OUR LADY OF FATIMA UNIVERSITY

College of Nursing – Valenzuela Campus

Bachelor of Science in
PROGRAM Student Name
Nursing
NCMB-312 Year and Section
Care of Clients with Instructor
Problem in Oxygenation,
Fluids &
Electrolytes, Infectious,
COURSE
Inflammatory &
Immunologic Response, Date
Cellular Aberrations
(Acute & Chronic)
(SKILLS LABORATORY)
PROCEDURE : Hand washing
EXPECTED OUTCOME : The student should be able to do hand washing aseptically
ASESSMENT TASK : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(4) (3) (2) (1)
1. Assess hands Performed Performed Performed the Failed to perform
for cuts and assessment with assessment assessment with the assessment.
breaks in the ease without with little some errors.
skin and supervision. errors
remove
jewelries and
wristwatch.
2. Do not touch The procedure The procedure The procedure Failed to perform
any part of the performed performed performed with the procedure.
sink. Open the accurately with but needs slight difficulty,
faucet and evident ease minimal needs supervision
adjust the flow without supervision. most of the time.
of water. supervision
3. Wet hands and The procedure The procedure The procedure Failed to perform
lower forearm performed performed performed with the procedure
under running accurately with but needs slight difficulty,
water. Keep evident ease minimal needs supervision
hands in without supervision. most of the time.
downward supervision
position.
4. Get the soap The procedure The procedure The procedure Failed to perform
and lather performed performed performed with the procedure
thoroughly. accurately with but needs slight difficulty,
evident ease minimal needs supervision
without supervision. most of the time.
supervision
5. While holding The procedure The procedure The procedure Failed to perform
the soap with performed performed performed with the procedure
one hand, use accurately with but needs slight difficulty,
other hand in evident ease minimal needs supervision
rubbing all without supervision. most of the time.
areas of the supervision
hand. Do the
same with
other hand
6. Rinse the soap Rinsed the soap Rinsed the Rinsed the soap Failed to perform
and return it to and placed it soap and but did not placed the procedure
the soap dish back without placed it in it in the dish
 and without touching any the dish but properly
touching any part of the dish. touching
part of the some of its
dish. part
7. With hands in Performed the Performed the Performed the Failed to perform
downward procedures with procedure procedures with the procedure
position, rinse ease with little some errors.
starting from errors
the wrist to
fingers.
8. Get a paper Performed the Performed the Performed the Failed to perform
towel and dry procedures with procedure procedures with the procedure
the hands ease with little some errors.
starting from errors
the fingers to
forearms
9. Close the Performed the Performed the Performed the Failed to perform
faucet using procedures with procedure procedures with the procedure
paper towel ease with little some errors.
and discard it errors
after use.

OVERALL SCORE: ________________

Target raw score is 27 out of 36. If raw score is less than 27, repeat the return demonstration.

__________________________________
_
FACULTY SIGNATURE OVER PRINTED NAME
 OUR LADY OF FATIMA UNIVERSITY
College of Nursing – Valenzuela Campus

PROGRAM Bachelor of Science in Nursing STUDENT NAME

COURSE NCMB-312 YEAR & SECTION

Care of Clients with Problem in
Oxygenation, Fluids & INSTRUCTOR
Electrolytes, Infectious,
Inflammatory & Immunologic DATE
Response, Cellular Aberrations
(Acute & Chronic)
(SKILLS LABORATORY)

PROCEDURE : SURGICAL SCRUB

EXPECTED OUTCOME : The student should be able to perform surgical scrubbing correctly.
ASSESSMENT TASK : Return Demonstration

Assessment Exceptional Good Average Poor

SCORE
Dimension (4) (3) (2) (1)
Gathered all the Gathered the Gathered the Failed to gather
1. materials to be materials to be materials to be the materials to
Gather the materials to used like sterile used like gowns, used like brush be used.
be used gowns, sterile gloves but failed and soap and
gloves, brush, and to prepare brush forgot to prepare
soap. and soap. sterile gowns and
gloves.
Inspected skin Inspected skin Inspected skin Failed to inspect
2. integrity. integrity. integrity. Failed skin integrity
Inspect skin integrity. Removed Removed jewelries to removed and removed
Remove jewelries and jewelries and nail but forget to jewelries and nail jewelries and
nail polish. polish. remove nail polish. nail polish.
polish.
Complete OR Complete OR Complete OR Failed to wear
3. attire with cap attire with cap but attire but complete OR
Wear appropriate and mask. without mask. without cap and attire without
attire (complete OR mask. cap and mask.
attire)
Skillfully observed Skillfully opened Skillfully opened Failed to open
4. principles of sterile gown and sterile gown but sterile packages
Opening of materials: sterile technique create a sterile failed to create a and becomes
4.1.1 sterile package in opening field but open and sterile field and contaminated.
containing the gown materials. drop the gloves open and drop
and create a sterile outside the sterile the gloves
field field. outside the
4.1.2. sterile gloves and sterile field.
drop the inner package
of the gloves on the
sterile field
Able to wet arms, Able to wet arms Able to wet arms Failed to wet
5. hands and elbows and hands but but failed to wet arms, hands and
At the surgical sink; at the surgical failed to wet hands and elbows at the
wet arms, hands and sink. elbows at the elbows at the surgical sink.
elbows surgical sink. surgical sink.
Maintained hands Maintained hands Maintained Failed to
6. in upright in upright position hands in upright maintained
Hands in upright position. with few position with hands in upright
position reminders. some reminders. position.
 7. Applied soap and Applied soap and Applied soap and Failed to apply
Apply soap and rub rub hands and rub hands and rub hands and soap and rub
hands and arms up to 2 arms up to 2 arms up to 2 arms up to 2 hands and arms
inches above elbows inches above inches above inches above up to 2 inches
elbows with no elbows with elbows with above elbows
errors. minimal errors. maximal errors.

8. Properly rinsed Properly rinsed Improperly Failed to rinse

Rinse both hands and both hands and hands but failed in rinsed both both hands and
arms arms. the arms. hands and arms. arms

9. Properly got the Properly got the Properly got the Failed to get for
Get/ask for a brush. brush, rinse and brush and rinse brush but failed a brush, rinse
Rinse brush and apply applied soap with but failed to to rinse and brush and
soap ease. applied soap. applied soap. applied soap.

10. Skillfully followed Skillfully followed Skillfully followed Failed to follow

Following hospital hospital protocols hospital protocols hospital hospital
protocol, brush non- in brushing the in brushing the protocols in protocols.
dominant hand by fingertips, nails, fingertips, nails brushing the
dominant hand starting hands and arms. and hands but fingertips and
from the fingertips and failed to brush the nails but forgot
nails and to all areas of arms. to brush hands
the hand and arm and the arms.

Properly rinsed Properly rinsed Properly rinsed Failed to

11. the brush and put the brush and put the brush and perform the
Rinse brush thoroughly some soap again. little soap again. failed to put soap procedure.
and re-apply soap again.

Thoroughly Thoroughly Thoroughly Failed to

12. brushed the brushed the brushed the perform the
Brush dominant hand dominant hand by dominant hand by dominant hand procedure.
by non-dominant hand. non-dominant non-dominant by non-dominant
Follow steps of no. 11. hand. hand with minimal hand with
errors. maximal errors.

Properly rinsed Properly rinsed Properly rinsed Failed to

13. brush, hands and brush, hands and brush, hands and perform the
Rinse brush, hands and arms and carefully arms and carefully arms and procedure.
arms. Be careful not to not to touch any not to touch any carefully not to
touch any part of the part of the sink part of the sink touch any part of
sink and faucet. Repeat and faucet. and faucet but the sink and
steps 11 to 12. Repeat steps 11 to failed to repeat faucet but failed
12. step 11. to repeat steps
11 and 12.

14. Properly dropped Improperly Properly dropped Failed to

Drop the brush into the the brush into the dropped the brush the brush but perform the
sink sink. into the sink. outside the sink. procedure.

Kept the arms Kept the arms Kept the arms Failed to
15. flexed and flexed but failed to slightly flexed perform surgical
Keep arms flexed and proceeded to the proceed to the and almost asepsis.
proceed to the area area with sterile area with sterile below the waist
with sterile field field. field. and proceeds to
the area with
sterile field.
 OVERALL SCORE: ______________

Target Raw Score: 45 out of 60. If raw score is less than 45, repeat the return demonstration.

___________________________________
FACULTY SIGNATURE OVER PRINTED NAME
 OUR LADY OF FATIMA UNIVERSITY
College of Nursing – Valenzuela Campus

PROGRAM Bachelor of Science in Nursing STUDENT NAME

COURSE NCMB-312 YEAR & SECTION
Care of Clients with Problem in
Oxygenation, Fluids & INSTRUCTOR
Electrolytes, Infectious, DATE
Inflammatory & Immunologic
Response, Cellular Aberrations
(Acute & Chronic)
(SKILLS LABORATORY)

PROCEDURE : CLOSED GOWNING AND GLOVING

EXPECTED OUTCOME : The student should be able to perform closed gowning and gloving using the proper techniques
ASSESSMENT TASK : Return Demonstration

Assessment Exceptional Good Average Poor

SCORE
Dimension (4) (3) (2) ( 1)
1. Skillfully Skillfully Not maintained Not maintained
Maintain the maintained the maintained the the sterility of the sterility of
sterility of gown and sterility of gown sterility of gown gown but skillfully gown and gloves
gloves during the and gloves during but not the gloves maintained the during the entire
entire procedure the entire during the entire gloves during the procedure.
procedure. procedure. entire procedure.
2. Skillfully grasp the Skillfully grasp the Skillfully grasp the Not skillfully
Grasp the gown and gown and step gown and step gown and do not grasp the gown
step backward backward. backward with step backward. and do not step
close supervision. backward.
3. Properly and Properly and Not properly and Not properly and
Allow the bottom skillfully allow the skillfully allow the skillfully allow the skillfully allow
part of the gown to bottom part of the bottom part of the bottom part of the the bottom part
fall. Dry hands and gown to fall and gown to fall and gown to fall but of the gown to
arms using the dry hands and arms forget to dry hands able to dry hands fall and forget to
bottom part of the using the bottom and arms using the and arms using dry hands and
gown. part of the gown. bottom part of the the bottom part of arms using the
gown. the gown. bottom part of
the gown.
4. Properly open the Properly open the Not properly open Not properly
Open the gown and gown and slip both gown and slip the the gown but slip open the gown
slip both arms in the arms in the gown arms one at a time the in the gown and slip the arms
gown simultaneously. in the gown. simultaneously. one at a time in
simultaneously the gown.
5. Maintained the One hand is inside Both hands are No sterility at all.
Keep your hands hands inside the the sleeves and the outside the Repeat hand
inside the sleeves of sleeves of the other hand is sleeves of the scrubbing.
the gown. The gown. outside the sleeves gown but still
circulating nurse will of the gown. maintained the
secure the ties of sterility.
the gown
6. Observed the Observed sterile Observed sterile Failed to
With hands still principle of sterile technique with technique with observed sterile
inside the sleeves, technique and able minimum closed supervision technique and
open the wrapper of to open the supervision and and able to open not able to open
the sterile gloves wrapper of the able to open sterile sterile gloves in sterile gloves in
already placed in sterile gloves in the gloves in sterile sterile field. sterile field.
the sterile field sterile field. field.
7. Properly placed the Properly placed the Properly placed Failed to place
With your dominant palm of the non- palm of the non- the palm of the the palm of the
sleeved hand, place dominant hand dominant hand non-dominant non-dominant
the palm of the non- glove against the glove against the hand glove against hand glove
dominant hand sleeved palm of the sleeved palm of the the sleeved palm against the
glove against the non-dominant non-dominant of the non- sleeved palm of
sleeved palm of the hand. hand with dominant hand the non-
non-dominant hand minimum with closed dominant hand.
supervision. supervision.
8. Skillfully grasped Skillfully grasped Skillfully grasped Failed to grasped
Grasp the cuff of the the cuff of the the cuff of the the cuff of the the cuff of the
glove with your non- glove with non- glove with non- glove with non- glove with non-
dominant hand. dominant hand, dominant hand, dominant hand, dominant hand
With your dominant and with the and the dominant and the dominant and able to put
hand, turn the cuff dominant hand, hand successfully hand successfully glove in the
over the end of the turn the cuff over put the glove with put the glove with dominant hand.
non-dominant hand the end of the non- minimum closed
and gown’s cuff. dominant hand and supervision. supervision.
gown’s cuff.
9. Slowly extended Slowly extended Slowly extended Failed to slowly
Slowly extend the the fingers into the the fingers into the the fingers into extend the
fingers into the glove while holding glove while holding the glove while fingers into the
glove while holding the glove and the the glove and the holding the glove glove while
the glove and the gown cuffs with gown cuffs with and the gown holding the glove
gown cuffs ease. some coaching. cuffs with and the gown
difficulty. cuffs.
10. Properly and Properly and Properly and Failed to repeat
With the gloved skillfully repeat skillfully repeat skillfully repeat steps 8 to 9 and
non-dominant hand, steps 8 to 9 and step 8 and forget steps 8 to 9 but interlock gloved
repeat steps 8 to 9. interlock gloved to perform step 9 forget to interlock fingers to fit the
Interlock your fingers to fit the but able to gloved fingers to gloves.
gloved fingers to fit gloves. interlock gloved fit the gloves.
the gloves. fingers to fit the
gloves.

OVERALL SCORE: ______________

Target Raw Score: 30 out of 40. If raw score is less than 30, repeat the return demonstration.

______________________________________________________
FACULTY SIGNATURE OVER PRINTED NAME
 OUR LADY OF FATIMA UNIVERSITY
College of Nursing – Valenzuela Campus

PROGRAM Bachelor of Science in Nursing STUDENT NAME

COURSE NCMB-312 YEAR & SECTION

Care of Clients with Problem in
Oxygenation, Fluids & INSTRUCTOR
Electrolytes, Infectious,
Inflammatory & Immunologic DATE
Response, Cellular Aberrations
(Acute & Chronic)
(SKILLS LABORATORY)

PROCEDURE : SURGICAL INSTRUMENTATION

EXPECTED OUTCOME : The student should be able to perform surgical instrumentation correctly
ASSESSMENT TASK : Return Demonstration

Assessment Exceptional Good Average Poor

SCORE
Dimension (4) (3) (2) (1)
Gathered all the Gathered the Gathered the Failed to gather
1. materials to be materials to be materials to be the materials to
Gather the materials used with ease. used with minimal used with be used.
supervision. maximal
supervision.

Enumerate five (5) Enumerate three Enumerate one Failed to

2. purposes of (3) to four (4) (1) to two (2) enumerate some
Purpose of surgical surgical operation. purposes of purposes of purposes of
operation surgical operation. surgical operation. surgical operation.

Enumerate and Enumerate and Enumerate and Failed to

3. define the stages of define the stages define the stages enumerate and
Stages of operation operation with of operation with of operation with define the stages
ease. minimal errors. maximal errors. of operation.

Name at least Name at least two Name at least one Failed to name
4. three (3) functions (2) functions of (1) function of some functions of
Functions of Scrub of scrub and scrub and scrub and scrub and
and Circulating Nurse circulating nurse circulating nurse circulating nurse circulating nurse
respectively. respectively. respectively. respectively.

Enumerate twenty Enumerate fifteen Enumerate ten Enumerate five (5)

5. (20) principles of (15) principles of (10) principles of principles of
Principle of Sterile sterile technique. sterile technique. sterile technique. sterile technique.
technique

Name at least Name at least two Name at least one Failed to name
6. three (3) (2) classifications (1) classification classifications of
Classification of classifications and and give (2) and give (2) instruments.
Instruments give (2) sample sample each. sample each.
each.
7. Identify five (5) Identify four (4) Identify three (3) Identify two (2)
Identification of types of blades types of blades types of blades types of blades
blades
8. Put the blade in the Put the blade in Put the blade in Failed to put the
Put the blade in the holder with ease. the holder with the holder with blade in the
 holder minimal maximal holder.
supervision. supervision.
9. Enumerate twenty Enumerate fifteen Enumerate ten Enumerate five (5)
Identification of (20) instruments in (15) instruments (10) instruments instruments in the
instruments the sterile field. in the sterile field. in the sterile field. sterile field.

10. Disposed the Disposed the Disposed the Failed to dispose

Dispose the sharps sharps in the sharps in the sharps in the the sharps in the
and wash the sharps container sharps container sharps container sharps container
equipment and wash the and wash the and wash the and wash the
equipment equipment equipment equipment
properly. properly minimal properly with properly.
supervision. maximal
supervision.

OVERALL SCORE: ______________

Target Raw Score: 30 out of 40. If raw score is less than 40, repeat the return demonstration.

___________________________________
FACULTY SIGNATURE OVER PRINTED NAME