Carly Legault

September 12, 2013

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 1
2nd Edition - Revised October 2008

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 2
2nd Edition - Revised October 2008

TABLE OF CONTENTS

SELF-ASSESSMENT TOOL - RATING SCALE..........................................................................4

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF PRACTICE.....................................4
A: Nursing Knowledge ...............................................................................................................4
B: Nursing Process..................................................................................................................... 5
C: Safety..................................................................................................................................... 5
D: Communication and Interpersonal Skills................................................................................5
W: Professionalism..................................................................................................................... 6
X: Nursing Practice and Leadership............................................................................................6
Self-Assessment Summary.......................................................................................................... 7
STEP 2: SELF-ASSESSMENT OF SPECIFIC COMPETENCIES..............................................8

STEP 3: LEARNING PLAN......................................................................................................10

RECORD OF PROFESSIONAL ACTIVITIES............................................................................11

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 3
2nd Edition - Revised October 2008

SELF-ASSESSMENT TOOL
The Self-Assessment Tool is used to assess your professional practice using the LPN Standards of
Practice and Competency Profile as a guide. Focus your assessment on your practice as a whole and
then those Specific Competencies which are directly related to your role and responsibilities.

RATING SCALE Use the following rating scale to complete your Self-Assessment.
1
Excellent

2
Competent

3
Requires
Improvement

4
Developmental

Demonstrates
excellence in the
expectations and /
or requirements of
the competency.

Meets the
expectations and /
or requirements of
the competency.

Has identified
weakness in
areas of
knowledge, skills,
attitudes, or
clinical judgment.

Requires
education and/or
orientation to
meet the
expectations and /
Or requirements
of the
competency.

5
Not Applicable
Not applicable to
current role and
responsibility.

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF

PRACTICE
Competency
Number

A: Nursing Knowledge

Year
2015

Year
2016

Year
20__

Year
20__

Year
20__

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

A-1

Applies knowledge of anatomy and physiology

of the human body to the assessment of client
and delivery of nursing care.

A-2

Applies knowledge of microbiology throughout

care, disease prevention, and health promotion.

A-3

Applies knowledge of pathophysiology to the

nursing care of the client.

A-4-4

Uses appropriate medical terminology to report

and document client care.

A-5-9

Adjusts nursing practice to the specific growth

and development of the client.

A-6

Applies principles of nutrition to the assessment

and care of the client.

A-7

Applies knowledge of pharmacology throughout

client care and teaching.

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 4
2nd Edition - Revised October 2008

Year
2015

Competency
Number

A-8-2

Integrates knowledge and skills from the

sciences and humanities into the application of
the nursing process.

B: Nursing Process

Rating
(1-5)

Performs health assessment of client using

assessment techniques and a systematic
process.

B-2-2

Implements the planning process and

establishes client priorities involving client in
planning.

B-2-3

Identify and analyze nursing diagnosis.

B-3

Implements nursing interventions to carry out

nursing care plan.

B-3-2

Reassess, review, and modify plan of care to

meet the needs of the client.

B-4

Evaluates the clients response to care and

treatment.

Year
20__

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

C-1 to
C-4

Applies critical thinking and clinical judgment

when responding to emergency situations.

C-5-1

Effectively uses protective devices to protect

client, self, and others.

C-6-1

Demonstrates the consistent application of

standard precautions.

C-7-1

Applies principles of medical and surgical

asepsis in the delivery of care.

C-12

Applies nursing knowledge and clinical

judgment to maintain physical safety of client.

2
Rating
(1-5)

D-1

Uses effective verbal and written

communication in the practice setting.

D-2

Appropriately establishes, maintains, and

closes the nurse-client relationship.

D-3

Collaborates with health care team to function

as an effective team member.

D-3-7

Adheres to the channels of communication

Within the employing agency.

Self-Assessment Tool CCP

College of LPNs of Alberta

Year
20__

Rating
(1-5)

D: Communication and Interpersonal Skills

Year
20__

B-1

C: Safety

Year
2016

Page 5
2nd Edition - Revised October 2008

Year
2015

Competency
Number

D-4

Provides client and family teaching.

D-5

Reports and documents following legal

protocols, agency policy and procedure.

D-7

Applies clinical judgment in identifying problems

and resolving issues in client care.

D-8-1

Effectively manages time and organizes client

care to meet priority needs.

D-8-2

Demonstrates ability to rank the priority of client

needs.

W: Professionalism

Rating
(1-5)

W-1-3

Understands the key components of the Health

Professions Act-LPN Regulation.

W-2-3

Understands the Restricted Activity

authorizations in the LPN Regulation.

W-3

Understands the CLPNA Standards of Practice.

W-4

Adheres to the CLPNA Code of Ethics and

Standards of Practice.

W-4-5

Acts as an advocate for client and empowers

clients and families.

W-5-1

Demonstrates accountability for own nursing

practice.

W-6

Maintains the confidentiality of client

information.

W-7

Recognizes professional boundaries within the

nurse-client therapeutic relationship.

W-9

Accepts responsibility for continuing

competence and professional development.

W-9-4

Participates in continuous quality improvement

and evidence based changes to nursing
practice.

W-11

Keeps informed of current research affecting

health care delivery.

X: Nursing Practice and Leadership

Rating
(1-5)

X-1-5

Recognizes own strengths and limitations as a

leader.

X-3-5

Uses appropriate channels of communication to

report risks within setting.

Self-Assessment Tool CCP

College of LPNs of Alberta

Year
2016

Year
20__

Year
20__

Year
20__

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Page 6
2nd Edition - Revised October 2008

Year
2015

Competency
Number

X-4

Applies critical thinking and clinical judgment

when assessing or managing risk.

X-7-1

Shares knowledge, skill, and expertise with

colleagues and students.

X-7-3

Seeks opportunities to teach and mentor others.

X-7-4

Participates in committees, task forces and

professional activities to offer the LPN
perspective.

Year
2016

Year
20__

Year
20__

Year
20__

SELF-ASSESSMENT SUMMARY
Year

Competency
Number

Describe the competency areas you want to improve or develop. List all items rated 2
(Competent), 3 (Requires Improvement), 4 (Developmental) in Step 1.

2015

A-1

I want to further improve the application of my anatomy and physiology

knowledge of the human body to the assessment of patient and delivery of
nursing care.

A-2

I want to improve my knowledge of microbiology so that I can further

promote disease prevention and promote health to patients.

2015

X-7-3

I want to develop the required leadership and knowledge skill to mentor

others in their journey in becoming a nurse.

2015

A-7

I want to improve my knowledge of pharmacology through patient care and

teaching so that I will be able to alert the patient of adverse reactions, drug
interactions, etc.

2015

STEP 2: SELF-ASSESSMENT OF SPECIFIC COMPETENCIES

Self-Assessment Tool CCP
College of LPNs of Alberta

Page 7
2nd Edition - Revised October 2008

In this section, describe, assess, and rate the competencies specific to your area of work, specialty,
role and responsibility. Review the competency sections in the Competency Profile to guide your
assessment of the Specific Competencies. Seek feedback from another health professional.
Year

2015

2015

Competency
Number

G-1-2

G-2-4

Demonstrate knowledge of clinical pathways related to surgical

procedures including:
Pre-operative
Intra-operative
Post-operative
Anticipated and unanticipated outcomes
Complications

G-4-1

Dressings
Empty,removeandshortendrains
Irrigation
Packing
Removalofpacking
Removalofstaplesandsutures
WoundVAC(vacuumassistedclosure)

Demonstrateknowledgeandabilitytoreceiveandmanage
clientforpostanestheticrecovery:

Self-Assessment Tool CCP

College of LPNs of Alberta

Demonstrateknowledgeandabilitytoassessandmanage
surgicalincisionandwoundcaretofacilitatehealing:

2015

Rating
(1-5)

Describe & Assess Specific Competencies

Performinitialandcontinuingclientassessmentincluding
Bloodloss
Drainsoinfusionlines
Levelofconsciousness
Painmanagement
Urineoutput
Vitalsigns
Wounddressings
Guideclienttoconsciousness
Monitorbloodandmanagefluidinfusions
Respondtoclientquestionsandpersonalneeds
Medicationadministration
Changeorreinforcewounddressingsasnecessary
Monitorclientforchangesincondition
Reportandmanagepostoperativecomplications
Consultandcollaboratewithinterprofessionalteam
Completepostoperativechecklistanddocumentation

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2nd Edition - Revised October 2008

2015

U-1-3

Demonstrateknowledgeandunderstandingof
pharmacologicalprinciplesincluding:

2015

U-1-8

Self-Assessment Tool CCP

College of LPNs of Alberta

Pharmacokinetics
o Absorption
o Distribution
o Metabolism
o Excretion
Pharmacodynamics
o Adverseeffect
o Anaphylactic/allergicreaction
o Antagonisticeffect
o Complementaryandalternativetherapyinteractions
o Desiredeffect
o Druginteractions
o Drugtoxicity
o Durationofaction
o Idiosyncraticreactions
o Synergisticeffect
o Therapeuticduration

Demonstrateknowledgeandabilitytoperformdrugcountson
controlledmedicationsaccordingtoagencypolicyincluding:
Maintainaccurate
Accuratelyrecordadditionand/orremoval
Participateinshiftcountandaccuratelyrecordinventory
Cosignwasteofcontrolledmedication

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2nd Edition - Revised October 2008

STEP 3: LEARNING PLAN

This page is intended to document your Learning Plan for one year. Photocopy this BLANK page for each additional year.

Your Learning Plan must consist of at least TWO objectives for each year. You are required to fill out
all FOUR columns for each objective. Transfer your Learning Plan onto your Annual CLPNA
Registration Renewal Form. Please refer to the Guidelines at www.clpna.com for more information.

YEAR 2016
Learning Objectives

Resources & Strategies

Target Date

Evaluation

(What I am going to learn?)

(What will I do to meet

objectives?)

(Realistic time
frame for
achievement)

(How will I know I learned it?)

Read my Potter and

Perry on Post
Operative assessments
Create a checklist on
the various things
required during a Post
Operative assessment
Practice this skill in
lab

March 28th
April 22nd 2016

Rate against the

checklist to ensure it
is followed
Have an instructor
watch as I perform the
different postoperative
assessment.

o Demonstrate
ability to receive
and manage
patient for Post
Anesthetic
Recovery;
Perform initial
and continuing
patient
assessment
including:
o Blood loss
o Level of
consciousness
o Pain management
o Urine output
o Vital signs
o Monitor patient
for changes in
condition
o Complete post
operative
checklist and
documentation
To 3 patients in March
28th April 22nd 2016
Demonstrate
knowledgeand
abilitytoprioritize
andmanagepatient
carerelatedtothe
followingfactors:
o Emergent
immediatethreat
Self-Assessment Tool CCP
College of LPNs of Alberta

Before the start of

each shift I will look
up patient health
history, current
diagnosis, and receive
bedside shift report
regarding patient.
Create a check list of

March 28h
April 22nd 2016

Have my instructor
evaluate whether or
not

Page 10
2nd Edition - Revised October 2008

tosurvivalor
safety
o Urgent
problems
requiring
immediate
intervention
o Lessurgent
problems
requiringnon
immediate
intervention
o Nonurgent
anticipated
problemsin
future
Toeachofmypatientsin
March28thApril22nd
2016

each patients
diagnosis and
consistently refer to
the list to prioritize
patients.

Name: Maurice Chow

Self-Assessment Tool CCP

College of LPNs of Alberta

CLPNA Registration #: ____________

Page 11
2nd Edition - Revised October 2008

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity
(include course,
seminar, research,
hours, details)
CPR Level C Certificate

25/03/2016

01/03/2015

07/03/2015

HBBP (Human Blood

Borne Pathogen)

WHMIS (Workplace
Hazardous Materials
Information Systems)

Name: Maurice Chow

Self-Assessment Tool CCP

College of LPNs of Alberta

Summary of Learning

Learned lifesaving skills of:

1. Cardiopulmonary resuscitation (CPR) and relief of
choking in adults (with option to include child and infants)
along with barrier device/pocket mask use automated
external defibrillator (AED) training.
Learned safe work practices in a work environment where I
can be exposed to blood borne pathogens. Learned different
types of blood borne diseases, risk assessment,
recommended work practices.
Learned proper safety procedure to follow when using
hazardous products in the workplace. Learned hazard
identification, product classification, product labeling and
warning signs.

CLPNA Registration #:__________

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2nd Edition - Revised October 2008