre properly, rationale not thoroughly explained. 95) 80)
3- Demonstrates produre properly, wrong rationale stated. 1.50 (90-92) 2.75 (76-77)
1.75 3.00 (75)
2- Procedure not completely and accurately done, rationale not thoroughly explained. (87-89)
1- Procedure not completely and accurately done, wrong rationale stated. 2.00 (84-86) 5.00 (below
75)
1 Reports on time
Total:
1 Correlates theory to practice.
2 Applies nursing process systematically and comprehensively.
3 Uses critical judgement in rendering nursing care.
4 Explains the correct principles behind every nursing action.
5 Conducts health teachings according to family's needs.
Total:
5 4 3 2 1 0
SKILLS 40% TOTAL POINTS:
1 Organizes work well and finishes tasks on time.
2 Attends to the needs of the client and and family promptly.
3 Works with other members of the health team effectively.
4 Exhibits technical skills in the performance of nursing procedures.
5 Takes proper care of equipment and supplies of the area.
Docuemnts pertinent data gathered and appropriate nursing action taken

6 accurately and chronology.
7 Endorses patient properly,
Total:
Grading System: RESEARCH _____________________10%

KNOWLEDGE (REQ) ________________________20%
SKILLS ________________________70%
__________________________________ ________________________
College of Nursing
COMMUNITY
Name of Student:_________________________________ Date:_________________ Rating:___________
5- Demonstrates produre properly, explains the correct rationale behind action. 1.00 (96-100) 2.25 (81-83)
4- Demonstrates produre properly, rationale not thoroughly explained. 1.25 (93- 2.50 (78-80)
95)
3- Demonstrates produre properly, wrong rationale stated. 2.75 (76-77)
1.50 (90-92)
2- Procedure not completely and accurately done, rationale not thoroughly explained. 3.00 (75)
1.75
1- (87-89)
Procedure not completely and accurately done, wrong rationale stated.
5.00 (below 75)
2.00 (84-86)
* The grade shall be computed: Score divided by total number of items, multiplied by 60, plus 40. Passing
cut-off score is 60%
1 Reports on time


Total:
1 Correlates theory to practice.
2 Applies nursing process systematically and comprehensively.
3 Uses critical judgement in rendering nursing care.
4 Formulates family nursing care plan appropriately.
5 Identifies family health and nursing problems correctly.
6 Recognizes family needs.
7 Explains the correct principles behind every nursing action.
8 Conducts health teachings according to family's needs.
Total:
SKILLS 40% TOTAL POINTS:
1 Organizes work well and finishes tasks on time.
2 Communicates to clients and family therapeutically.
Exhibits technical skills in the implementation of the nursing procedures

3 correlation with physical assessment.
4 Attends to the needs of the client and and family promptly.
5 Works with physician and other members of the health team
effectively.
6 Takes proper care of CHN bag and supplies of the area.

7 Resourceful in meeting client and family needs.
8 Docuemnts pertinent data gathered and appropriate nursing action taken

accurately and chronology.
Total:
Grading System: RESEARCH _____________________10%

KNOWLEDGE (REQ) ________________________20%
SKILLS ________________________70%

__________________________________ ___________________________
College of Nursing

Concept: Acute Biological Crisis
Area: SCHOOL NURSING
Name of Student:_____________________________ Date:_______________ Rating:___________

4 - Demonstrates produre properly, rationale not thoroughly explained. 1.25 (93- 2.50
3 - Demonstrates produre properly, wrong rationale stated. 95) (78-80)
2 - Procedure not completely and accurately done, rationale not thoroughly explained. 1.50 (90-92) 2.75 (76-77)
1 - Procedure not completely and accurately done, wrong rationale stated. 1.75 3.00
(87-89) (75)
2.00 (84-86) 5.00
* The grade shall be computed: Score divided by total number of items, multiplied by 60, plus 40.75)
(below
1 Reports on time

5 Shows
6 Acknowledges
masterycriticism/suggestion
of the activity openly
Total:
Assess different manifestations that are related to Acute Biological Crisis

through the different methods used in physical and appropriate data
1 gathering
2 Performs physical examinations correctly and with confidence
Identifies and differentiates between normal and abnormal findings in Acute

3 Biological Cases
Determines the significance of laboratory and diagnostic findings to the

4 emergent problems
Picks out critical and essential data in nursing history relevant to the current
5 situations
Total:
PLANNING 20% TOTAL POINTS:
Knowledge in setting goals and prioritization of patient's needs with Acute
1 Biologic Crisis in the emergency room
Identify changes in patient's needs and nursing problems as they occur and
2 make necessary adjustments in nursing measures
Total:
INTERVENTIONS 20% TOTAL POINTS:
1 Assess the capability needed by the client for selfmanagement in the

emergency room.
2 Ensures safety, comfort and privacy in rendering care of patients with acute
biological crisis.
3 Provides necessary curative measures.
4 Provides immediate restorative/rehabilitative measures during temporary stay

in the ER.
5 Utilizes available physical and professional resources.
6 Makes referrals to appropriate health professionals, as needed.
7 Shows commitment to the welfare of the client.
8 Implements the plan of care jointly with the client.
9 Performs nursing procedures/activities: 9.1 with ease and confidence
9.2 correctly
9.3 systematically
9.4 practices bioethical principles in care
9.5 provides after care
9.6 demonstrate situational flexibility and adaptability.
Total:
1 Evaluates plan of care of client using the outcome criteria and performs
appropriate documentation and recording of changes in the client's
evident status after the interventions.
2 Displays critical thinking in the analysis of the current management
being employed and modifications that has to be done as needed.
3 Discusses with the appropriate health team results of interventions
4 Accepts suggestions, constructive criticisms and employ appropriate
modifications in the plan of care.
Total:
Requirements: 20% = ______________ = _____________
Pre and Pre Exam: 10% = ______________ = _____________
__________________________________ ________________________
25 (81-83)
2.50
8-80)
2.75 (76-77)
3.00
5)
5.00
elow 75)
College of Nursing
Clinical Performance Evaluation Tool
HEAD NURSING
Name of Student:______________________________ Date:_________________ Rating:__________
2.75 (76-
2 - Procedure not completely and accurately done, rationale not thoroughly explained. 1.50 (90-92) 77)
3.00
(87-89)
0 - Procedure not done/not mentioned. 5.00
2.00 (84-86) (below 75)
1 Reports on time
Total:
1 Establishes rapport with subordinates
2 Able toinvolve patient's in plan of care
3 Punctual and prompt in all activities
4 Able to maintain stability under pressure
5 Gathers data using interview, observation, records review and reports
6 Formulates appropriate nursing care plan
Total:
IMPLEMENTATION 20% TOTAL POINTS:
Carries out assigned tasks based on the criteria of distribution of
1 assignments
2 Follows principles of time management
3 Equipped with requuired paraphernalis for RLE
4 Observes proper channels of communication
5 Carries out plan of care, including:
A. Bedside Care
B. Administration of medications
C. Administration of treatments (nebulization, IVF)
6 Shows initiative in performing tasks.
7 Accomplishes delagated tasks within prescribed time frame.
8 Accepts supervision and criticisms.
9 Conducts appropriate health teachings
Total:
1 Notifies immediate superior about untoward situations or conditions
related to patient care in the area.
2 Make revisions in the plan of care as necessary.
3 Evaluates Nursing Care needed.
ETHICOLEGAL CONSIDERATION 20% TOTAL POINTS:
1 Demonstrates honesty at all times
2 Conducts self in tactful manner
3 Keeps confidential patient information.
4 Observes the 11 Core Competency Guidelines.
Total:

Requirements: 20% = ______________ = _____________
Pre and Pre Exam: 10% = ______________ = _____________
__________________________________ ________________________
College of Nursing
PRACTICING CLINICAL INSTRUCTOR
Name of Student:_____________________________________ Date:____________ Rating:________
4- Demonstrates produre properly, rationale not thoroughly explained. 1.25 2.50 (78-80)
(93-95)
3- 2.75 (76-77)
Demonstrates produre properly, wrong rationale stated. 1.50 (90-
92) 3.00 (75)
2- Procedure not completely and accurately done, rationale not thoroughly explained.
1.75 (87-89)
1- Procedure not completely and accurately done, wrong rationale stated. 5.00 (below 75)
0- Procedure not done/not mentioned. 2.00 (84-86)
TOTAL POINTS:
Presents the subject matter effectively in such a way that the student can
have good grasp of the lesson.
Exhibits mastery of the subject matter. He/she does not lecture from his
notes or books.
Uses variety of techniques and strategies to make the lesson interesting, to

deepen understanding and to develop or strengthen skills.
Manifests interest and enthusiasm in teaching the subject matter.
Asks questions
6 Shows mastery that enhance
of the activitystudent's higher order thinking skills.
Answer's students' questions clearly and satisfactorily.
Relates lessons learned from the classroom to actual situation.
Utilizes instructional materials effectively.
Articulately speaks medium of instruction.
Encourages students to ask questionns and clarifications.
Uses appropriate words and gramatically correct sentences.
Acknowledges student's performance objectively.
Speaks in clear and well modulated voice,
Welcomes students' opinions, questions, comments and reactions.
Starts and ends class on time. Uses class time productively for the
teaching learning process.
Projects responsibility in terms of dressing and grooming.
Administers various forms of student's evaluation.
Maintains discipline in the classroom.
Shows integrity and fairness in dealing with students.
Exhibits professionalism in the area.
Total:
__________________________________ ______________________
College of Nursing
Clinical Performance Evaluation Tool
STUDENT STAFF NURSE TO STUDENT HEAD NURSE
Name of Student:______________________________ Date:_________________ Rating:__________
2.75 (76-
2 - Procedure not completely and accurately done, rationale not thoroughly explained. 1.50 (90-92) 77)
3.00
(87-89)
0 - Procedure not done/not mentioned. 5.00
2.00 (84-86)
* The grade shall be computed: Score divided by total number of items, multiplied by 60, plus(below 75)
40. Passing
ESTABLISHMENT OF WORKING RELATIONSHIP TOTAL POINTS:
1 Establishes rapport with subordinates.
2 Gains trust and confidence of subordinates.
3 Able to mediate between subordinates and patients
4 Able to maintain stability under pressure.
5 4 3 2 1 0
ASSESSMENT/PANNING TOTAL POINTS:
1 Utilizes appropriate resources for ward assessment.
2 Utilizes different techniques in gathering data (interview, observation,
review, reports)
Gathers data on:
3 Nursing sevice history
Physical set up
Organizational chart
Ongoing appraisal evaluation
Ward rules and regulation ad SOP's
Channel of communication
Record and reports
4 Analyze data gathered based on scientific concepts and principles.
5 Briefs student staff nurses on data gathered.
Identifies and prioritizes problems based on data gathered according to the
urgency of the problem, availablity or resources (manpower, materials,
6 money/budget)
5 4 3 2 1 0
PROBLEM SOLVING PROCESS TOTAL POINTS:
Involves the staff, other members of the health team and administrative
1 units in identifying problems in the unit.
Generates suggestions and recommendations for the resolution of
2 identifies problems
1 Analyze the existence of the problem.

2 Identifies specific and appropriate strategies tonattain objectives
3 Develops altrnative course action
4 Implements plan of action
5 Sets criteria for evaluation using the different parameters of
evaluation
5 4 3 2 1 0
LEADERSHIP TOTAL POINTS:
1 Conducts a pre conference with his/her staff to discuss the objectives
and activities for the day, helps subordinates formulate strategies in
accomplishing assigned tasks, address questions pertaining to
accomplishments of tasks.
2 Prepares and brief subordinates on the learning objectives for the day
3 Distributes patient assignment evenly
4 Delegates tasks to student staff nurses
5 Prepares and brief subordinates on daily plan of activities
6 Evaluates if the objectives are met
7 Identifies constraints for non-attainment of objectives and activities
8 Come up with resolutions to address constraints
9 Supervise hisher staff during procedures and other assigned tasks
10 Manage tasks using the pinciples of time management
11 Coordinates and collaborates with other members of the health team
other administrative units in the attainment of objectives.
12 Evaluates performance of staff and the unit as a whole through the use
of reports, records, observations, interviews and conferences
13 Troubleshoot as necessity arise
14 Conducts post conference at the end of the shift, resolves issues
informed and updated
15 Requires incident reports as necessary, keeps the clinical instructor
informed and updated
16 Utilizes the existing chain of command in implementing activities
Total:
__________________________________ ______________________
College of Nursing
TAKING VITAL SIGNS
Name of Student:_____________________________________ Date:________________ Rating:_________
4 - Demonstrates produre properly, rationale not thoroughly explained. 1.25 (93-95) 2.50 (78-80)
1.50 (90- 2.75 (76-77)
2 - Procedure not completely and accurately done, rationale not thoroughly explained. 92)
3.00 (75)
1 - Procedure not completely and accurately done, wrong rationale stated. 1.75 (87-89)
5.00
*0The
grade shall mentioned. Score divided by total number of items, multiplied
be computed: by 60, plus(below
2.00 (84-86) 40. Passing
75)
1 Reports on time
Total:
5 4 3 2 1 0
Total:
Assemble Equipment:
1 Digital thermometer
2 Stethoscope
3 Aneroid Sphygmomanometer
4 Wet and dry cotton balls
5 Black watch with second hand
Total:
OVER-ALL PROCEDURE TOTAL POINTS:
Introduce yourself and verify the client's identity. Explain to the client
1 what you are going to do, why is it necessary, and how the client can
cooperate,
Perform hand hygiene and observe other appropriate infection control

2 procedures.
3 Provide client privacy.
4 Place client in appropriate position.
TEMPERATURE: Assessment
1 Clinical signs of fever
2 Clinical signs of hypothermia
3 Site most appropriate for measurement
4 Factors that might alter core body temperature
PROCEDURE:
1 Disinfect the thermometer from bulb to stem (cleanest to dirtiest)
2 Place the thermometer accordingly
3 Wait for the appropriate amount of time till the reading is
complete via light or tone.
4 Read the temperature
If the temperature is obviously too high, too low, or
inconsistent with the client's condition, recheck it with a
thermometer known to be functioning properly
5 Observe proper nursing interventions depending on the result
6 Disinfect the thermometer from stem to bulb (cleanest to dirtiest)
7 Document the temperature in the client's record.
PERIPHERAL PULSE: Assessment
2 Factors that might alter pulse rate
3 Clinical signs of cardiovascular alterations
PROCEDURE:
1 Select the pulse point
2 Assist the client to a comfortable position
3 Palpate and count the pulse. Place 2 fingertips lightly over the
pulse point
Count for 1 whole minute
4 Assess the pulse rhythm, volume and your actions in the client
record
APICAL PULSE: Assessment
2 Factors that might alter pulse rate
3 Clinical signs of cardiovascular alterations
PROCEDURE:
1 Assist the client to a comfortable position
2 Expose the area of the chest over the apex of the heart
3 Locate the apical pulse
4 Auscultate and count the heartbeats
A. Use antiseptic wipes to clean the earpeices and diaphragm of
the stethoscope
B. Warm the diaphragm of the stethoscope by holding it in the
palm of your hand for a moment
C. Insert the earpieces of the stethoscope into the ears in the
direction of the ear canals, or slightly forward to facilitate
hearing.
D. Tap your finger lightly on the diaphragm to be sure
E. If you have difficulty hearing the apical pulse, ask the supine
client to roll onto the left side, or the sitting client to lean
slightly forward.
5 Assess the rhythm and the strength of the heartbeat
A. Assess the rhythm of the heartbeat by noting the pattern of
intervals between the beats
B. Assess the strength of the heartbeat
6 Document the pulse rate, rhythm, and volume and your actions in
the client record
RESPIRATION: Assessment
1 Skin and mucous membrane color
2 Position assumed for breathing
3 Signs of cerebral anoxia
4 Chest movements
5 Activity tolerance
6 Chest pain
7 Dyspnea
8 Medications affecting respiratory rate
PROCEDURE:
1 If you anticipate the client's awareness of respiratory assessment
place a hand against the client's chest and observe the chest
movements while supposedlt taking the radial pulse.
2 Count the respiratory rate for 1 whole minute: An inhalation and
exhalation count as one.
3 Observe the depth, rhythm and character of respirations.
A. Observe the respiratios for depth by watching the movement
of the chest
B. Observe the repirationss for regular or irregular rhythm
C. Observe the character of resprations-the sound they produce
and the effort they require
4 Document the respiratory rate, depth, rhythm and character on the
appropriate record.
BLOOD PRESSURE: Assessment
1 Signs and symptoms of hypertension
2 Signs and symptoms of hypotension
3 Factors affecting blood pressure
4 Client for allergy to latex cuff
PROCEDURE:
1 Position the client appropriately
A. The adult client should be sitting unless otherwise specified.
Both feet should be flat on the floor
B. The elbow shoould be slightly flexed, with the palm of the hand
facing up the forearm supported at heart level.
C. Expose the upper arm
2 Wrap the deflated cuff evenly around the upper arm.
3 Locate the brachial artery
4 Apply the center of the bell directly over the artery
A. For an adult, place the lower border of the cuff approximately
2.5cm(1inch) above the antecubital space.
5 If this is the client's initial examination, perform a preliminary
palpatory determination of systolic pressure
A. Palpate the brachial artery with the fingertips
B. Close the valve on the bulb
C. Pump the cuff untill no longer feel the brachial pulse.
D. Note the pressure on the sphygmomanometer at which pulse is
no longer left.
E. Release the pressure completely in the cuff, and wait 1-2
minutes before taking further measurements.
6 Position the stethoscope appropriately
A. Cleanse the earpieces with antiseptic wipe.
B. Insert the ear attachments of the stethoscope in your ears so
that they tilt slightly forward
C. Ensure that the stethoscope hangs freely from the ears to the
diaphragm
D. Place the bell side of the amplifier of the stethoscope over the
brachial pulse
E. Place stethoscope directly on skin, not on clothing over the site
7 Auscultate the client's blood pressure
A. Pump up the cuff until the sphygmomanometer is 30mmHg above
the point where the brachial pulse disappeared
B. Release the valve on the cuff carefully so that the pressure
decreases at the rate of 2-3mmHg per second
C. As the pressure falls, identify the manometer reading at Korokoff
phases I, IV and V
D. Deflate the cuff rapidly and completely.
E. Wait 1-2 minutes before making further determinations
F. Repeat the above steps once or twice as necessary to confirm the
accuracy of the reading
8 If this is the client's initial examination, repeat the procedure on the
client's other arm.
9 Remove the cuff.
10 Document and report pertinent assessment data according to
agency policy.
__________________________________ ___________________________
Co Evaluated by:
nf
or ________________________
m ___
e: Clinical Instructor's Signature
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
St
ud
en
t's
Sig
na
tur
e
________
Signature
College of Nursing
ADMINISTERING ORAL MEDICATIONS
Name of Student:________________________________ Date:_____________ Rating:_________
1.25 (93- 2.50

4- Demonstrates produre properly, rationale not thoroughly explained. 95) (78-80)
3- Demonstrates produre properly, wrong rationale stated. 1.50 (90-92) 2.75 (76-77)
1.75 3.00
2- Procedure not completely and accurately done, rationale not thoroughly explained. (87-89) (75)
1- Procedure not completely and accurately done, wrong rationale stated. 2.00 (84-86) 5.00
(below 75)
CRITERIA 5 4 3 2 1
1 Reports on time

Total:
CRITERIA 5 4 3 2 1
Total:
CRITERIA 5 4 3 2 1
Assemble Equipment:
1 Oral Medications (tablets, capsule, enteric caoted tablets and liquid
medications)
2 Measuring cup
3 Medication card
4 Medication tray
5 Drinking Glass of water
Assess:
1 Allergies to medication
2 Client's ability to swallow the medication
3 Presence of vomitting or diarrhea that would interfere with the ability
to absorb medication
4 Specific drug action, side effects, interactions, and adverse reactions

5 Client's knowledge of and learning needs about the medication
6 Perform appropriate assessments specific to the medication.
7 Determine if the assessment date influences the administation of the
medication.
Know the reason why the client is receiving the medication, the drug
classification, contraindications, usual dosage range, side effects, and
8 nursing considerations for administering and evaluating the intended
outcomes for the medication.
Total:
CRITERIA 5 4 3 2 1
1 Perform hand hygiene and observe the appropriate infection control
procedures
2 Obtain appropriate medication, check for discrepancy & expiration
date
3 Check the doctor's orders: name, dosage, frequency of the drug with
the medication sheet
4 Prepare the medication: Dosage, with medicationcard and tray.
5 Calculate medication dosage accurately
6 Prepare the correct amount of medication for the required dose,
without contaminating it.
Tablets or capsules
7 Place packaged unit-dose capsules or tablets directly into the
medicine cup.
8 Do not remove the medication from the wrapper ntil at the bedside.
9 Break scored tablets only, if necessary to obtain the correct
dosage.
10 If the client has difficulty swallowing, crush the tablets (check to make
sure tablets may be crushed) to a fine powder.
Liquid Medication
1 Thoroughly mix the medication before pouring
2 Discard any medication that has changed color or turned cloudy
3 Remove the cap and place it upside down on the countertop.
4 Hold the bottle so the label is next to your palm, and pour the
medication away from the label.
5 Place the medication cup at eye level and fill it to the desired level,
using the bottom of the meniscus to align with the container scale.
6 When giving small amounts of liquids (<5ml), prepare the medication
in a sterile syringe without the needle, or in a specially designed oral
syringe. Label the syringe with the name of the medication and the
route(PO). Or a dropper can be used.
GIVING MEDICATION
1 Provide for client privacy
2 Prepare the client
A. Observe the 10 "RIGHTS" in giving medications
B. Assist the client to a sitting position or, if not possible, to a side
lying position
C. If not previously assessed, take the required assessment measures
such as pulse and respiratory rates or blood pressure
3 Explain the purpose of the medication and how it will help, using
language that the client can understand. Include relevant information
about effects.
4 Administer the medication at the correct time.
5 If the client is unable to hold the pill cup, use it to introduce the
medication into the client's mouth, and give only one tablet
or capsule at a time.
6 If an older child or adult has difficulty swallowing, ask the client to
place the medication on the back of the tongue before taking the water
7 If the medication has as objectionable taste, ask the client to suck
a few ice chips beforehand, or give the medication with juice if there
are no contraindications
8 If the client ssys that the medication you are about to give is
different from what the client has been receiving, do not give the
medication without first checking the original order.
9 Stay with the client until all medications have been swallowed.
10 Document each medication given.
A. Record the medication given, dosage, time, any complaints or
assessments of the client, and your signature
B. If medication was refused or omitted, record this fact on the
appropriate record; document the reason, when possible, and the
nurse's actons, according to agency policy
11 Dispose of all supplies appropriately
12 Evaluate the effects of the medication.
A. Return to the client when the medication is expected to take effect
to evaluate the effects of the medication on the client.
Total:

__________________________________ ___________________________
______
ure
College of Nursing
ADMINISTERING AN INTRAMUSCULAR INJECTION
Name of Student:________________________________ Date:_____________ Rating:_________
1.25 (93- 2.50 (78-80)
4- Demonstrates produre properly, rationale not thoroughly explained. 95)
2.75 (76-
1.50 (90-92) 77)
3- Demonstrates produre properly, wrong rationale stated. 3.00
1.75 (75)
(87-89)
2- Procedure not completely and accurately done, rationale not thoroughly explained. 5.00
2.00 (84-86) (below 75)
1- Procedure not completely and accurately done, wrong rationale stated.
1 Reports on time
Total:
Total:
Assemble Equipment:
1 Correct mediacation
2 Sterile syringe and a needle
3 Aspirating needle
4 Wet and dry cotton balls
5 Medication tray
6 Medication card
Assess:
1 Allergies to medication
2 Specific drug action, side effects, interactions, and adverse reactions
3 Client's knowledge of and learning needs about the medication
4 Tissue integrity of the selected site.

5 Client's age and weight, to determine site & needle size
6 Client's ability or willingness to cooperate
Determine
1 Whether the size of the muscle is appropriate to the amount of medi-
cation to be injected
Procedure
1 Check the doctor's orders: name, dosage, frequency of the drug with
the medication sheet
2 Obtain appropriate medication, check for discrepancy & expiration
date
3 Organize the equipment & prepare the medication: Dosage, with
medication card and tray
4 Calcualte medication dosage accurately.
5 Perform hand hygiene and observe other appropriate infection control
procedures
6 Prepare the correct amount of medication for the required dose,
without contaminating it.
Giving Medication
1 Perform hand hygiene and observe other appropriate infection control
procedures
2 Prepare the medication from the vial or ampile for drug withdrawal
3 Provide for client privacy
4 Prepare the client
A. Introduce yourself and verify the client's identity
B. Explain the purpose of the medication and how it will help, using
language that the client can understand. Include relevant information
about effects of the medication
C. Assist the client to a supine, lateral, prone or sitting position,
depending on the chosen site.
5 Select, locate and clean the site.
Select a site free of tenderness, hardness, swelling, scarring, itching,
burning and localized inflammation.
B. select a site that has not been used frequently
C. If injection are not to be frequent, alternate sites. Avoid using the
same site twice in a row
D. Locate the exact site for the injection
E. Clean the site with an antiseptic swab. Using a circular motion, start
at the center and move outward about 5cm(2 inches).
F. Transfer and hold the swab between the third and fourth fingers of
your nondominant hand in readiness for needle withdrawal, or position
the swab on client's skin above the intended site. Allow the skin to dry
prior to injecting medication.
6 Preparethe syringe for injecting.
7 Inject the medication using Z-track technique.
A. Use the ulnar side of the nondominant hand to pull the skin
approximately 1 inch to the side.
B.Holding the syringe between the thumb and forefinger, pierce the skin
quickly and smoothly at a 90 degree angle, and insert the needle into
the muscle.
C. Hold the barrel of the syringe steady with your nondominant hand,
and aspirate by pulling back on the plunger with your dominant hand.
Aspirate for 5-10 seconds.
D. If blood appers in the syringe, withdraw the needle, discard the

syringe, and prepare new injection.
E. If blood does not appear, inject the medication steadly and slowly
(approximately 10 secconds per milliliter) while holding the syringe
steady.
8 Withdraw the needle
A. Withdraw the needle smoothly at the same angle of insertion. Release
the skin
B. Applly gentle pressure at the site with dry sponge.
C. If bleeding occurs, apply pressure with dry, sterile gauze until it stops
9 Dispose of supplies appropriately.
10 Document all relevant information.
A. Include the time of administration, drug name, dose, route, and
client's reaction.
11 Assess effectiveness of the medication at the time it is expected to act.
total
__________________________________ _______________________

Nursing Skills (NCM 100) and 4th Year Eval Tool

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Pamantasan ng Lungsod ng Marikina

Student's Performance Evaluation Tool

CRITERIA 100% SCORE TOTAL

Conforme: Evaluated by:

Student's Performance Evaluation Tool

3 Turns on the water and adjusts its flow and temperature

7 Washes hands and wrists for at least 15 seconds

CRITERIA 100% SCORE TOTAL

Conforme: Evaluated by:

Student's Performance Evaluation Tool

3 Neat and well groomed

EVALUATION 20% TOTAL POINTS:

Student's Performance Evaluation Tool

Conforme: Evaluated by:

Student's Performance Evaluation Tool

Name of Student:_______________________________ Date:_____________ Rating:_____________

Conforme: Evaluated by:

Student's Performance Evaluation Tool

Name of Student:_______________________________ Date:________________ Rating:________

0- Procedure not done/not mentioned.

CRITERIA SCORE TOTAL

Conforme: Evaluated by:

Student's Performance Evaluation Tool

Name of Student:__________________________________ Date:______________ Rating:________

Docuemnts pertinent data gathered and appropriate nursing action taken

Grading System: RESEARCH _____________________10%

Conforme: Evaluated by:

Student's Performance Evaluation Tool

Name of Student:_________________________________ Date:_________________ Rating:___________

2 Wears complete uniform

3 Neat and well groomed

5 Acknowledges criticism/suggestion openly

Exhibits technical skills in the implementation of the nursing procedures

6 Takes proper care of CHN bag and supplies of the area.

8 Docuemnts pertinent data gathered and appropriate nursing action taken

Grading System: RESEARCH _____________________10%

Conforme: Evaluated by:

Student's Performance Evaluation Tool

Name of Student:_____________________________ Date:_______________ Rating:___________

4 Observes proper decorum

Assess different manifestations that are related to Acute Biological Crisis

Identifies and differentiates between normal and abnormal findings in Acute

Determines the significance of laboratory and diagnostic findings to the

1 Assess the capability needed by the client for selfmanagement in the

4 Provides immediate restorative/rehabilitative measures during temporary stay

Conforme: Evaluated by:

Clinical Performance Evaluation Tool

Name of Student:______________________________ Date:_________________ Rating:__________

Performance Checklist: 70% = ______________ = _____________

Student's Performance Evaluation Tool

PRACTICING CLINICAL INSTRUCTOR

Name of Student:_____________________________________ Date:____________ Rating:________

Uses variety of techniques and strategies to make the lesson interesting, to

Conforme: Evaluated by:

Clinical Performance Evaluation Tool

STUDENT STAFF NURSE TO STUDENT HEAD NURSE

Name of Student:______________________________ Date:_________________ Rating:__________

1 Analyze the existence of the problem.

Conforme: Evaluated by:

Student's Performance Evaluation Tool

TAKING VITAL SIGNS

Name of Student:_____________________________________ Date:________________ Rating:_________

Perform hand hygiene and observe other appropriate infection control

Name of Student:_________________________ Date:_ Rating:_______

Name of Student:_______________________ Date: Rating:

Name of Student:________________________ Date: Rating:

Name of Student:_________________________ Date:_ Rating:___

Name of Student:_____________________ Date:_ Rating:_____

Name of Student:______________________ Date:_ Rating:__

Performance Checklist: 70% = __ = _

Name of Student:_____________________________ Date: Rating:

Name of Student:______________________ Date:_ Rating:__

Name of Student:_____________________________ Date: Rating:_

Name of Student:__________________________ Date:_ Rating:___

Name of Student:__________________________ Date:_ Rating:___