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Name:

Dimension/Criteria
Effective Detection
Patient identification

Focused observation

Effective Preparation
Equipment and supply
preparation

Effective Execution
Clear communication

4-Exemplary
Asks patient's name and
date of birth and looks
at identification tag.

3-Accomplished

2-Developing

1-Beginning

Year and section:


Remarks

Asks either patient's


name or date of birth
and looks at
identification tag.
Regularly observes and
monitors a variety of
data, including both
objective and
subjective; most useful
information noticed;
may miss the most
subtle signs.

Verifies patient using


only one identifier.

Did not identify the


patient.

Attempts to monitor a
variety of objective and
subjective data but is
overwhelmed by the
array of data; focuses on
the most obvious data,
missing some important
information.

Confused by clinical
situation and the
amount and kind of
data; observation is not
organized and important
data are missed;
assessment errors are
made.

Selects and prepares all


equipment and supplies
prior to peritoneal
dialysis.

Selects and prepares


most equipment and
supplies prior to
peritoneal dialysis.

Selects and prepares


some equipment and
supplies prior to
peritoneal dialysis.

Selects and prepares


inadequate or
inappropriate
equipment prior to
peritoneal dialysis.

Communicates
effectively; explains
interventions; calms and
reassures patients and
families; directs and
involves team members,
explaining and giving
directions; checks for
understanding.

Generally communicates
well, explains carefully
to patients, gives clear
directions to team;
could be more effective
in establishing rapport.

Shows some
communication ability
(e.g., giving directions);
communications with
patients, families, and
team members are only
partly successful;
displays caring but not
competence.

Has difficulty
communicating,
explanations are
confusing, directions are
unclear or contradictory,
patients and families are
made more confused or
anxious and are not
reassured.

Focuses observation
appropriately; regularly
observes and monitors a
wide variety of objective
and subjective data to
uncover any useful
information.

Dimension/Criteria
Well-planned
intervention/flexibility

4-Exemplary
Interventions are
tailored for the
individual patient;
monitors patient
progress closely and is
able to adjust treatment
as indicated by patient
response.

3-Accomplished
Develops interventions
on the basis of relevant
patient data; monitors
progress regularly but
does not expect to have
to change treatments.

2-Developing
Develops interventions
on the basis of the most
obvious data; monitors
progress but is unable to
make adjustments as
indicated by the
patients response.

1-Beginning
Focuses on developing a
single intervention,
addressing a likely
solution, but it may be
vague, confusing, and/or
incomplete; some
monitoring may occur.

Technique

Shows mastery of
necessary nursing skills

Is hesitant or ineffective
in using nursing skills

Is unable to select and/


or perform nursing skills

Asepsis

Hand hygiene was


performed; Dialysate
bottle was disinfected
before spiking;
Maintained sterile
insertion site and
equipment throughout
the procedure.
Disciplined use of time
and resources,
performed skill in the
minimum suggested
simulation time
expectation (SSTE).

Displays proficiency in
the use of most nursing
skills; could improve
speed or accuracy
Errors were made in
maintaining sterility of
tubing and/or
equipment, but selfcorrected.

Unrecognized errors
made in maintaining
sterility of tubing and/or
equipment.

Contaminated tubing
and/or equipment
during procedure.

Organized and able to


perform the skill within
the SSTE.

Disorganized but met


the maximum SSTE.

Disorganized and
exceeded the maximum
SSTE.

Evaluates and analyzes


personal clinical
performance with
minimal prompting,
primarily about major
event or decisions; key
decision points are
identified, and
alternatives are
considered.

Even when prompted,


briefly verbalizes the
most obvious
evaluations; has
difficulty imagining
alternative choices; is
self-protective in
evaluating personal
choices.

Even when prompted,


evaluations are brief,
cursory, and not used to
improve performance;
justifies personal
decisions and choices
without evaluating
them.

Procedure efficiency

Effective reflection-reaction
Evaluation and selfIndependently evaluates
analysis
and analyzes personal
clinical performance,
noting decision points,
elaborating alternatives,
and accurately
evaluating choices
against alternatives.

Remarks

Total score:_____/36

Passed Failed

Lecturer:
Signature over printed name

Prepared by: Cara Jaye Garcia, RN MAN & Les Paul Valdez, RN MAN

Date