Schools of Health and Allied Health Sciences

College of Nursing

PERFORMANCE EVALUATION CHECKLIST

INDWELLING CATHETER INSERTION

1. Reviews doctor's order - to ensure that the procedure is appropriate for the patient and the
specific indication.
2. Identifies the patient - to ensure that the correct patient receives the procedure.
3. Assesses for allergies to iodine and latex - to prevent allergic reactions during the
procedure.
4. Explains the procedure, the type, and the purpose of catheterization - to obtain informed
consent from the patient and reduce anxiety.
5. Washes hands and prepare materials needed - to reduce the risk of infection.
6. Provides privacy - to maintain the patient's dignity and comfort.
7. Positions patient - to provide a comfortable and accessible position for the procedure.
8. Covers patient with bath towel - to maintain privacy and reduce exposure.
9. Places a waterproof pad under the patient's hip - to protect the bed from urine leakage.
10. Checks water temperature - to prevent discomfort or injury to the patient during the
procedure.
11. Wears disposable/clean gloves - to prevent contamination and reduce the risk of infection.
12. Washes patient's perineal area with soap and water, pat dry - to reduce the risk of
infection.
13. Removes gloves - to prevent contamination.
14. Opens pack containing drainage system maintaining sterility - to maintain sterility during
the procedure.
15. Places sterile dressing under the hips - to maintain sterility and reduce the risk of infection.
16. Drapes perineal area using sterile fenestrated sheet - to maintain sterility and reduce the
risk of infection.
17. Wears sterile gloves - to maintain sterility during the procedure.
18. Places sterile tray and contents on sterile dressing in between the patient's thighs - to
maintain sterility and provide easy access to the necessary equipment.
19. Tests balloon by injecting fluid (NSS) into the balloon port - to ensure proper functioning
of the catheter.
20. Withdraws fluid content and leave the syringe in place - to prepare for balloon inflation.
21. Lubricates the catheter: 2.5-5 cms (female); 12.5-17.5 cms (male) - to facilitate the
insertion of the catheter and reduce discomfort.
22. Female: Retracts labia and cleanses urethral meatus using iodine swab; Male: Grasps and
cleanses the glans penis using iodine swab - to reduce the risk of infection during the
insertion of the catheter.
23. Female: With dominant hand, inserts catheter 5 cms into the meatus; Male:
a. Holds the penis perpendicular to the body and gently pull up;
b. Injects 10 ml sterile water-soluble lubricant into the urethra;
c. Steadily, inserts the catheter about 8 inches into the meatus –
to insert the catheter into the bladder.
24. As urine drains, advances the catheter further - to ensure the catheter is correctly placed.
25. Holds the catheter and inflates balloon - to secure the catheter in place and prevent it from
falling out.
26. Tugs the catheter gently until resistance is felt - to ensure that the balloon is properly
inflated.
27. Secures catheter on patient's thigh using a leg strap or a plaster, makes sure it is not too
tight/not too loose - to prevent the catheter from being dislodged.
28. Places the drainage bag below the level of the bladder - to allow urine to drain efficiently.
 29. Disposes of materials, remove gloves, and wash hands - to prevent contamination and
reduce the risk of infection.
30. Repositions the patient - to ensure their comfort and safety.
31. Assesses and documents: character, color, and amount

TESTICULAR SELF-EXAMINATION

Rationale

STEPS
Knowledge and Skills: 70%
1. Cup the testicles with one hand to feel the weight. Cupping the testicles allows the individual to assess
● One testis may be larger /lower than the other. for any differences in size or weight, which may
indicate an underlying issue.
2. Check one testicle at a time. Checking one testicle at a time ensures that each
● Index and middle finger underneath the scrotum and testicle is thoroughly examined for any abnormalities,
thumb on top. and using the proper technique of rolling and feeling
a. Gently roll the testicle between fingers and thumb. allows for the detection of lumps or bumps that may
not be visible.
b. Do not squeeze too hard.
c. Check for any lumps, bumps, or painful areas.
d. Feel the epididymis
● Testicle should be round and smooth (like a hard-
boiled egg)
● Epididymis is not as smooth as the egg-shaped
testicle.

3. Repeat to the other testicle. Repeating the examination on the other testicle
allows for comparison and detection of any
differences between the two.
4. Palpate/feel the spermatic cord going up to the Palpating the spermatic cord allows for the detection
testicles. of any abnormal swelling or tenderness, which may
● The Spermatic cord is firm and smooth. indicate an underlying issue.

Total (12 points)

Attitude: 30%
1. Displays readiness in the performance of the This step ensures that the person performing the
procedure. testicular self-exam is mentally and emotionally
prepared to carry out the procedure effectively.
2. Shows spontaneity in the execution of each step. This step emphasizes the importance of carrying out
each step without hesitation or delay, as any delay
may cause the person to lose focus or become
distracted.

BREAST SELF EXAMINATION

RATIONALE
STEPS
Knowledge and Skills: 70 %
Standing Position: Checking for changes in breast size,
1. Stands in front of a mirror and places arms at the sides: skin, nipple, and vein patterns as a
baseline comparison for future breast
Checks for changes in the following:
self-examinations.
▪ Shape: Compare one to the other. One breast may normally be larger
than the other, but sudden changes in size should not occur.
▪ Skin: Check for rash, redness, puckering, dimpling, or orange-peel-
textured appearance.
▪ Nipples: Check for any physical changes such as a sudden inversion,
scaling, redness, itching, swelling, or discharge.
▪ Vein patterns: Look for a noticeable increase in size or number of veins
compared to the other breast.
2. Places hands on the hips and presses hands firmly. Bows slightly toward Checking for changes in breast
the mirror as shoulders are pulled and elbows pointed forward. Note any change contour and symmetry.
in the contour of both breasts.

3. Raises arms behind the head, clasps hands and presses hands forward. Checking for changes in breast
Bows slightly forward. Note any change in the contour of both breasts. contour and symmetry from a
different angle.
 4. Raises left arm over the head. Using the right hand (flat pads of the three Checking for any palpable lumps in
middle fingers), palpates left underarm for lumps in circular motion. the left underarm, which can indicate
cancerous lymph nodes.

5. Begins palpating the left breast by moving finger pads of the right hand Checking for any palpable lumps or
starting at the outer edge of the breast in small circles while applying pressure changes in breast tissue texture, which
until reaching the nipple. Squeeze the nipple gently. Palpates the entire breast can indicate breast cancer.
area.

6. Repeats on the right breast. Repeating the same examination

steps on the right breast to compare
with the left breast.

Lying Position:
1. Lies flat with a folded towel/pillow under the left shoulder to check the left Lying down with a towel or pillow
breast with the right hand. under the shoulder can help flatten
the breast tissue and make it easier to
detect lumps or changes.

2. Begins palpating the left breast by moving finger pads of the right hand Examining the breasts in different
starting at the outer edge of the breast in small circles while applying pressure positions can help identify changes in
until reaching the nipple. Squeeze the nipple gently. Palpates the entire breast contour or shape that may not be
area. noticeable in one position.

3. Repeats on the right breast. Repeating the self-exam on both

breasts can help ensure that any
changes are detected and monitored
over time.

Attitude: 30%
1. Displays readiness in the performance of the procedure.
2. Shows spontaneity in the execution of each step.
3. Readily accepts constructing criticism if found to be incorrect.
4. Answers all questions readily.
5. Observes precautionary measures and neatness at all times.
6. Accomplishes the procedure on time.

NASOGASTRIC TUBE INTUBATION AND ADMINISTERING

ENTERAL NUTRITION VIA NASOGASTRIC TUBE

PROCEDURE RATIONALE
ATTITUDE: 30% (15 points)
1. Displays readiness in performing the procedure
2. Displays conscientious efforts to correct mistakes.
3. Shows enthusiasm and interest in performing the procedure.
4. Employs professionalism, reliability and confidence in the procedure.
5. Answer rationale questions correctly.

TOTAL
KNOWLEDGE AND SKILLS 70% (117 points)
A. NASOGASTRIC TUBE INTUBATION
1. Verifies the patient’s need for enteral tube feedings. to ensure appropriate intervention.
2. Assesses for presence of skin breakdown and patency of nostrils: to prevent further injury or discomfort
Ask the patient to breathe, occluding one nostril at a time. to the patient.
3. Reviews patient’s medical history (gag reflex, nostril surgery, unusual to identify potential complications
nostril bleeding, bowel sounds, mental status). during the procedure.
4. Explains the procedure to the patient. to promote informed consent.
5. Informs the patient on how to communicate during intubation (hand signal to ensure patient comfort and safety.
or raise index finger for discomfort).
to ensure all necessary materials are
6. Prepares the equipment.
available.
7. Positions patient in sitting or high-Fowler’s position. to facilitate tube insertion.
If patient is comatose: semi-Fowler’s position with head propped forward
using pillow
8. Covers the patient’s chest with a towel. to maintain cleanliness.
9. Washes hands and puts on clean gloves. to prevent the spread of infection.
10. Determines the length of the tube to be inserted and mark with a to ensure proper placement.
tape.
11. Lubricates the first 4 inches of the tube with water-soluble lubricant. to ease insertion.
12. Asks the patient to slightly flex the neck backward. to facilitate tube insertion.
13. Gently insert the tube into the naris. to begin the intubation process.
14. Asks the patient to flex head forward once the tube reaches the to guide the tube towards the
nasopharynx. stomach.
15. Advances the tube several inches at a time as the client swallows. to ensure proper placement and
Withdraw the tube immediately if there are signs of respiratory prevent discomfort.
distress.
16. Advances the tube until the taped mark is reached. to ensure proper tube length.
17. Secure the tube to the nose with a tape. to prevent dislodgment.
Checks the placement of the tube
18. Checks the placement of the tube: through auscultation, pH
a. Injects 10 cc of air and auscultate. measurement, and x-ray to ensure
b. Aspirates gastric content and measures pH. proper placement and prevent
c. Prepares the patient for x-ray check-up, if prescribed. complications.

19. Caps or clamps the distal end of the tube or connects to suction machine or to begin enteral nutrition.
drainage bag.
20. Fastens the tube to the patient's gown with a tape. to prevent dislodgment.
21. Removes gloves, disposes used materials appropriately, and washes hands. to prevent the spread of infection.
22. Assists patients to a comfortable position. to ensure patient comfort.
to maintain accurate patient records
23. Documents procedure.
and ensure continuity of care.
B. ADMINISTERING ENTERAL NUTRITION VIA NASOGASTRIC TUBE
To ensure that enteral nutrition is
1. Assesses patient’s need for enteral tube feedings, food allergies. necessary and that allergies are
avoided.
To assess bowel motility and
2. Auscultates bowel sounds.
determine tolerance to feedings.
3. Obtains baseline weight and reviews laboratory values. Assesses patients for To assess baseline fluid and
fluid volume excess or deficit, electrolyte abnormalities and metabolic electrolyte status to prevent
abnormalities such as hyperglycemia. imbalances caused by feeding.
To ensure that the feeding is ordered
4. Verifies the health care provider’s order. by the healthcare provider and that
it is appropriate for the patient.
To inform the patient about the
5. Explains the procedure to the patient. feeding procedure to promote
cooperation and understanding.
To prepare the feeding and materials
6. Prepares feeding and the materials needed. to ensure that the feeding is
administered correctly.
To position the patient in high-
7. Positions patient in high-fowler’s position. fowler's position to facilitate tube
feeding.
To maintain aseptic technique and
8. Washes hands and applies gloves.
prevent infection.
To verify proper tube placement to
9. Check tube placement. ensure safety and efficacy of
feeding.
To check for gastric residual volume
10. Check gastric residual volume. Measure residual volume if present. to prevent complications such as
aspiration or vomiting.
To maintain tube patency and
11. Irrigates tube.
prevent clogging.
To start feeding and provide
12. Start tube feeding.
adequate nutrition.
To ensure complete delivery of the
13. When feeding is done, irrigate the tube.
feeding and prevent clogging.
To prevent reflux or regurgitation of
14. Caps or clamps the distal end of the tube.
stomach contents.
15. Maintains patient in high-fowler’s position for 30 minutes to1 hour after To prevent complications such as
feeding. aspiration or vomiting.
To document the feeding procedure
16. Documents procedure. for accurate patient records and
continuity of care.