OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING –Quezon City Campus

PROGRAM Bachelor of Science in Nursing Student Name

NCMA 217 RLE Year and Section
COURSE MATERNAL AND CHILD Instructor
HEALTH NURSING Date

PROCEDURE : Acetic Acid Test

EXPECTED OUTCOME : The student should be able to perform Acetic Acid test to client
ASESSMENT TASK : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(4) (3) (2) (1)
Explained the procedure Explained the Explained the
1. Explain the Failed to explain
to the client and procedure but procedure but in
procedure the procedure
significant others clearly lacks details an unclear manner
Gathered materials Gathered materials Gathered materials Failed to gather
2. Prepare
needed with little time with more time all the materials
equipment
preparation preparation needed
3. Ask the client to Performed the procedure Performed but Performed with Failed to perform
get a mid-stream accurately with evident needs minimal slight difficulty, the procedure
catch urine and ease without supervision supervision needs supervision
place it in a most of the time
receptacle
Observed principle of Hand washing was Hand washing was Hand washing
4. Perform hand
medical hand washing done with minimal done with maximal was not done
washing
error error
Performed the procedure Performed but Performed with Failed to perform
5. Put on clean accurately with evident needs minimal slight difficulty, the procedure
gloves ease without supervision supervision needs supervision
most of the time
Performed the procedure Performed but Performed with Failed to perform
6. Fill in the test
accurately with evident needs minimal slight difficulty, the procedure
tube with 2/3 or
ease without supervision supervision needs supervision
5ml of urine
most of the time
7. Heat the upper Performed the procedure Performed but Performed with Failed to perform
portion of the accurately with evident needs minimal slight difficulty, the procedure
test tube with ease without supervision supervision needs supervision
urine without most of the time
shaking. Wait
until it boils
8. If cloudiness Performed the procedure Performed but Performed with Failed to perform
appears in the accurately with evident needs minimal slight difficulty, the procedure
heated portion, ease without supervision supervision needs supervision
add 5 drops of most of the time
acetic acid
solution one at a
time and reheat
until it boils
9. Interpret the Performed the procedure Performed but Performed with Failed to perform
color and the accurately with evident needs minimal slight difficulty, the procedure
result of the test ease without supervision supervision needs supervision
most of the time
 Performed the procedure Performed but Performed with Failed to perform
10. Give health
accurately with evident needs minimal slight difficulty, the procedure
teaching to the
ease without supervision supervision needs supervision
client
most of the time
Performed the procedure Performed but Performed with Failed to perform
11. Aftercare of the accurately with evident needs minimal slight difficulty, the procedure
materials used ease without supervision supervision needs supervision
most of the time
Performed the procedure Performed but Performed with Failed to perform
12. Remove the accurately with evident needs minimal slight difficulty, the procedure
gloves ease without supervision supervision needs supervision
most of the time
Washed hands and Washed hands and Washed hands but Washed hands
13. Perform hand
documented the some of the details most of the details but
washing and
information about the of procedure were of the procedure documentation
document the
procedure properly and not documented. were not was not done.
procedure done
completely. documented

SCALE:
3 – (EXCEPTIONAL) Works competently and independently at all times
2 – (GOOD) Requires minimum guidance and supervision
1 – (AVERAGE) Requires frequent guidance and supervision
0 – (POOR) Requires close guidance and supervision most of the time

OVERALL SCORE: ________________

Target raw score is 29 out of 39. If raw score is less than 29, repeat the demonstration.

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FACULTY SIGNATURE OVER PRINTED NAME STUDENT NURSE SIGNATURE OVER PRINTED NAME