Far Eastern University

Institute of Nursing

STUDENT PERFORMANCE EVALUATION TOOL

12 LEAD ECG

Name:Abad, Ysabel Francesca T. Sec/Group No:BSN 315 Group 1-A Date: November 11, 2022
Area: Faculty: Ms. Glenda Moraño Concept:

DIRECTION: Rate the learner based on the competencies listed below

KEY:
3 – Acceptable Demonstrates expected procedure/behavior correctly.
2 – Moderately Acceptable Demonstrates expected procedure/behavior with minimal error.
1 – Slightly Acceptable Demonstrates expected procedure/behavior with many errors.
0 – Unacceptable Missed procedure or procedure done but entirely incorrect

NURSE AS PRACTITIONER RATING REMARKS

Demonstrate responsible citizenship and pride in being a Filipino.
Demonstrate the core values of FEU (Fortitude, Excellence, and Uprightness) in the practice of the nursing
profession.
Perform safe, appropriate, and holistic care to individuals, families, population groups, and communities utilizing the
nursing process
A. ATTENDANCE AND ATTITUDE 0 1 2 3
1. Displays proper grooming and wears complete well pressed uniform 0 1 2 3
2. Observes proper decorum at all times 0 1 2 3
3. Accepts constructive criticism 0 1 2 3
4. Handles mannequin/patient with care and respect 0 1 2 3
5. Performed hand hygiene 0 1 2 3
Practice nursing in accordance with existing laws, legal, ethical and moral principle
Communicate effectively in writing, speaking, and presenting using culturally-appropriate language.
Document and report on client care accurately and comprehensively.
Adopt the nursing core values in the delivery of nursing care.
Demonstrate the core values of FEU (Fortitude, Excellence, and Uprightness) in the practice of the nursing
profession.
B. PROCEDURE
ASSESSMENT RATING REMARKS
1. Introduces self and identifies the patient 0 1 2 3
2.Explains the procedure to the patient and the rationale 0 1 2 3
3. Assesses for the client’s condition, history of heart ailment and others 0 1 2 3
4. Prepares all the necessary equipment and materials prior to procedure 0 1 2 3
5. Provides privacy, observe proper draping 0 1 2 3
6. Places patient in supine position, with head slightly elevated 0 1 2 3
7. Prepares client’s skin should there be a need for:
a. Hair needs to be shaved
b. Greasy skin to be washed and dried
c. Remove all metals, pins, coins
d. Turn on the machine to check if functioning and check for tracing paper
e. Wipe area using alcohol swab / water 0 1 2 3
PROCEDURES
8. Applies the 4 limb leads properly on correct placement
Right Arm
Left Arm
Right Leg
Left leg 0 1 2 3
9. Applies the 6 precordial leads 0 1 2 3
V1- 4TH ICS Right Sternal margin 0 1 2 3
V2- 4th I CS Left Sternal margin 0 1 2 3
V3- midway bet V2 and V4 Left 0 1 2 3
V4- 5th ICS Mid Clavicular Line (MCL) Left 0 1 2 3
V5- 5th ICS Anterior Axillary line Left 0 1 2 3
V6- 5th ICS Mid Axillary Line ( MAL) Left 0 1 2 3
10. Instructs client to relax and standstill 0 1 2 3
11. Turns on the machine and set according to the doctor’s order/need 0 1 2 3
12. Places/ Encode name of the patient, time, age, date of ECG 0 1 2 3
13. Turns off the ECG machine 0 1 2 3
14. Removes the leads gently , starting with the chest leads followed by limb 0 1 2 3
leads
15. Places client in comfortable position 0 1 2 3
16. Performs aftercare 0 1 2 3
TOTAL SCORE =

Signature of Student Signature of Faculty