EVALUATION FORM

Clinical Facilitator: Sabiha Tariq Perceptor Name: Ms. Sumaira Asim

SAP ID:70145200 Date: 25-04-2024

WEEK-4 12-02-
WEEK-5 19-02-2024 WEEK-6 26-02- WEEK-7 04-3- 2024 WEEK-8 11-03- WEEK-9 1-04- WEEK-12 15-04-
WEEK-1 22-1-2024 WEEK-2 29-01-2024 WEEK-3 05-02-2024 2024 WEEK-10 1-04-2024 WEEK-11 8-04-2024
CHECKLIST 2024 Participate in Wean off 2024 2024 2024
SNO SAP ID Name CHECKLIST CHECKLIST CHECKLIST CHECKLIST Interpret Cardiac Monitor Prepare Ventilator under
(Nutrition in Critical CHECKLIST Patient from Mechanical Participate in ACLS Flowchart Dose calculation of
(Providing ABCD care) (ECG Interpretation) (Intubation procedure) (Fluid and Electrolyte Findings Staff Supervision
Care-NG Feeding) (How to Measure CVP) Ventilation Protocol Documentation Ionotropic Drugs
Imbalance)

Evaluatio Evaluatio
Objectives Evaluation Objectives Evaluation Objectives Evaluation Objectives Evaluation Objectives Evaluation Objectives Objectives Evaluation Objectives Evaluation Objectives Objectives Evaluation Objectives Evaluation Objectives Evaluation
n n

Select and Recognize and Verify the Verify the

Assess patient's Determine the prepare the Assess readiness respond to signs Define the physician's patient's weight
Ghulam Coordinate care with Determine the heart Verify the need of purpose and Identify the heart order and and other Need
1 70121627 Satisfactory Satisfactory Achieved fluid volume Achieved need for NG Achieved appropriate Achieved for weaning based Achieved Satisfactory Achieved Achieved Achieved
Dastagir multidisciplinary teams. rate. for intubation. cardiopulmonary scope of the rate and rhythm. patient-specific relevant Improvement
status. tube placement. central venous on clinical criteria. arrest flowchart. ventilator demographic
catheter site. immediately. settings. information.

Perform a Assemble and

Choose the Establish a zero Apply basic life Identify and Confirm the
Identify the rhythm Prepare necessary Identify specific spontaneous inspect all
support (BLS) understand all Recognize normal appropriate
Build rapport and trust through appropriate size reference point ventilator Need
2 70122075 Aisha khalil Achieved as regular or Satisfactory equipment and satisfactory electrolyte Achieved Achieved Achieved breathing trial Achieved techniques Achieved processes and Satisfactory and abnormal P Achieved Achieved inotropic drug
effective communication. and type of NG at the level of the including CPR decisions waves.
components for
and indication
Improvement
irregular. medications. imbalances. (SBT) to evaluate functionality and
tube. mid-axillary line. effectively. involved. for use.
tolerance. cleanliness.

Monitor vital Prepare the Position the Monitor patient's Use standard Connect and Calculate the
Assess the P wave Position the Utilize ACLS
symbols to Measure the PR test the power initial dose
Rowaid Ahmad Coordinate care with signs and patient by patient properly, respiratory rate, algorithms to Partially Partially Need
3 70121593 Achieved morphology and Satisfactory patient to optimize Achieved Achieved Achieved Achieved Achieved represent interval and identify Achieved supply and Achieved based on
Khan Yousafzai multidisciplinary teams. laboratory explaining the typically in a oxygen saturation, guide treatment Achieved different types of Achieved abnormalities. backup standard dosing
Improvement
presence. airway alignment. decisions.
values. procedure. supine position. and comfort. actions or steps. systems. guidelines.

Calibrate
Administer Measure and Adjust ventilator Administer Adjust the dose
Administer Connect the Organize the sensors and
appropriate Analyze the QRS according to
Measure PR interval appropriate Need mark the NG settings gradually flowchart alarms
4 70122169 Mah Noor Deliver personalized interventi Achieved Achieved appropriate IV Achieved Achieved transducer to the Satisfactory Achieved medications as Satisfactory Achieved complex duration Achieved Achieved patient-specific Satisfactory
duration. sedation and Improvement tube for correct as per weaning indicated by the
logically to reflect
and morphology.
according to
factors (e.g.,
or oral fluids. CVP catheter. actual workflows. manufacturer
paralysis agents. placement. protocol. ACLS protocol. renal function).
guidelines.

Set initial
Perform oral or Correct Insert the NG Calibrate the Evaluate arterial Manage airway Ensure all Evaluate the ST ventilator Convert dose
Document all care activities Measure QRS nasal intubation Need electrolyte tube through the transducer blood gases to using advanced components are segment for parameters units as
5 70121906 Aqsa Tasaddiuq Achieved Achieved Achieved Achieved Satisfactory Achieved Satisfactory Achieved Achieved Achieved Satisfactory
accurately and timely. complex duration. using a Improvement deficiencies or nostril to the system to ensure assess gas techniques as clearly labeled elevation or based on necessary (e.g.,
laryngoscope. excesses. stomach. accuracy. exchange. required. for clarity. depression. prescribed mg to mcg).
settings.

Confirm Provide Link all elements Perform a

Educate patients and families Analyze ST segment Confirm Evaluate the placement of the Record the CVP respiratory therapy Monitor and Determine
accurately to Interpret the T wave safety check to
Muhammad interpret cardiac infusion rate
6 70121715 about care plans and health Satisfactory for elevation or Satisfactory placement of the Achieved effectiveness of Achieved NG tube using Achieved reading from the Achieved and exercises to Satisfactory Achieved depict true Achieved for abnormalities in Achieved ensure all Achieved Satisfactory
Faiz Alam rhythms using standard
management depression. endotracheal tube. interventions. appropriate monitor. strengthen process morphology. systems are
accurately. formulas.
methods. breathing muscles. dependencies. operational.

Educate the Educate and Attach the

Implement
Follow up to evaluate care Evaluate T wave patient and Secure the NG Monitor and reassure the Review and Look for additional ventilator circuit Prepare the
electrical therapy
Shahzana Secure the validate the waves, such as U to the patient drug dilution if Need
7 70121868 effectiveness and adapt as Satisfactory shape and Satisfactory Satisfactory family on Achieved tube to prevent Achieved document CVP Achieved patient throughout Achieved (defibrillation or Achieved Satisfactory waves or abnormal Achieved Achieved
Aslam endotracheal tube. pacing) when
flowchart with interface (e.g., required for Improvement
needed. orientation. management displacement. trends over time. the weaning stakeholders. Q waves. endotracheal administration.
strategies. process. indicated.
tube).

Adjust treatment Assess patient Collaborate with Document all

Provide care Coordinate and Update the Document setup
Monitor patient based on response and the Assess trends and calculations and
Check for presence and communicate flowchart as procedures and
Evaluate & support normal for any ongoing adjust treatment multidisciplinary changes over time preparations Need
8 70121681 Saad Aslam Satisfactory of additional waves Satisfactory Satisfactory Achieved maintenance of Achieved Achieved Achieved effectively with Achieved processes Satisfactory Achieved initial settings in Achieved
circulation complications assessments and as necessary team for the resuscitation change or
to guide clinical
the patient's
accurately in the Improvement
like U waves. the NG tube and decisions. patient's
post-intubation patient based on CVP comprehensive team. improve. medical record.
site. medical record.
response. readings. care management.

Perceptor Signatures:________________________