CENTRO ESCOLAR UNIVERSITY

MAKATI CAMPUS
Nursing Department

BSN Level III Performance Checklist

PSYCHIATRIC NURSING

Name of Student Score

Year Section/Group Number

Rate the student's performance by checking the appropriate box using the following criteria

5 - Excellent (Carries out procedures efficiently, systematically and independently)

4 - Very Satisfactory (Carries out procedures efficiently and systematically but requires minimal guidance
and supervision )
3 - Satisfactory (Carries out procedures efficiently and systematically but requires moderate guidance
and supervision )
2 - Fair (Carries out procedure efficiently and systematically but requires close guidance and supervision
1 - Poor (Carries out procedure inefficiently, unsystematically even under guidance and supervision

* Average mean shall be computed and multiplied by factor 20. The product shall be transmuted using the table for 100 points.
Passing cut-off score is 65%.

Criteria 5 4 3 2 1
I. ASSESSMENT
1. Participates willingly in self awareness activity
2. Asssess patients readiness to participate with activities
3. Gathers information by chart reading and interview
a. History taking- personal data, chief complaint/
presenting problem, family history, past and present
medical illness, previous psychiatric disorders, social
patterns, sexual patterns, interest and abilities
and coping abilities
b. Physical assessment (focused assessment)
c. MSA- General appearance, motor behavior, speech
mood, affect, thought process and content
4. Prepares and presents plan of activities for the day
5. Facilitate and participates in social interaction with client.
6. Sets contract with the patient for the nurse-patient interaction
II. DIAGNOSIS
1 Determines appropriate nursing cues
2. Makes correct Psychiatric nursing diagnosis
3. Interprets and analyzes psychodynamics of the problem
4. Prioritizes nursing diagnosis that are NANDA based
III. PLANNING
1. Facilitate reorientation of patient to people, place and time
through psychotherapy
1.1 Explain and orient patient to each activity
1.2 purpose, goals and objectives
1.3 priorities and expectations of the activity
2. Plans correct nursing interventions for specific client.
IV. IMPLEMENTATION (PSYCHOTHERAPY)
Music and Art Therapy
1. Prepares all materials needed for the therapy, topic, cassette for

Copy to: Faculty

AAF-NU 175
Rev. 1 01/27/2009 Page 1 of 2

Criteria 5 4 3 2 1
music, crayons/watercolor and paper for art
2. Ensures materials are adequate and all participants have adequate
3. Distributes materials in an organized manner
4.Plays music without lyrics and lets patient draw using their choices
5 Gathers patients in a form of a circle for the sharing session
6. Accepts the verbalizations of patients based on the drawings
7. Asks relevant questions based on given information
Occupational therapy
1 Explains the therapy in simple understandable terms
2. Emphasize rules and regulations of the therapy
3 Do not use sharp objects
4 Do not use potentially hazardous materials
5. Allo/Ass
llow/ Assist the patients to do activities on his own
6. Supervise the patients althroughout the activity
7. Attends to patients needs

Bibliotherapy
1. Match patients capabilities with appropriate materials
2. Check that the book is within the patients reading ability level
3. Book texts must be interesting
4. Reading theme matches the identified needs of the patient
5. The book has believable characters wherein the patient can
empathize with the predicament.
6. Decides on the setting and time of the session
7. Motivates the patient with interesting introductory activities
8. Engage the patient in reading, viewing and listening
9. Allows the patient to reflect on the topic
10. Asks leading questions and starts short discussions throughout
the reading.

Play therapy
1. Divide the participants into two groups according to the physical
strengths and weaknesses of the clients
2. Chooses appropriate game or play duly approved by the CI
3. Secure safety of the environment and organization of the activity
4. Conducts psychosocial conference about the activity
5. Gets feedback of patients feelings and reaction towards the game
6. Integrate clients reaction or response according to present
situation.

Remotivation Technique
1. Promotes open communication with the patient and significant
others involved in the therapy
2. Recognizes and appreciates patient participation
3. Assists and makes progress with the clients verbatim
4. Facilitates therapeutic communication techniques to illustrate
clients thoughts and perceptions
5. shows concern to client by listening and responding attentively
6. responds objectively to clients behaviors and needs
7. Facilitates the progress of the therapy and uses the following
techniques. STEPS: 1. Climate of acceptance 2. Bridge to reality
3. Sharing the world we live in 4. An appreciation of the work of
the world and 5. Climate of appreciation
8. Promotes sharing of ideas, feelings and concerns of client to group
9. Make clear ans explain sentiments, emotions and feelings of client
10. Records the details of interaction accurately during the session

IMPLEMENTATION (THERAPEUTIC RELATIONSHIP)

1. Maintains a therapeutic relationship with the client
2. Identify and facilitates behavior changes with the client during
the working phase
3. Promotes clients problem solving activities
4. Practices alternative adaptive behavior with the client
V. EVALUATION
1. Evaluates data about the client's response to care.
2. Reviews with the patient the progress made during the
therapeutic relationship
3. Plans and facilitates the Scialization day activities
4. Shares and participates in the post exposure reflection activity
VI. ATTITUDE (10%)
1. Complies with the rules and regulations set by the college
2. Give due respect to authorities and is courteous at all times
3. Responds promptly to client's needs
4. Accepts criticisms constructively
 5. Demonstrates honesty at all times
6. Exhibits genuine interest and kindness in caring for patients
7. Devises effective method or approaches to meet individual
needs of patients
9. Maintains the confidentiality of the patient
9. Treats each patient as a unique and individualized, while
maintaining acceptable standards
10. Shows empathy to patient

Comments/Suggestions:

Computation: Part I = Total score divided by (number of items x 20 (factor) x .90 = ________
Part II = Total score divided by 10 (number of items x 20 (factor) x .10 = ________

Part I = 90%
Part II = 10%
Total Points ______

*Total points shall be transmuted using the table for 100 pts. Passing cut-off point is 65.

Equivalent Numeric Grade: _______________

Interpretation: _________________________

Copy to: Faculty

AAF-NU 174
Rev. 1 01/27/2009 Page 2 of 2