Bachelor of Science in Nursing Program

A Collaborative Partner of Laurentian University

Student Clinical Practice Self-Assessment Booklet

Student: Gregory Wendt Date: 2024

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This Self-Assessment Booklet provides you with an opportunity to take inventory of your past experiential learning in classroom,
laboratory and clinical settings. Completion of the document is intended to assist you to identify priority learning needs that may be
met in this final nursing practice course. It is anticipated that you will share your completed Self-Assessment Booklet with both your
Clinical Instructor and Preceptor at the beginning of your clinical placement.

Within PART A, you are provided with an opportunity to identify the settings in which you completed your clinical learning. Your
preceptor will be able to determine where the learning opportunities available in the practice setting may align with your identified
learning needs. It is not the intent to “collect” checkmarks for each item identified in PART B of the assessment, but rather to
stimulate dialogue as to how you may continue learning in your current clinical placement.

PART A - PAST CLINICAL PLACEMENTS

In the following table, list the clinical areas where you completed your acute and non-acute placements.
Year I
Acute Non-Acute

N/A Mapleview

Year II
Acute Non-Acute

SAH 2C & SAH 3C N/A

Year III
Acute Non-Acute

SAH 1C & SAH 3A Algoma Ontario Health Team &

Algoma Nurse Practitioners Led Clinic

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 Year IV
Acute Non-Acute

Algoma Public Health - Immunizations

Sault Area Hospital – 2B physical rehab

PART B – SELF-ASSESSMENT OF CLINICAL EXPERIENCES

In the following table:

 Designate your past experience with each identified item by placing a checkmark in either the 1 st or 2nd
column.
 In the 3rd column, rate your confidence with each identified item by scoring yourself on a scale from 1
to 4. (1= not at all confident; 3 = confident; 4 = highly confident)
 You may identify comments and examples in the 4th column.

Applied Self-
Theory
in Confidence
Introduced Comments / Examples
Practice Rating (1 to
4)
A. Influencing Health Care
1. Organizational Skills X 3
2. Prioritization Skills X 3
3. Collaboration Skills X 3
4. Problem Solving Skills X 3
5. Critical Thinking Skills X 3
6. Political Awareness & Action X 2
7. Determinants of Health X 2
8. Health Promotion X 3
9. Health Education X 3
10. Social Marketing X 3

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 Applied Self-
Theory
in Confidence
Introduced Comments / Examples
Practice Rating (1 to
4)
11. Community Development X 3
12. Accessing Evidence (searching) X 3
13. Applying Evidence in Practice X 3
(knowing theories behind care &
using them in practice)
14. Inter-team Communication X 3
15. Client Communication X 3
16.
B. Admission/Referral of a Client
1. Admission Assessment X 3
2. Health History X 3
3. Documentation X 3
4. Care of valuables and clothes X 3
5. Processing orders X 3
6. Consents X 3
7. Allergy procedure X 3
8. Initiation of Care Plans X 3
9.Identification of Client Supports, X 3
Strengths & Challenges
10.
C. Administration of Medications
1. Administration of oral meds X 3
2. Handling/admin/documentation X 3
of narcotics and controlled
substances
3. Subcutaneous injection X 3
4. Intramuscular injection X 3
5. Intradermal injection X
6. Administration of insulin X 3
7. Administration of anti-coagulants X
8. Administration of rectal and X 3
vaginal medications
9. Administration through a X

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 Applied Self-
Theory
in Confidence
Introduced Comments / Examples
Practice Rating (1 to
4)
subcutaneous set
10. Administration of antineoplastics X
11. Disposal Cytotoxic/Biohazards X 3
12. Instillation of eye drops X 3
13. Administration of aerosol X 3
medications
14. Epidural Analgesia X
15. Administration of Immunizations X 3
15. Documentation X 3
16.Medications administered to X 3
different populations (adults,
paediatrics, infants, pre op,
elderly)
17. Identification of multiple X 2
medication collaborative
problems
18. Pharmacology X 3
19. Health Assessments X 3
20.
D. Administration of Intravenous Therapy
1. Infusion pumps X
2. Setting up an I.V. X 3
3. Flushing/maintenance of saline X 3
locks
4. Intravenous additives-into bag- X
into injection ports-into Buretol-
change of mini bag
5. Setting up of blood transfusion X
6. Monitoring of blood transfusion X
7. Discontinuing an I.V. X 3
8. Care of venipuncture site X 3
9. Extravasation Protocol X
10. Documentation X 3

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 Applied Self-
Theory
in Confidence
Introduced Comments / Examples
Practice Rating (1 to
4)
11.
E. Administration of Oxygen
1. Use of wall outlet X 3
2. Use of O2 tank X 3
3. Use of nasal prongs X 3
4. Use of mask X
5. Use of venture mask X
6. Use of oximeter X 3
7. Use of tracheostomy mask X
8. Liquid oxygen X
9. BiPAP setup and monitoring X
10. Optimal positioning of client X 3
11.

F. Client Preparation for Diagnostic Testing

1. Psychological support X 3
2. Client and/or family teaching X 3
3. Obtaining a consent when X 3
needed
4. Review of appropriate resources X
5. Specific preparation for X 3
diagnostic procedures
6. Procedure for inter-site X 3
transporting of clients
7.
G. Miscellaneous Procedures
1. Insertion of a foley catheter X 2
2. Suprapubic catheter X
3. Catheter care and irrigation X 3
4. Intermittent catheterization X
5. Aseptic technique (sterile X 3
dressing)
6. Compresses/wound packing X 3

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 Applied Self-
Theory
in Confidence
Introduced Comments / Examples
Practice Rating (1 to
4)
7. Removing sutures/staples X 2
8. How to set up suction X
9. Use of intermittent suction X
10. Insertion of levine tubes X
11. Irrigation of levine tubes X
12. Enema X
13. Perineal Care X 3
14. ROM exercises X 3
15. How to use bed scale X 3
16. Continuous Bladder Irrigation X 2
17. Peritoneal Dialysis continuous X
protocol.
18. PNT X
19. AV Fistula Check X
20. Peritoneal Dialysis X
21. TB Skin tests X 3
22.
H. Advanced Skills
1. Total Parenteral Nutrition (TPN) X 2
2. Enteral Feeds-Open system – X
Closed system
3. Tracheostomy Care X
4. Glucose Meter (per agency X 3
policy)
5. Chest Tube Management X
6. Changing G-Tube X
7. Central Line Management- X 2
Tunnelled-Implanted-PICC
Non-Tunnelled PICC
8. Pain Management Pumps:- X
CADD Pump-PCA Pump-Pain
Mgt. Provider
9. Pain Management-PCA (IV/SC)- X

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 Applied Self-
Theory
in Confidence
Introduced Comments / Examples
Practice Rating (1 to
4)
Narcotic Infusions (IV/SC)
10. Glascow Coma Scale X 3
11. Stroke Scale X 3
12.
I. Client Preparation for OR/ Procedures
1. Ensure signed consent on chart X
2. Pre-op medications X
3. Anaesthetic Record X
4. Anaesthetic Protocol X
5. Pre-op Checklist X
6. O.R. identification band X
7. All necessary lab work X
8. Pre-Admission Clinic (PAC) X
9.
J. Post Operative Care
1. Post-operative checks X
2. Client and/or family teaching X
3. Deep breathing and coughing X 3
(Respirex/Insentive Spirometer)
4. Early ambulation X
5. Compression Stockings X 3
6.
K. Client Discharge
1. Discharge planning e.g. X 3
notification of family, ambulance,
appropriate agency follow up
2. Returning valuables X 3
3. Transfer of client to another X 3
facility
4. Teaching to client and family- X 3
medications-diet-activities-
hygiene
5. Discharge summary X 3

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 Applied Self-
Theory
in Confidence
Introduced Comments / Examples
Practice Rating (1 to
4)
6.
L. Client Death
1.Pre-death communication with X
client & family*
2. Notification of the family/clergy X
3. Care of family during end of life X
care & after notification of death
4. Pronouncement of Expected X
Death
5. Death Notice forms X
6. Computer Death X
Discharge/Transfer
7. Autopsy Consent X
8. Coroner’s case X
9. Care of the body after death X
10. Release of belongings and X
valuables
11. Documentation X
12.
M. Emergency Measures
1. Basic Cardiac Life Support X
(BCLS)
2. Use of airway X
3. Use of resuscitation bag X
4. Crash Cart X
5. Code Responses X
6. Naso-pharyngeal suctioning X
7. Assisting with intubation X
8. Compression board (know how to X
use)
9.
N. Communication
1. Obtaining shift report X 3

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 Applied Self-
Theory
in Confidence
Introduced Comments / Examples
Practice Rating (1 to
4)
2. Regular communication with X 3
covering RN
3. Reporting: client changes; when X 3
leaving/returning client to unit;
end of shift to covering RN.
4. Documentation X 3
5. Communication to X 3
interprofessional team members
6. Communication to clinical X 3
educators
7.Communication with unregulated X 3
care providers, admin support,
volunteers
8.Workplace harassment policy X
reviewed
9.
O. Safety
1. Isolation procedures X 3
2. Infection Control Admission X 3
Screening procedures
3. Safe Client Handling Procedures X 3
(assessment, transfer
techniques, signage,
documenting, mechanical lifting
aids, ceiling & portable lift use
etc.)
4. Fall Prevention Procedures X 3
(universal fall precautions, risk
assessment, signage,
interventions, documentation)
5. Least Restraint Policy review X 2
(assessment, alternatives, order
requirements etc.)
6. Medication Safety Procedures & X 3

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 Applied Self-
Theory
in Confidence
Introduced Comments / Examples
Practice Rating (1 to
4)
Policy review
7.Reporting & documentation of X
Medication Errors
8.Incident Reporting Procedures X
(e.g. SAFE reporting)
9. Code White response X
10. Home/community visiting safety X 3
protocols
P. Informatics
1. Meditech—order entry X 3
2. Online policy/procedures X 3
3. Medication Dispensing Cabinets X 3
4. Electronic thermometer X 3
5. Oximeter X 3
6. Auto BP/P monitor X 3
7.
Q. Health Promotion
1.Preparation of print material X 3
2.Health promotion activity planning X 2
3.Faciliating groups X 2
4. Presenting at conference to a X
group
5.Development of online resources X 3
6. Use of social media for health X 3
promotion
7.Answering telephone inquiries / X 3
telephone counseling
8. Working in schools or community X 3
setting
9. Application of change theory (e.g. X 3
stages of change)
10. Chronic disease & injury X
prevention

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 Applied Self-
Theory
in Confidence
Introduced Comments / Examples
Practice Rating (1 to
4)
11.
R. Home Care
1.Home visiting X
2. Community drop in/clinic X
3.Chronic illness management X 2
4.Home care needs assessment X
5.Community support identification X 2
& referral

R. Clinical Agency In-services

S. Clinical Agency Self-Learning Packages

T. Specialty Area Skills (Paediatrics, critical care, labour & delivery, mental health etc.)

There are many area-specific protocols, policies, standards and guidelines in nursing practice. Please check with
your Preceptor and Clinical Instructor to identify the ones that apply to your clinical practice area and
responsibilities as a nursing student.

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