WESLEYAN UNIVERSITY-PHILIPPINES

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

NCM 103 CHECKLIST

PERFORMANCE EVALUATION TOOL

NCM 103 – FUNDAMENTALS OF NURSING PRACTICE

DIRECTIONS:
● The evaluation tool will be discussed by the clinical instructor/s.
● During the discussion, the instructor/s may demonstrate the procedures or may use
video viewing for students’ orientation.
● The students should be given sufficient time to prepare for the return demonstration.
● The students will do the return demonstration based on the checklist given.
● The following rating scale shall be used in grading student’s performance:

2 points - able to perform

Perform the procedure safely and accurately in a very consistent and
independent manner without supportive assistance from the instructors.
Perform a difficult action quickly and skillfully
Spends minimal time on task
Focuses on client while giving care

1 point - able to perform with assistance

Perform the procedure safely and accurately with frequent guidance and
supervision from the instructor.
Demonstrate incomplete skills in some part of the procedure.
Takes longer time to complete the procedure.

0 point - unable to perform

Unable to perform procedure even under close supervision of guidance
Require continuous, supportive and directive cues
Performs in unskilled manner

● At the end of each laboratory session, the instructor/s will give remarks based on the
student’s performance in accordance to the procedures indicated.
 WESLEYAN UNIVERSITY-PHILIPPINES
COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

NCM 103 CHECKLIST

PERFORMANCE EVALUATION TOOL

NCM 103 – FUNDAMENTALS OF NURSING PRACTICE

NAME OF STUDENT: _______

BSN I- Block #______

PROCEDURE: HAND HYGIENE

PURPOSE 2 1 0 REMARKS
• To reduce the number of microorganisms on the
hands
• To reduce the risk of transmission of microorganisms
to clients
1 • To reduce the risk of cross contamination among
clients
• To reduce the risk of transmission of infectious
organisms to oneself

PREPARATION
• Soap
1. • Warm running water
• Paper towels
ASSESSMENT
1 For the nurses:
● Nails should Rationale: Short, natural
be kept short. nails are less likely to
harbor microorganisms,
scratch a client, or
puncture gloves.

● Removal of Rationale: Removal

all jewelry is facilitates proper cleaning
 WESLEYAN UNIVERSITY-PHILIPPINES
COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

NCM 103 CHECKLIST

recommende of the hands and arms.

d.

● Check hands
for breaks in Rationale: A nurse who
the skin, such has open sores may
as hangnails require a work assignment
or cuts. with decreased risk for
transmission of infectious
organisms due to the
chance of acquiring or
passing on an infection
IMPLEMENTATION RATIONALE 2 1 0 REMARKS
Duration of the entire
procedure: 40-60 seconds
If you are washing your
hands where the client can
observe
you, introduce yourself and
1
explain to the client what
you are
going to do and why it is
necessary.
Turn on the water and Warm water removes less
2 adjust the flow so that the of the protective oil of the
water is warm. skin than hot water.
Apply enough soap to
3
cover all hand surfaces.
Rub hands palm to palm. The circular action creates
friction that helps
4 remove microorganisms
mechanically.
 WESLEYAN UNIVERSITY-PHILIPPINES
COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

NCM 103 CHECKLIST

Right palm over left dorsum Interlacing the fingers

5 with interlaced fingers and and thumbs cleans the
vice versa. interdigital spaces.
Palm to palm with fingers
6
interlaced.
Back of fingers to opposing
7 palms with fingers
interlocked.
Rotational rubbing of left
8 thumb clasped in right palm
and vice versa.
Rotational rubbing,
backwards and forwards
9 with clasped fingers of right
hand in left palm and vice
versa.
10 Rinse hands with water.
Dry the hands thoroughly
11
with a single use towel.
Use the towel to turn off the This prevents the nurse
faucet. from picking up
12
microorganisms from the
faucet handles
TOTAL: /30

Student’s Signature: ___________ Instructor’ Signature_____________

Date: _06/30/21__ Date: _06/30/21________

Comments/Suggestions: __________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________
 WESLEYAN UNIVERSITY-PHILIPPINES
COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

NCM 103 CHECKLIST

PERFORMANCE EVALUATION TOOL

NCM 103 – FUNDAMENTALS OF NURSING PRACTICE

NAME OF STUDENT: _______

BSN I- Block #______

PROCEDURE: ALCOHOL BASED HAND RUB

PURPOSE 2 1 0 REMARKS
• To reduce the number of microorganisms on the
hands
• To reduce the risk of transmission of microorganisms
to clients
1 • To reduce the risk of cross contamination among
clients
• To reduce the risk of transmission of infectious
organisms to oneself

PREPARATION
1. • Alcohol
ASSESSMENT
1 For the nurses:
● Nails should Rationale: Short, natural
be kept short. nails are less likely to
harbor microorganisms,
scratch a client, or
puncture gloves.

● Removal of Rationale: Removal

all jewelry is facilitates proper cleaning
recommende of the hands and arms.
d.
 WESLEYAN UNIVERSITY-PHILIPPINES
COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

NCM 103 CHECKLIST

● Check hands
for breaks in Rationale: A nurse who
the skin, such has open sores may
as hangnails require a work assignment
or cuts. with decreased risk for
transmission of infectious
organisms due to the
chance of acquiring or
passing on an infection
IMPLEMENTATION RATIONALE 2 1 0 REMARKS
Duration of the entire
procedure: 20-30 seconds
If you are doing hand rub
where the client can
observe
you, introduce yourself and
1
explain to the client what
you are
going to do and why it is
necessary.
Apply a palmful of the
2 product in a cupped hand,
covering all surfaces.
3 Rub hands palm to palm.
Right palm over left dorsum
5 with interlaced fingers and
vice versa.
Palm to palm with fingers
6
interlaced.
Back of fingers to opposing
7 palms with fingers
interlocked.
 WESLEYAN UNIVERSITY-PHILIPPINES
COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

NCM 103 CHECKLIST

Rotational rubbing of left

8 thumb clasped in right palm
and vice versa.
Rotational rubbing,
backwards and forwards
9 with clasped fingers of right
hand in left palm and vice
versa.
Once dry, your hands are
10
safe.
TOTAL: /26

Student’s Signature: _______________ Instructor’ Signature________________

Date: _____ Date: __________

Comments/Suggestions: __________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________