COLLEGE OF NURSING

SKILLS LABORATORY
PERFORMANCE EVALUATION TOOL
NCM 109 – CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS
(ACUTE AND CHRONIC)

PROCEDURE:
ADMINISTERING PHOTOTHERAPHY

NAME OF STUDENT :______________________________________ Score:

Block :______ Date:______________

DIRECTIONS:
● The evaluation tool will be discussed by the clinical instructor/s.
● During the discussion, the instructor/s may demonstrate the procedures or may use video viewing for students’
orientation.
● The students should be given sufficient time to prepare for the return demonstration.
● The students will do the return demonstration based on the checklist given.
● The following rating scale shall be used in grading student’s performance:
DONE- able to perform
Perform the procedure safely and accurately in a very consistent and independent manner without
supportive assistance from the instructors.
Perform a difficult action quickly and skillfully
Spends minimal time on task
Focuses on the client while giving care
NOT DONE - unable to perform
Unable to perform the procedure even under close supervision of guidance
Require continuous, supportive, and directive cues
Takes a longer time to complete the procedure.
Performs in an unskilled manner
● At the end of each laboratory session, the instructor/s will give remarks based on the student’s performance per
the procedures indicated.

PROCEDURES DONE NOT DONE

1. Application of fluorescent light to the infant’s exposed skin

used to breakdown the bilirubin in the skin

Assessment:

2. Assess the newborn for the following:

3. Yellowish discoloration of the baby’s skin and sclera.

4. Check the doctor’s order

5. Consent for the procedure

6. Newborn/s weight

7. Check the newborn’s skin color

8. Watch out for the following side effects:

9. bronze-baby syndrome

10. loose, greenish stools

11. Transient skin rashes

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12. Increasing metabolic rate

Planning:

13. Gather the necessary materials

14. Eye patches –to protect the baby’s eye

15. Diaper

16. Assess and adjust thermoregulation

17. Baby is turned every two hours after each feeding- to

neutralize the baby’s skin color

18. Check the baby’s bilirubin level once everyday

19. Weight is taken once daily

20. Monitor urine output

21. Proper hydration

22. Check the newborn’s skin color

23. Promote elimination and skin integrity

24. Do not interrupt phototherapy treatment except during normal

bathing or diaper changes

25. Instruct parents to refrain from using lotions or oil on the skin
during phototherapy treatment

26. Instruct parents to reposition pad and inspect skin

underneath pad for any unusual changes every 2 hours

STEPS

1. Do hand washing and other infection control

2. Undress the infant and place in the incubator(to expose as

much skin as possible to the lights

3. Apply the diaper

4. Place infant on covered fiber optic pad so that lighted section

of pad is in contact with the skin and secure with self-
adhesive tabs

5. The cover should be worn snug, around infant's torso, not

tight

6. A good rule of thumb is to place one finger between the pad

and the infant's body to ensure proper ventilation

7. Attach protective eye patches

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8. Insert fiber optic pad into a new disposable cover, and secure
the cover around the cable with tape or per manufacturer
recommendation
9. If cover becomes soiled, replace with a new one

10. Connect the power cord to the light source box and plug into
a grounded electrical outlet
11. Do not use an extension cord unless it is heavy duty

12. Firmly place the fiber optic cable into the light source port

13. 1Place light source box on a level surface below the level of
infant, but close enough to infant so that it will not be pulled
off of surface

14. Turn variable intensity knob on light source box to highest

setting, and turn power switch on

15. Provide nursing care to the infant and educate parents on

caring for infants under phototherapy

16. Document assessment, procedure and nursing care done on

the infant’s chart

TOTAL

***nothing follows***
REMARKS:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

EXPECTED LEVEL OF PERFORMANCE:

32 to 42 items done: PASS

31 items below done: Repeat the procedure to PASS

Student’s Signature:_______________
Date:__________

Instructor’ Signature:________________
Date:__________

GEN-FM-019 Rev 2 Effective Date 24 July 2023