PERFORMANCE EVALUATION TOOL

NCM 109 – CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS

(ACUTE AND CHRONIC)

DIRECTIONS:
● The evaluation tool will be discussed by the clinical instructor/s.
● During the discussion, the instructor/s may demonstrate the procedures or may use
video viewing for students’ orientation.
● The students should be given sufficient time to prepare for the return demonstration.
● The students will do the return demonstration based on the checklist given.
● The following rating scale shall be used in grading student’s performance:

2 points - able to perform

Perform the procedure safely and accurately in a very consistent and
independent manner without supportive assistance from the instructors.
Perform a difficult action quickly and skillfully
Spends minimal time on task
Focuses on client while giving care

1points - able to perform with assistance

Perform the procedure safely and accurately with frequent guidance and
supervision from the instructor.
Demonstrate incomplete skills in some part of the procedure.
Takes longer time to complete the procedure.

0 point - unable to perform

Unable to perform procedure even under close supervision of guidance
Require continuous, supportive and directive cues
Performs in unskilled manner

● At the end of each laboratory session, the instructor/s will give remarks based on the
student’s performance in accordance to the procedures indicated.
 PERFORMANCE EVALUATION TOOL
NCM 109 – CARE
OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC)
NAME OF STUDENT: _____________________
Block #______

PROCEDURE: WOUND CARE (DRY DRESSING)

N PURPOSE/S: 2 1 0 REMARKS
O
1 To promote healing.
2 To prevent infection
3 ASSESSMENT RATIONALE
To ensure the right
4 Doctor’s order order is carried out at
the right time.
5 Client’s level of consciousness Determine client’s ability
and level of knowledge and to follow instructions.
understanding
Ask the client about allergy to Helps the nurse to
6 latex or Chlorhexidine select another cleansing
gluconate or any cleansing solution and materials.
solution.
Completeness of the materials To save the nurse’s
7 needed time and energy.
8 Procedure/Implementation RATIONALE
1.Identify the client, explain >Ensures correct
9 the procedure, why it is patient and promotes
necessary and how she can client’s cooperation and
cooperate. participation during the
procedure.
2.Wash hands and wear clean Reduces the
10 gloves and other Personal transmission of
Protective Equipment. microorganisms.

>Saves time and effort.

11 3.Gather the necessary >Avoids leaving the

materials and arrange at the client unattended to
client’s bedside table. retrieve missing
materials.
>Promotes client’s
safety.
12 a.Clean exam gloves
b.Container for proper
13
 disposal of soiled dressing
N PURPOSE/S:
O
14 c.Sterile 4x4 gauze
15 d.Washcloth (optional)
16 e.Abdominal pads (optional)
17 4.2 inch tape (foam or paper)
4.Close the door and draw the
18 curtain divider.
5.Raise the bed to its’
19 comfortable level and lower
the siderails where you will
work and put away call light.
6.Remove gloves, do hand
20 rub and wear another clean
gloves.
21 7.Remove dressing and place
in appropriate receptacle.
8.Removed soiled gloves with
22 contaminated surfaces inward
and discard in appropriate
receptacle
9.Assess the appearance of
the undressed wound bed for
23 healing as well as signs of
infection and delayed healing
such as pain, redness,
inflammation around the
surrounding tissue, type and
volume of exudate
24 10.Do hand rub and wear
clean gloves.
RATIONALE 2 1 0 REMARKS
>Promotes client’s
privacy
Helps the nurse to work
at ease.
>Prevents strain at the
nurse’s back.
>Prevents spread of
microorganism.
Dressing and soiled
gloves with body fluids
are considered
contaminated and
subject to biohazard
disposal in correct
manner per institution
protocol
>Helps the nurse to
identify what nursing
management is needed.
>Reduces transmission
of microorganisms
>Dressing changes are
considered to be clean
procedures once the
initial dressing has been
removed if the skin
margins are well
approximated
N PURPOSE/S: RATIONALE 2 1 0 REMARKS
O
11. If inspection of wounds
25 revealed delayed
epithelialization, don sterile
gloves
12.Clean the skin around the Dry blood or drainage
26 incision if needed with can act as a medium for
moistened gauze. bacterial growth
13.Cleanse the incision if
needed with gauze or cotton
27
tipped applicator moistened
with saline (or with solution
ordered by the physician or
qualified practitioner)
14.Used applicators should
28 not be reintroduced into the
cleansing solution
15.Apply the gauze dressing No touch technique
29 using the “no touch” prevents the
technique; grasp just the edge contamination of the
of the dressing, fold if needed, dressing
and apply to the wound.
16.Secure with tape (or
30 tubular mesh for client with
sensitivity to tape)
17.Initial the dressing and This maintains the
31 indicate the date and time it record of the dressing
was changed. change for the next
nurse
18.Optional: An abdominal >To promote client’s
32 pad may be applied over the comfort
gauze dressing if needed >For absorption of
exudate
19.Lower the bed. Raise the >Promotes client’s
33 side rails and put the call light safety.
within the client’s reach.
20.Dispose all soiled >Prevents spread of
34 dressings properly according disease and bacteria
to hospital policy.
>Maintains orderliness
35 21.Rearrange reusable of materials and the
 materials in its proper places. environment.

N PURPOSE/S: RATIONALE 2 1 0 REMARKS

O
22.Remove gloves and other
36 PPE, discard properly and do
hand washing.
23.Conduct client and family
37 education about the dressing;
which may include the
dressing technique to the
client and family
24.Document the procedure
38 and other important findings
on the client’s chart.
> Refer any abnormal findings
to the attending physician.
>Prevents spread of
microorganisms.
To prepare the client
and family for proper
wound care as they
prepare of going home.
>Provides record of the
client’s care and serves
as a baseline for further
management.

TOTAL SCOR/GRADE: __________

Student’s Signature: ________________ Instructor’s Signature:

______________
Date: _______

Comments/Suggestions:
__________________________________________________
______________________________________________________________________
______________________________________________________________________

Reference: Daniles, Grendell, Wilkins (2010) Fundamentals of Nursing. Nursing Human

Functions. Volume 2. ESP Printers, Inc.Philippines