Central Mindanao University

University Town, Musuan, Maramag Bukidnon

College of Nursing

PERFORMANCE CHECKLIST

13 DOH APPROVED HERBAL PLANTS PREPARATION

NAME: _________________________________________ SCORE: _________________

SEC/GRP: ______________________________________ DATE: __________________

General Instruction: Provide the definition, purpose and materials needed for herbal plants
preparation. Kindly write the steps on how to prepare the herbal plants base on the uses and give the
dosage both for children and adults. Also provide the scientific name or other name of each herbal plant.

Definition:
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Purpose:
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Materials needed:
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STEPS/PREPARATION USES DOSAGE REMARKS

Preparatory Phase
Prepare all the equipment use RATIONALE
for herbal preparation.
1

Identify which part of the RATIONALE

herbal plant will be used
2 during treatment.

Wash thoroughly the part/s of RATIONALE

the plant to be used.
3

Working Phase
• SAMBUNG
Other name/s:

Anti-edema
Diuretic
4 Anti-urolithiasis
 STEPS/PREPARATION USES DOSAGE REMARKS
• AKAPULKO
Other name/s:

Anti-fungal: Tinea
Flava, Ringworm,
5 Athlete’s Foot, and
Scabies

• NIYUG-NIYOGAN
Other name/s:

Anti-helminthic
(used to expel
6 parasitic worms)

• TSAANG GUBAT
Other name/s:

Diarrhea

Stomach ache

• AMPALAYA
Other name/s

Diabetes Mellitus
(lower blood sugar
9 levels)

• LAGUNDI
Other name/s:

Asthma, cough, and

fever
10

Dysentery, colds,
and body pain/
11 ache
 STEPS/PREPARATION USES DOSAGE REMARKS

Skin diseases and

12 wounds

Headache
13

Rheumatism,
14 sprain, contusions,
and insect bites

• ULASIMANG BATO
Other name/s:

Lowers uric acid for

Rheumatism and
15 Gout.

• BAWANG
Other name/s:
*Caution: Take in full stomach to prevent stomach and intestinal ulcers

Hypertension
Lowers cholesterol
16 levels in the blood

Toothache

17

• BAYABAS
Other name/s:

Washing wounds

18

Toothache

19
 STEPS/PREPARATION USES DOSAGE REMARKS

Diarrhea

20

• YERBA BUENA
Other name/s:

Pain in different
parts of the body
21

Rheumatism,
arthritis, and
22 headache

Cough and colds

23

Toothache
24

Menstrual pain
25

Nausea and fainting

26

Insect bites
27

• MALUNGGAY
Other name/s:

Anti-fungal

28
 STEPS/PREPARATION USES DOSAGE REMARKS

Purgative
29

Anti-viral
30

Anti-depressant
31

Anti-inflammatory
32

• TAWA-TAWA
Other name/s

Diarrhea
33

Fever
34

Anti-viral
35

Anti-malaria
36

Anti-dengue
37
 STEPS/PREPARATION USES DOSAGE REMARKS
• BANABA
Other name/s:

Anti-oxidant

38

Cholesterol-
39 lowering

Anti-obesity effects
40

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
guidelines but
Performed the Performed the
showed little The student is
procedure procedure
unpreparedness unprepared, there
guidelines with guidelines with
PREPAREDNESS during the steps, is an inaccuracy,
great accuracy, minimal
with some incompleteness of
completeness, and inaccuracy,
inaccuracy the performance.
confidence. incompleteness.
and
incompleteness of
the performance.
Performed totally Performed the
Performed entirely Performed the
the procedure procedure with
the procedure procedure with
COMPLETENESS guidelines with lots of inadequacy
guidelines some inadequacy
minimal and
correctly. of steps.
incompleteness. incompleteness.
The student is
The student is The student is
partially The student is not
competent competent but less
competent, not yet competent and
observant, observant,
CONSISTENCY observant, is distracted in
accurate, and focus accurate, and focus
accurate, and focus doing the steps of
in doing the steps in doing the steps
on doing the steps the procedure.
of the procedure. of the procedure.
of the procedure.
Questions included
ABILITY TO ASK Ask questions with Some questions
Ask questions has little
QUESTIONS TO mostly good are not connected
comprehensively. connection to the
CLIENT points. to the topic.
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 Rationale and
information are
information are information are not information
LANGUAGE AND described well but
clearly described described well and described vaguely
GRAMMAR language or words
using correct and words used is not using incorrect
used are sometimes
clear language. correct or inaccurate. words.
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.
exhibits focus and
ORGANIZATION focus and coherent focus, relatedness of It does not exhibit
coherent
organization on the the steps and commands of focus
organization on the
steps and organized. and relatedness of
steps and
relatedness. the 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