Republic of the Philippines

CENTRAL MINDANAO
UNIVERSITY
College of Nursing

PERFORMANCE CHECKLIST
"NGT OGT FEEDING"

Name: Sec/Group: Score: Rating: 0

Scal Description Interpretation Assisstance Needed

e
The student demonstrates exceptional performance and mastery of the procedure with
5 Outstanding Without Direction
proficiency, coordination and confidence.
The student demonstrates the step-by-step procedure with efficiency, coordination, With occasional physical or
4 Very
confidence and uses time effectively but failed to mention some of verbal direction
Satisfactory
the rationale.
The student meets the standards or basic requirements of the procedure with partial
3 Satisfactory With frequent verbal and/or
demonstration of skills, inefficient, uncoordinated, misses some steps and rationale
direction
and has delayed time expenditure
The student is unskilled and inefficient considering the prolonged use of time and barely With continuous verbal and/or
2 Fair physical
meets the standard requirements of the procedure.
direction
Needs The student misses most of the steps, without rationale, lacks confidence, coordination and With close mentoring and
1 efficiency and failed to meet the standard requirements of the continuous
Improvement
procedure. verbal and physical direction

Procedure 5 4 3 2 1
Preparatory Phase

1 Assemble equipment. Check amount, concentration, type, and frequency of tube

feeding on patient’s chart. Check expiration date of formula.
2 Perform hand hygiene and put on PPE, if indicated.
3 Identify the patient.
Explain the procedure to the patient and why this intervention is needed. Answer
4
any questions as needed.

5 Assemble equipment on overbed table within reach.

6 Close the patient’s bedside curtain or door. Raise bed to a comfortable working
position, usually elbow height of the caregiver. Perform key abdominal assessments
as described above.
7 Position patient with head of bed elevated at least 30 to 45 degrees or as near
normal position for eating as possible.
8 Put on gloves. Unpin tube from patient’s gown. Verify the position of the marking on
the tube at the nostril. Measure length of exposed tube and compare with the
documented length
Assessment Phase

9 Attach syringe to end of tube and aspirate a small amount of stomach contents, as
described in Skill 11-2.
Check the pH as described in Skill 11-2.
10
11 Visualize aspirated contents, checking for color and consistency.
12 If it is not possible to aspirate contents; assessments to check placement are
inconclusive; the exposed tube length has changed; or there are any other
indications that the tube is not in place.

13 Aspirate all gastric contents with the syringe and measure to check for the residual
amount of feeding in the stomach. Return the residual based on facility policy.
 Proceed with feeding if amount of residual does not exceed agency policy or the limit
indicated in the medical record.

14 Flush tube with 30 mL of water for irrigation. Disconnect syringe from tubing and cap
end of tubing while preparing the formula feeding equipment. Remove gloves.

15 Put on gloves before preparing, assembling and handling any part of the feeding
system.
16
Administer feeding.
Termination Phase

17 Observe the patient’s response during and after tube feeding and assess the
abdomen at least once a shift.
18 Have patient remain in upright position for at least 1 hour after feeding.
19 Remove equipment and return patient to a position of com fort. Remove gloves.
Raise side rail and lower bed.
20 Put on gloves. Wash and clean equipment or replace accord ing to agency policy.
Remove gloves
21 Remove additional PPE, if used. Perform hand hygiene.
TOTAL 0 0 0 0 0

Knowledge/Assignment Score 0
Total 110

Data source: BCIT, 2015b; Berman & Snyder, 2016; Perry et a Skills (Video) score
Comments:

Clinical Instructor:
Signature over printed name Date
 Rubrics Return Demonstration
Video
Paramete 15 10 8 6 Point
r s
It covers all the topics in
It includes basic knowledge It includes essential information
Content depth with details. The The content includes minor details
about the topic. The content about the topic, but it has some
knowledge on the topic is and it has several mistakes. Most of
and seems to be good. mistakes.
excellent. With rationale the steps have no rationale.
About 70% of the steps have About 40% of the steps
Organizati all throughout the video.
rationale. have rationale.
on
The student use language
The student use language The patient minimally
appropriately and
Use of understandably to deliver understands the language The student use language that confuses
understandable to deliver
Langua information to the patient with being used by the student to the patient on the information being
the information to the
about 70% grammatical error. deliver information with about delivered most of the time.
ge patient with no
40% grammatical error.
grammatical error.

Meets the standards or basic

Demonstrates Able to state and Barely of fails to meet the requirements
requirements of the procedure.
exceptional demonstrate the step-by-step of the performance of the procedure,
Misses some steps and
Executio performance and procedure but failed to
rationale with partial
misses not of the steps, without
n mastery all throughout mention the rationale. rationale. Unskilled and inefficient.
demonstration of skills,
the procedure. Efficient, coordinated, Considerable and prolonged time
inefficient, uncoordinated.
Proficient, coordinated confident. Expedient use of expenditure. Lacks confidence,
Delayed time Expenditure
and confident time. coordination and efficiency.

Timely Submits the output on or Submits the output 3 hours Submits the output 5 hours Submits the output more than 5 hours
submissi before the LATE form the set LATE from the set LATE from the set time.
on deadline. time. time.

SCORE 0