WESLEYAN UNIVERSITY-PHILIPPINNES

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

PERFORMANCE EVALUATION TOOL

NCM 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolyte
Balance, Nutrition and Metabolism and Endocrine

NAME OF STUDENT: ________________________

Block #______

1. I. PURPOSE 3 2 1 REMARKS
1. Demonstrate knowledge of the procedure by
2. identifying health needs of the patient.
2. Review medical orders and obtain information on
drug/s, dosage/s, specifics of administration,
responses to previous treatments and other medical
and nursing history.
3. Explain to client the procedure, its purpose.

3. II. ASSESSMENT
4. Assess for the following:
5. Doctor’s order
6. Client’s level of consciousness and level of knowledge
and understanding
7. Client’s vital signs
8. Client’s respiratory status
9. Availability and functionality of the needed
materials/equipment.
10. Assess the patient for pain and administer pain
medication, as prescribed, if deep breathing may cause
pain.
Rationale: Presence of pain may interfere with learning
and performing required activities.
11.
Assess lung sounds before and after use to establish a
baseline and determine the effectiveness of the
medication.
Rationale: Often, patients have wheezes or coarse
lung sounds before medication administration.

12.
2. If ordered, assess patient’s oxygenation saturation
level before medication administration.
Rationale: The oxygenation level will usually increase
after the medication has been administered. Verify
 patient name, dose, route, and time of administration.

13.
3. Assess the patient’s knowledge and understanding of
the medication’s purpose and action.

14. Assess vital signs and oxygen saturation to provide

baseline data to evaluate patient response.
Oxygen saturation may increase due to bronchial
dilation.

15. III. Planning/Outcome

16. The expected outcome to achieve is that the patient
receives the medication.
Other outcomes that may include the following:
1. Patient exhibits improved lung sounds and
respiratory effort;
2. Patient demonstrates steps for use of nebulizer; and
3. Verbalizes understanding of medication purpose and
action.

17. IV. IMPLEMENTATION/PROCEDURE

18. 1. Identify patient at least two identifiers
19. 2. Check and verify doctor's order. 
20. 3. Gather all equipment needed.
21. 4. Place the patient in a comfortable sitting or a
semi-Fowler’s position.
22. 5. Perform hand hygiene. put on PPE, if indicated.
23. 6. Remove the nebulizer cup from the device and
open it.
24. 7. Place premeasured unit-dose medication in the
bottom section of the cup or use a dropper to
place a concentrated dose of medication in cup
and add prescribed diluent, if required.
25. 8. Screw the top portion of the nebulizer cup back
in place and attach the cup to the nebulizer.
Attach one end of tubing to the stem on the
bottom of the nebulizer cuff and the other end to
the air compressor or oxygen source.
26. 9. Turn on the air compressor or oxygen. Check
that a fine medication mist is produced by
opening the valve.
27. 10. Have patient place mouthpiece into mouth and
grasp securely with teeth and lips.
28. 11. Instruct patient to inhale slowly and deeply
through the mouth. A nose clip may be
necessary if the patient is also breathing through
 the nose. Hold each breath for a slight pause,
before exhaling.
29. 12. Continue this inhalation technique until all
medication in the nebulizer cup has been
aerosolized (usually about 15 minutes). Once
the fine mist decreases in amount, gently flick
the sides of the nebulizer cup.
30. 13. Have the patient gargle and rinse with tap water
after using the nebulizer, as necessary. Clean
the nebulizer according to the manufacturer’s
directions and store.
31. 14. Remove gloves and additional PPE, if used.
Perform hand hygiene.
32. 15. Document the administration of the medication
immediately after administration.
33. 16. Evaluate patient’s response to medication within
appropriate time frame.
34. 17. Reassess lung sounds, oxygenation saturation if
ordered, and respirations.
TOTAL SCORE:

Student’s Signature: _______________ Instructor’ Signature________________

Date: _____ Grade: _______ Date: __________

Comments/Suggestions: __________________________________________________