PROGRAM Bachelor of Science in Nursing STUDENT NAME

YEAR AND SECTION

COURSE NCMA 217 INSTRUCTOR
DATE

PROCEDURE : ADMINISTERING PERILIGHT THERAPY

EXPECTED OUTCOME : The student should be able to administer perilight therapy correctly.
ASSESSMENT TASK : Return Demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
1. Verify doctor’s order. Verified the doctor’s Verified the Verified the Failed to verify
order doctor’s order doctor’s order the doctor’s
with minimal incorrectly order
error
2. Gather equipment. Gathered the materials Gathered the Gathered Failed to
Ensure lamp is working. needed completely materials with materials with gathered all the
little time more time materials
preparation preparation needed
3. Explain procedure. Explained the Explained the Explained the Failed to
Provide privacy procedure to the client procedure but procedure but in explain the
and significant others lacks details an unclear procedure
clearly and completely manner
with approval
4. Position client in dorsal Performed the Performed but Performed with Failed to
recumbent position procedure accurately needs minimal slight difficulty, perform the
with evident ease supervision needs supervision procedure
without supervision most of the time
5. Do proper draping Performed the Performed but Performed with Failed to
(diamond fashion procedure accurately needs minimal slight difficulty, perform the
draping) with evident ease supervision needs supervision procedure
without supervision most of the time
6. Administer the perilight Performed the Performed but Performed with Failed to
therapy procedure accurately needs minimal slight difficulty, perform the
with evident ease supervision needs supervision procedure
without supervision most of the time
7. Place the patient in Demonstrated the Demonstrated the Demonstrated the Failed to
comfortable position procedures with ease procedure with procedure with perform the
after the procedure little errors some errors procedure
8. After care of the Performed the Performed but Performed with Failed to
materials used procedure accurately needs minimal slight difficulty, perform the
with evident ease supervision needs supervision procedure
without supervision most of the time
9. Do handwashing and Washed hands and Washed hands Washed hands Washed hands
document. documented the and some of the but most of the but
information about the details of details of the documentation
procedure properly and procedure were procedure were was not done.
completely. not documented. not documented

OVERALL SCORE: ________________

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

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FACULTY SIGNATURE OVER PRINTED NAME