CU-QMS-NURSING-006

Capitol University
College of Nursing

CLINICAL PERFORMANCECHECKLIST FOR PEDIATRIC WARD

Name: __________________________________ Period of Rotation: _____________________

Level: __________________________________ Rating: _______________________________

I: KNOWLEDGE / COGNITIVE (40%) RATING

1. Identify significant assessment limits, diagnostic examination
And laboratory findings pertinent to child’s condition. 1 2 3 4
2. Identify child’s growth and development 1 2 3 4
3. Correlates significant clinical manifestation with the
Pathophysiology of the disease condition. 1 2 3 4
4. Identify common problem on different age group
And prioritize them accordingly 1 2 3 4
5. Formulates appropriate, relevant & realistic nursing
Care plan 1 2 3 4
6. Formulates specific, measurable, attainable nursing,
goals and objectives and identifies independent /dependent
nursing function. 1 2 3 4
7. Familiarized and explained the indication of drugs and solution
used in child’s care 1 2 3 4
8. Describes the health benefits of breastfeeding and nutritional
options to the non-breastfeeding infant. 1 2 3 4
9. Anticipates discharged planning. 1 2 3 4
10. Evaluates and assess the effectiveness of care rendered. 1 2 3 4

II: SKILLS/ PSYCHOMOTOR (40%)

1. Conduct physical assessment on child general appearance
and obtain vital sign. 1 2 3 4
2. Provide child needs during their acute, chronic and
life – threatening illness. 1 2 3 4
3. Observes and assist other member of the health team during
the intensive diagnostic procedure. 1 2 3 4
4. Records and reports significant data/observation about
the child’s condition with promptness and accuracy. 1 2 3 4
5. Perform nursing procedures skillfully, (NGT feeding,
Pulmophysiotheraphy, 02 therapy, specimen collection,
Chest tapping and positioning.) 1 2 3 4
6. Prepares, administer & documents medicines
given as ordered. 1 2 3 4
7. Provide practical and psychosocial support for the family
with high risk child. 1 2 3 4
8. Perform routine therapeutic intervention & maintain
Thermo-regulation. 1 2 3 4
9. Records appropriately on the flow sheets and narrative
nurse’s notes 1 2 3 4
10. Organized work & manage time effectively & ensure
environmental safety. 1 2 3 4
III: ATTITUDE /AFFECTIVE (20%)
1. Abides all institutional policies. 1 2 3 4
2. Accept nursing service responsibilities with interest
and willingness to work 1 2 3 4
3. Allows considerable time to be with the patient and give
physical and emotional & spiritual support
to patient significant others. 1 2 3 4
4. Accomplishes assigned task with no competence, calmness,
confidence, compassion, initiative, resourcefulness
and creativity. 1 2 3 4
5. Establishes professionalism with patients, co-students, nurses
and other health team members. 1 2 3 4

_______________________________
STUDENT’S SIGNATURE
______________________________
CLINICAL INSTRUCTOR

Issue: 05 April 2006 Revision Code : 003