Central Mindanao University

University Town, Musuan, Maramag Bukidnon

College of Nursing

PERFORMANCE CHECKLIST

STEAM INHALATION

NAME: _________________________________________ SCORE: _________________

SEC/GRP: ______________________________________ DATE: __________________

Definition:
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Purpose:
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Materials/Equipment:
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STEPS RATIONALE REMARKS

Preparatory Phase
Assess the health and living condition of the
1 client and family to be visited.

Recognize the needs and determine the health

2 teachings needed and provide necessary health
care activities.

Prepare for a home visit by consolidating

3 records and studying the case to be visited.

Gather equipment needed.

4

Greet client or household members and

5 introduce yourself.

Explain to the client the purpose of your home

6 visit.

Inquire/ask about any health and health related

7 problems.

Working Phase
Explain procedure to the patient and significant
8 others.

Prepare the equipment.

9
 STEPS RATIONALE REMARKS

Heat up the water to boiling using heater or pot.

10

Place pitcher/bowl on a flat surface.

11

Carefully pour the boiling water about 1/3 to

12 1/2 full in a pitcher/bowl.

Let patient sit on a chair and position the head

13 about 8-12 inches above the water and instruct
to keep eyes closed.

Drape the towel over the back of the head to

14 create an enclosed space.

Instruct patient to inhale with slow, deep

breaths for at least 2-5 minutes or as prescribed
16 and limit the duration of the session to 10-15
minutes.
Repeat sessions 2-3 times a day, as needed.
17

Remove pitcher/bowl at end of prescribed

18 period.

Wipe face of patient dry and make him

19 comfortable.

Wash equipment with soap and water, rinse and

20 return to proper place.

Chart: time, procedure, medication used if

21 there’s any, reaction of patient and nurse’s
observation.

If electric inhaler is used, operate based on

22 manual. Follow instructions carefully.

Termination Phase
Take a record and write down all the necessary
data gathered, observations, nursing care
23 treatment gathered. Give instructions if
necessary.

Make appointment for the next visit (for follow-

24 up).

Make referrals as needed.

25

References: in APA form 7th edition.

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 SKILLS RUBRICS
NEEDS
PERFORMANCE EXCELLENT GOOD UNACCEPTABLE
IMPROVEMENT SCORE
CRITERIA 5 4 2
3
Performed the
procedure
Performed the guidelines but
Performed the The student is
procedure showed little
procedure unprepared, there
guidelines with unpreparedness
PREPAREDNESS guidelines with is an inaccuracy,
great accuracy, during the steps,
minimal inaccuracy, incompleteness of
completeness, and with some
incompleteness. the performance.
confidence. inaccuracy
and incompleteness
of the performance.
Performed totally
Performed entirely Performed the Performed the
the procedure
the procedure procedure with procedure with lots
COMPLETENESS guidelines with
guidelines some inadequacy of of inadequacy and
minimal
correctly. steps. incompleteness.
incompleteness.
The student is The student is The student is
The student is not
competent competent but less partially competent,
yet competent and
observant, accurate, observant, accurate, not observant,
CONSISTENCY is distracted in
and focus in doing and focus in doing accurate, and focus
doing the steps of
the steps of the the steps of the on doing the steps
the procedure.
procedure. procedure. of the procedure.
ABILITY TO ASK Some questions are Questions included
Ask questions Ask questions with
QUESTIONS TO not connected to has little connection
comprehensively. mostly good points.
CLIENT the topic. to the topic.

Total Score
20

KNOWLEDGE RUBRICS
VERY
SATISFACTORY GOOD POOR
CRITERIA SATISFACTORY SCORE
4 3 0-2
5
Rationale and
Rationale and Rationale and Rationale and
information are less
IDEAS AND information are information of most information are often
accurate and with
CONTENT accurate and correct steps are accurate inaccurate and with
some incorrect
for all steps. and correct. lacking entries.
entries.
Rationale and
Rationale and Rationale and
information are Rationale and
information are information are not
LANGUAGE AND described well but information described
clearly described described well and
GRAMMAR language or words vaguely using incorrect
using correct and words used is not
used are sometimes words.
clear language. correct or inaccurate.
vague and inaccurate.
Rationale and
Rationale and Rationale and
information are well
information are well Organization exhibits information lack
organized. It mostly
organized. It exhibits some commands of proper organization. It
exhibits focus and
ORGANIZATION focus and coherent focus, relatedness of does not exhibit
coherent
organization on the the steps and commands of focus and
organization on the
steps and organized. relatedness of the
steps and
relatedness. steps.
relatedness.
Total Score
15

Remarks/Comments:
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Signature over the printed name of Student

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Signature over the printed name of Clinical Instructor

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DATE