OUR LADY OF FATIMA UNIVERSITY

College of Nursing – Valenzuela Campus

STUDENT NAME
PROGRAM Bachelor of Science in Nursing
BSN 1-Y0-18
YEAR & SECTION

NCM-113 INSTRUCTOR
COURSE FUNDAMENTALS OF NURSING PRACTICE
SKILLS LABORATORY
DATE

PROCEDURE : APPLICATION OF ICE BAG

EXPECTED OUTCOME : The student should be able to use and apply ice bag correctly.
ASSESSMENT TASK : Return Demonstration

Assessment Exceptional Good Average Poor

SCORE
Dimension (3) (2) (1) (0)
1.Preparation to Verified the doctor’s Gathered procedure Some procedure Failed to gather
the procedure order. materials completely materials are procedure
but disorganize. lacking. materials
2.1. Place the ice Performed at least Performed at least Performed only
into the ice bag. If three (3) steps of the two (2) or three (3) one (1) step or
crushed ice is used, procedure. steps of the none at all.
place crushed ice procedure.
under running
water.
2.Preparing the 2.2. Fill the bag at
ice bag least two-thirds
(2/3).
2.3. Cover and
secure the top.
2.4. Invert the bag
to check for the
leakage.
Greeted and Performed at least two Performed one (1) Failed to greet
identified patient by (2) ways of identifying way of identifying and identify
3.Identifying the
asking his/her name patient. patient. patient.
client
and checking his/her
ID band and bed tag.
Explained procedure Explained procedure Explained procedure Failed to explain
and its purpose to but lacks some details. but in an unclear procedure and
4.Informing the
the client clearly manner. its purpose.
Procedure
and completely with
client’s consent.
5.1. Applied the ice Performed at least two Performed at least Failed to
bag on the (2) steps of the one (1) step of the perform any
5.Applying the treatment site. procedure. procedure. step of the
Ice Bag 5.2. Maintained the procedure.
temperature of the
ice bag.
5.3. Assessed
application site
frequently.

6.1. Removed bag Performed at least two Performed at least Failed to

unhurriedly after (2) steps of the one (1) step of the perform any
6.Removing the
the treatment. procedure. procedure. step of the
Ice Bag
6.2. Assessed the procedure.
application site after
 the treatment.
6.3. Evaluated effect
of the treatment.

Positioned client Positioned client Not positioned Not positioned

comfortably in bed comfortably in bed but client comfortably in client
observing proper not observing proper bed observing comfortably in
7. Positioning body alignment. body alignment. proper body bed and not
client alignment. observing
proper body
alignment.

Cleaned thoroughly Cleaned the materials Cleaned thoroughly Failed to clean

the materials used used and keep them in the materials used the materials
8.Caring
and keep them in their proper place but and but failed to used.
equipments after
their proper place. slips some details. keep them in their
used
proper place.

Documented the Some of the details of Most of the details Documentation

information about procedure were not of procedure were was not done.
the procedure documented. not documented.
9.Documenting properly and
the procedure completely.

SCALE:
3 – (EXCEPTIONAL) Works competently and independently at all times
2 – (GOOD) Requires minimum guidance and supervision
1 – (AVERAGE) Requires frequent guidance and supervision
0 – (POOR) Requires close guidance and supervision most of the time

OVERALL SCORE: ______________

Target Raw Score: 20 out of 27. If raw score is less than 20, repeat the return demonstration.

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FACULTY SIGNATURE OVER PRINTED NAME STUDENT NURSE SIGNATURE OVER PRINTED NAME