Republic of the Philippines

Catanduanes State University

Virac, Catanduanes

COLLEGE OF HEALTH AND SCIENCES

NCM 109 RLE – Care of Mother and Child at Risk or with Problems

PERFORMANCE EVALUATION CHECKLIST FOR BREAST SELF-EXAMINATION

Name: ___________________________________ Score: _______________
Year/Block/Group_________________________________ Date of Exposure: ______________

CRITERIA FOR RATING:

5 – EXCELLENT Performs the expected behaviour in a consistent and independent manner without guidelines and
supervision.

4 – VERY SATISFACTORY Performs the expected behaviour in a consistent and independent manner requiring minimal
guidance and supervision.

3 – SATISFACTORY Performs the expected behaviour most of the time requiring moderate guidelines and supervision.

2 – FAIR Performs the expected behaviour from time to time requiring moderate guidance and
supervision.

1 – POOR Fails to perform the expected behaviour even under close supervision.

DIRECTIONS: Rate the student’s performance by checking the appropriate box. Refer to Criteria for Rating for the descriptive meaning of the
number in each column.

PROCEDURE 5 4 3 2 1 Remarks
1. Gather equipment and supplies needed.
2. Greet the client, introduce yourself and explain the procedure
to the client. (Rationale: Decreases client’s anxiety)
3. Review personal history, medication, allergies and family
health history. (Rationale: To have baseline data about the
clients)
4. Ask the client to disrobe completely and to put on a gown.
(Rationale: Provide easy access while maintaining maximum
privacy)
5. Perform hand hygiene, apply gloves and observe appropriate
infection control. (Rationale: To prevent spread of
microorganisms)
6. Assist client to sitting position facing you and expose chest and
breast. (Rationale: Promote patient’s comfort)
7. Inspect the breast, areola and nipples:
 With the client’s arms at side
 With the client’s arms raised
 With client’s hands pressed on hips
 With client’s arms extended straight ahead as client leans
forward (*omit this position for male unless gynecomastia is
present)
Observe for:
 Change in the size
 Change in the shape
 Presence of lumps
 Thickening
 Rashes or skin irritation
 Dimpled or puckered skin
 Discharges
 Changes in nipples
8. Palpate adjacent lymph nodes: supraclavicular, infraclavicular
and subclavian (Rationale: Most of the lesions or lumps occur in
the upper outer quadrant. Breast tissue extends up to axilla,
where the tail of Spence is located)
9. Examine each breast for at least 2 minutes. Large breast takes
longer time to be examined.
 Republic of the Philippines
Catanduanes State University
Virac, Catanduanes

 Observe for arm temperature, elasticity, tenderness, pain,

erythema, masses or nodules which are abnormal.
10. Explain and teach breast self-examination as you examine
(Rationale: To provide information and increases knowledge of
the client)
11. Palpate areola and nipple using similar circular techniques as
with breast. Pay special attention to subareolar area. Gently
press the nipple between your fingers.
 Observe abnormalities such as inflammation, discharge,
nodules, fissuring or lesions.
12. Examine both breast.
 Identify posterior axillary, central axillary, anterior axillary and
lateral axillary node locations. Nodes should be less than 1 cm
and non-tender.
13. Repeat actions 7 to 9 on left breast, areola, nipple and axilla.
 Identify normal versus abnormal as with the right breast.
Compare breast bilaterally.
14. Assist client to supine position. Place arm on examination
side under head and place a small pillow under the same side
scapula.
15. Palpate breast, areola, nipple as in actions 7 to 10.
 Re-evaluate examination in second position
16. Assist the client to a sitting position. Review the steps and
ask the client to return-demonstrate breast self-examination.
(Rationale: Provides more comfort for client. Evaluates success
of your teaching)
17. Assist client in dressing. (Rationale: Provides for client
comfort)
18. Give the client written materials to reinforce teaching.
(Rationale: To provide information about the procedure)
TOTAL

________________________________ JERIC V. GIANAN, RN, LPT

Student’s Signature Over Printed Name Name and signature of Clinical Instructor