HEAD NURSING EVALUATION CHECKLIST 1

Head Nurse: Laidelle Tricia M. Lampitoc

Date: April 1-3, 2019 Time: 7 AM-3 PM
Section: BSN IV-D Group: 2
Area: Medical Intensive Care Unit (MICU)

Rate your fellow students using the following

3 – very satisfactory; works competently and independently at all times
2 – satisfactory; requires minimum guidance and supervision
1 – needs improvement; requires frequent guidance and supervision
0 – not observed; did not exhibited behavior even under close supervision

Name of Students
Quilala,
Mann, Negre, Pascual, Peralta, Ragsac, Sanchez,
COMPETENCIES Ibarra, Mercado, Poleracio, Ray
Veronica Cedrick Edward Aljon Mae Kathleen Rizza Mae
Nicole I. Jed Aira F. Angel A. Jethroland
Joyce A. Jann S. Jan Leign L. Joy C. L.
V.
KNOWLEDGE ( 30% )
1. Identifies client needs and
2 3 3 3 3 2 2 3 3 3
problems
2. Formulates correct nursing
3 3 3 3 3 3 3 3 3 3
diagnosis
3. Prioritizes nursing
problems and patient 3 3 3 3 3 3 3 3 3 3
needs
4. Identifies appropriate
2 3 2 3 3 2 2 3 3 3
nursing action
 5. Explains rationale for
nursing
2 3 2 3 2 3 3 2 2 2
procedures/intervention
done
6. Provides relevant health
teachings to client and 3 2 3 3 2 3 3 2 3 3
family
7. Contributes relevant
health teachings to client 3 2 3 3 2 3 3 3 3 3
and family
8. Makes correct
computations of 3 3 3 3 3 3 3 3 3 3
medicines, IV fluids, etc
Total: 21 22 22 24 21 22 22 22 23 23
SKILLS ( 50%)
Applies correct principle in:
1. Carrying doctor’s orders 3 3 3 3 3 3 3 3 3 3
2. Preparing and
administering medications 3 3 3 3 3 3 3 3 3 3
and IV fluids
3. Rendering bedside care 3 3 3 3 3 3 3 3 3 3
4. Performing special
2 3 3 3 3 3 2 3 3 3
procedures
5. Documenting patient care 3 3 3 3 3 3 3 3 3 3
6. Makes appropriate
decision on modality of
3 3 2 3 3 2 2 3 3 3
care based on patient’s
condition
7. Demonstrates appropriate
infection control practices 2 3 3 3 3 3 3 3 3 3
in the area
8. Demonstrates effective
communication skills to 3 3 3 3 3 3 3 3 3 3
fellow students and other
 staff in the area
9. Provides continuity of care
through proper 2 3 2 3 3 2 2 2 2 3
endorsement
Note: Write NA if an item
is not applicable and
subtract corresponding
points from the total score
Total: 24 27 25 27 27 25 24 26 26 27
ATTITUDE ( 20% )
1. Punctual in reporting for
3 3 3 3 3 3 3 3 3 3
duty
2. Punctual in submitting
3 3 3 3 3 3 3 3 3 3
reports and requirements
3. Displays appropriate
3 3 3 3 3 3 3 3 3 3
grooming and hygiene
4. Performs assigned tasks
2 2 2 2 2 2 2 2 2 2
willingly
5. Tactful in disseminating
2 2 2 2 2 2 2 2 2 2
information
6. Is concerned with
cleanliness and orderliness 2 2 2 2 2 2 2 2 2 2
of the area
7. Accepts responsibility
2 3 2 3 3 3 3 2 3 3
beyond assigned tasks
8. Manifests rapport with
health team members,
2 2 2 2 2 2 2 2 2 2
fellow students, client and
family
9. Observes proper decorum
3 3 3 3 3 3 3 3 3 3
at all times
10. Demonstrates other
qualities such as:
a. Honesty 3 3 3 3 3 3 3 3 3 3
 b. Organization 3 3 2 3 3 2 2 2 2 3
c. Fairness 2 2 2 2 2 2 2 2 2 2
d. Respect 3 3 3 3 3 3 3 3 3 3
e. Commitment 3 3 3 3 3 3 3 3 3 3
Total: 36 37 35 37 37 36 36 35 36 37

COMPUTATION: Reference:

KNOWLEDGE = Total Score/Highest Possible Score X 100% X 30% 100 1.0

95-99 1.25
SKILLS = Total Score/Highest Possible Score X 100% X 50% 90-94 1.5
85-89 1.75
ATTITUDE = Total Score/Highest Possible Score X 100% X 20% 80-84 2.0
75-79 2.25
70-74 2.5
65-69 2.75
60-64 3.0
55-59 3.25
50-54 3.5
45-49 3.75
40-44 4.0
35-39 4.25
30-34 4.5
25-29 4.75
20-24 5.0

NAME OF STUDENTS KNOWLDEGE ( 30% ) SKILLS ( 50% ) ATTITUDE (20 %) TOTAL GRADE
1. Ibarra, Nicole I. 28.25 44.44 17.14 89.83 1.75
2. Mann, Veronica Joyce A. 30 50 17.61 97.61 1.25
3. Mercado, Jed Aira F. 29.5 46.29 16.66 92.45 1.5
4. Negre, Cedrick Jann S. 30 50 17.61 97.61 1.25
5. Pascual, Edward Jan Leign 28.25 50 17.61 95.86 1.25
6. Peralta, Aljon Mae L. 28.5 46.29 17.14 91.93 1.5
7. Poleracio, Angel A. 28.5 44.44 17.14 90.08 1.5
8. Quilala, Ray Jethroland V. 29.5 48.14 16.66 94.3 1.5
9. Ragsac, Kathleen Joy C. 30 48.14 17.14 95.28 1.25
10. Sanchez, Rizza Mae L. 30 50 17.61 97.61 1.25