COLLEGE OF NURSING

PERFORMANCE EVALUATION TOOL

COLOSTOMY CARE PROCEDURE 1 Check the doctors order. 2 Identify the client, introduce self and explain the procedure. 3 Gather the materials Clean washcloth or 4x4 gauze pads Warm tap water Appropriate drainable ostomy appliance Scissor Pen or pencil measuring card skin wafer Disposable gloves 4. Do hand washing 5. Provide privacy 6 Apply disposable gloves 7 Prepare garbage bag 8 Remove current ostomy appliance after emptying pouch of stool, if present 9 Dispose of appliance in appropriate waste container. 1 Remove gloves and wash hands. Apply disposable 0 gloves 1 Cleanse stoma and skin with warm tap water. Pat dry. 1 1 Measure stoma using a measuring guide for 2 appropriate length and width of stoma at base (where skin meets stoma) 1 Place gauze pad over orifice of stoma to wick stool 3 while you are preparing the wafer and pouch for applications 1 Trace pattern onto paper backing of wafer 4 1 Cut wafer as traced 5 1 Remove gauze pad from the orifice of stoma 6

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Remove paper backing from wafer and place on skin with stoma centered in cutout opening of wafer Remove gloves. Discard all non reusable materials. Arrange reusable materials on its proper place. PROCEDURE Do hand washing Ensure clients comfort and safety Document the procedure.

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Students Signature:_______________ Date:_____

Instructor Signature________________ Date:__________

Comments/Suggestions:__________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

COLLEGE OF NURSING
PERFORMANCE EVALUATION TOOL
NCM 104- CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC RESPONSE AND COORDINATION NGT FEEDING 1 2 3 PROCEDURE Check for the doctors order Identify the client. Introduce self and explain the procedure Gather materials: Catheter tip syringe, 60 ml Stethoscope Gloves pH indicator strip Emesis basin Measuring container with the desired amount of feeding towel Arrange materials on top of the overside table. Wash hands. Apply gloves. Place towel on clients chest Assess placement of the tube by auscultation: Place the stethoscope over left upper quadrant of the abdomen Quickly inject 10-20 ml of air with the 60 ml syringe Assess for resistance (if resistance is felt, aspirate GI content) Listen for sound ( a whooshing or gargling sound can be heard as air enters the stomach) Measure pH of GI contents; Aspirate 10 ml of GI contents with 60 ml syringe Position client on a high Fowlers position if tolerated Put towel on the clients chest 5 4 3 2 1 REMARK

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Proceed with feeding and medication. Continue to monitor client for discomfort Flush tube with 30 ml warm water after medication or tube feeding Do after care and rearrange materials on its proper places. Ensure clients comfort and safety. Remove gloves and wash hands PROCEDURE Document the procedure and other relevant data on the clients chart. 5 4 3 2 1 REMARK

Students Signature:_______________ Date:_____

Instructor Signature________________ Date:__________

Comments/Suggestions:__________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

COLLEGE OF NURSING
PERFORMANCE EVALUATION TOOL
NCM 104- CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC RESPONSE AND COORDINATION INSULIN INJECTION 1 2 3 PROCEDURE Check the doctors order. Identify the patient. Introduce self and explain the procedure. Gather the materials: Tuberculin syringe Aspirating needle, if needed Insulin medication Cotton balls with alcohol in a receptacle or alcohol swab Medication card Hypo tray Pair of gloves Arrange materials on top of the overhead table Wash hands and put on gloves. Provide clients privacy, comfort and safety Position client on a sitting position if tolerated. Prepare the medication using aseptic technique Disinfect the rubber stopper of the medication with alcohol swab or cotton ball with alcohol Remove the cap of the tuberculin syringe and aspirate the desired dose of insulin injection. Change the needle if needed. Select injection site Inspect skin for bruises, inflammation, edema, masses, tenderness, and sites of previous injection 5 4 3 2 1 REMARK

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Disinfect the site of injection Use alcohol swab or cotton ball with alcohol starting from the inner site going to outer site in circular motion Remove the cap of the syringe and with the alcohol swab on the nondominant hand, administer the insulin medication IM route if using insulin injection Withdraw the needle by pressing the swab on the site while withdrawing the needle PROCEDURE Ensure client safety and comfort Discard used materials and rearrange other materials on its proper places. Remove gloves and do hand washing Document the procedure and other relevant data on the clients chart

5 4 3 2 1 REMARK

Students Signature:_______________ Date:_____

Instructor Signature________________ Date:__________

Comments/Suggestions:__________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

COLLEGE OF NURSING
PERFORMANCE EVALUATION TOOL
NCM 104- CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC RESPONSE AND COORDINATION PROCEDURE Test Distant Visual Acuity Position client 20 feet from the Snellen or E chart Ask patient to read each line until the client cannot decipher the letters or their direction Results: Normal Findings: 20/20 with or without corrective lenses Abnormal Findings:: myopia: impaired far vision- when the second number in the test result Test near Visual Acuity Give the client a hand held-vision chart to hold 14 inches from the eyes. Have the client cover one eye with an opaque card before reading from top ( largest print) to bottom (smallest print). Repeat test for other eye. Results: Normal Findings: Normal near visual acuity (14/14) with or without corrective lenses This means the client can read what the normal eye can read from a distance of 14 inches Abnormal Findings: Presbyopia impaired near vision Indicated when the client moves the chart away 5 4 3 2 1 REMARK

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from the eyes to focus on the print CORNEAL LIGHT REFLEX TEST Hold a penlight approximately 12 inches from the clients face Shine the light toward the bridge of the nose while the client stares straight ahead. Results: Normal Findings: the reflection of light on the corneas should be exact same spot on each eye which indicates parallel alignment PROCEDURE Abnormal Findings: asymmetric position of the light reflex indicates deviated alignment of the eyes COVER TEST Ask the client to stare ahead and focus on a distant object Cover one eye of the client with an opaque card As you cover the eye, observe the uncovered eye for movement Remove the opaque card and observe the previously covered eye for any movement Repeat test on the opposite eye Results: Normal Findings: The uncovered eye should remain fixed straight ahead The covered eye should remain fixed straight after being uncovered Abnormal Findings: The uncovered eye will move to establish focus when the opposite eye is covered When the covered eye is uncovered, movement to reestablish focus occurs Indicates a deviation in alignment of the eyes and muscle weakness POSITIONS TEST ASSESS EYE MUSCLE STRENGTH AND CRANIAL NERVE FUNCTION Instruct the client to focus on an object you are holding (approximately 12 inches from the clients face) Move the object through the six cardinal positions of gaze in a clockwise direction and observe the clients eye movement. 5 4 3 2 1 REMARK

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Results: Normal Findings: Eye movement should be

Abnormal Findings: Failure of the eyes to follow movement symmetrically in any or all directions indicates a weakness in one or more extraocular muscles

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PROCEDURE TEST FOR PUPILLARY CHANGES Darken the room and ask the client to focus on a distant object. Shine a light obliquely into one eye and observe the pupillary reaction. Results: Normal Findings: the normal direct pupillary response is constriction TEST FOR ACCOMODATION OF PUPILS Hold your finger or a pencil about 12 to 15 inches from the client Ask the client to focus on your finger or pencil and to remain focused on it as you move it closer in toward the eyes Results: Normal Findings: pupillary response is constriction and convergence of the eyes when focusing on Abnormal Findings: pupils do not constrict, eyes do not converge TEST FOR EQUILIBRIUM: ROMBERG TEST Ask the client to stand with feet together and arms at sides and eyes open and then with the eyes closed Result: Normal Findings: Client maintains position for 20 seconds without swaying or with minimal swaying Abnormal Findings: Client moves feet apart to prevent falls or starts to fall from loss of balance. TEST FOR HEARING: RINNE TEST Strike a tuning fork and place the base of the fork on

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the clients mastoid process Ask the client to tell you when the sound is no longer heard Move the prongs of the tuning fork to the front of the external auditory canal

PROCEDURE Ask the client to tell you if the sound is audible after the fork is moved. Results: Normal Findings: air conduction sound is normally heard longer than bone conduction sound (AC > BC) Abnormal: With conductive hearing loss, bone conduction sound is heard longer than or equally as long as air conduction sound

5 4 3 2 1 REMARK

Students Signature:_______________ Date:_____

Instructor Signature________________ Date:__________

Comments/Suggestions:__________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________