OUR LADY OF FATIMA UNIVERSITY

College of Nursing – Valenzuela City

PROGRAM Bachelor of Science in Nursing STUDENT NAME

COURSE NCMB-312 YEAR & SECTION

Care of Clients with Problem in
Oxygenation, Fluids & INSTRUCTOR
Electrolytes, Infectious,
Inflammatory & Immunologic DATE
Response, Cellular Aberrations
(Acute & Chronic)
(SKILLS LABORATORY)

PROCEDURE :BREAST SELF EXAMINATION

EXPECTED OUTCOME : The student should be able to perform breast self examination correctly.
ASSESSMENT TASK : Return Demonstration
Assessment Exceptional Good Average Poor
SCORE
Dimension (4) (3) (2) (1)
Clearly verified Verified the Verified the Failed to
1. the presence of presence of doctors presence of verified the
Verify the doctor’s doctor’s written ritten order with doctors written presence of
order and secure order and secured minimal order incorrectly doctors written
consent if necessar consent if error and and secured order.
necessary. secured consent consent if
if necessary. necessary.
2. Performed Performed Performed Medical hand
Hand washing medical hand medical hand medical hand washing not
washing wash- ing with washing with performed
properly. least error. most error
3. Gathered all With lacking of 1- With lacking of Failed to
Gather all the the necessary 2 materials. 3 or more gather
necessary materials materials materials. necessary
needed. (drape, ruler completely. materials
in centimeter, marker, (Drape, ruler completely.
gloves) in centimeter,
marker, glove)
4 Greeted and Performed at least Performed one (1) Failed to greet
Identify the patient identified patient two (2) ways of way of identifying and identify the
by asking his/her identifying the the patient. patient.
name and patient.
checking his/her
ID band and bed
tag.
5. Explained Explained procedure Explained Failed to explain
Explanation the procedure to the but lacks details. procedure but in procedure.
procedure patient clearly and an unclear manner.
completely with
patient’s approval.
6. Provided privacy Privacy and Provided privacy Failed to provide
Privacy and position and position positioning of the but unable to privacy and
appropriately and patient was not position patient position the
comfortably maintained all comfortably and patient.
throughout the throughout the appropriately or
procedure. procedure. vice versa.
 7. Performed breast Performed Performed Performed
Perform Breast inspection incomplete breast incomplete breast incomplete
Inspection. Note its completely. Taking inspection with at inspection with at breast inspection
size and symmetry, note all its details. least 1-2 details least 3-4 details with at least 5-6
color and texture, missing. missing details missing
superficial venous
patterns, retraction
and dimpling, areola
and nipples.

8. Performed breast Performed Performed Performed

Perform Breast inspection incomplete breast incomplete breast incomplete
Palpation. Note its completely. Taking inspection with at inspection with at breast inspection
texture and elas- ticity, note all its details. least 1-2 details least 3-4 details with at least 5-6
tenderness and missing. missing. details missing.
temperature, masses,
nipples.
9. Documented the Some of the details Most of the details Failed to
Documentation information about of procedure were of procedure were document the
the procedure, not documented. not documented. procedure.
date and time
properly and
completely.

OVERALL SCORE: _____

Target Raw Score: 21 out of 36. If raw score is less than 36, repeat the return demonstration.

FACULTY SIGNATURE OVER PRINTED NAME