2022-2023

MEDICAL-SURGICAL NUSING CHECKLIST

CONAMS
Wesleyan University Philippines
2022-2023
 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

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 #

I. Procedure: Incentive Spirometry

I. Purposes: DONE NOT REMARKS

DONE
1. To provides visual reinforcement for deep
breathing by the patient.
2. To assists the patient to breathe slowly and
deeply, and to sustain maximal inspiration,
while providing immediate positive
reinforcement.
3. To maximize lung inflation and prevent or
reduce atelectasis.
II. Assessment:
Assess for the following
1. Assess the patient for pain and administer
pain medication, as prescribed, if deep
breathing may cause pain.
2. Assess lung sounds before and after use to
establish a baseline and to determine the
effectiveness of incentive spirometry.
3. Assess vital signs and oxygen saturation to
provide baseline data to evaluate patient
response.
III. Planning
1. Gather and prepare the following materials:
a. Incentive spirometer
b. Stethoscope
c. Folded blanket or pillow
d. PPE, as indicated
IV. Procedure/Implementation
1. Review health care provider's order for Incentive
Spirometry (IS).
 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

2. Identify patient using at least two identifiers.
3. Explain the procedure to the patient and family.
4. Gather all equipment needed.
5. Perform hand hygiene and put on PPE, if
indicated.
6. Placed patient in appropriate position. (Semi or
High Fowlers position)
7. Instruct patient to hold IS upright, exhale
completely, place the lips tightly around
mouthpiece.
8. Instruct patient to take slow, deep breath and
maintain a constant flow, remove mouthpiece at
point of maximal inhalation, had patient hold
breath for 3 seconds and exhale normally.
9. Let patient repeat maneuver, encourage patient
to reach prescribed goal.
10. Encourage patient to independently use IS at
prescribed frequency (5 to 10 times every 1 to 2
hours, if possible).
11. Observe patient's ability to use IS by return
demonstration.
12. Remove PPE if used. Perform hand hygiene.
13. Asses response and vital signs. Document
evaluation of learning and procedure.
TOTAL SCORE: /20

Student’s Signature: Instructor’ Signature

Date : Date:

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