SAINT FRANCIS OF ASSISI COLLEGE

045 Admiral Street, Admiral Village, Talon 3, LPC

COLLEGE OF NURSING
Name of Student:__________________________________
Year and Section:__________________________________

Score:____________

Clinical Performance Evaluation Checklist

NCM 100: Moving a Client Up in Bed: Two Nurses Using a Turn Sheet

1.
2.
3.
4.
5.
6.
7.

8.

9.

Procedure
Assess clients physical abilities and your own
strength and ability to move client
Introduce yourself and verify the clients identity.
Explain to the client what you are going to do,
why it is necessary, and how the client can
cooperate.
Prepare equipment:
4.1 Pull and/or turn sheet
4.2 Transfer or sliding board
Perform hand hygiene and observe other
appropriate infusion control procedures.
Provide for client privacy.
Adjust the bed and the clients position.
7.1 Adjust the head of the bed to a flat position
7.2 Raise the bed to the height of your center of
gravity.
7.3 Lock the wheels on the bed, raise the rail on
the side of the bed opposite you.
7.4 Remove all pillows, place one against the
head of the bed.
Place a drawsheet or a full sheet folded in half
under the client, extending from the shoulders to
the thighs. Each person rolls up or fanfolds the
turn sheet close to the clients body on either
side.
Both individuals grasp the sheet close to the
shoulders and buttocks of the client. Follow the
method of moving clients with limited upper
extremity strength.

Score
5

Yes

No

Remarks

2
5
(4)
5
5
(8)
2
2
2
2

5
5

5
10. Ensure client comfort.
10.1 Elevate the head of the bed and provide
appropriate support devices for the clients
new position
Document all relevant information.
TOTAL

Students Signature
Date:_____________________
/meemafmrep09

5
100

Clinical Instructors Printed Name over Signature

SAINT FRANCIS OF ASSISI COLLEGE

045 Admiral Street, Admiral Village, Talon 3, LPC

COLLEGE OF NURSING
Name of Student:__________________________________
Year and Section:__________________________________

Score:____________

Clinical Performance Evaluation Checklist

NCM 102: Initiating, Maintaining and Terminating a Blood Transfusion using a Y-Set
Procedure
1. Verify doctors order and signed informed
consent for the procedure.
2. Obtain the correct blood component for the
client.
2.1 Check the requisition form and the blood bag
label with laboratory technician.
2.2 Check the clients name, ID number, Blood
type and Rh group, Blood donor number and
the expiration date of the blood.
3. Prepare the equipment:
3.1 Blood product
3.2 Blood Administration Set
3.3 Normal saline (500ml/1L)
3.4 IV pole
3.5 Venipuncture set g.18 or g.19
3.6 Alcohol swab
3.7 Micropore tape
3.8 Pair of clean gloves
4. Introduce yourself and verify the clients identity.
5. Explain to the client what you are going to do,
why it is necessary, and how the client can
cooperate.
6. Perform hand hygiene and observe other
appropriate infusion control procedures.
7. Provide for client privacy.
8. Set-up the infusion equipment:
8.1 Put on clean gloves.
8.2 Ensure that the blood filter inside the drip
chamber is suitable for the whole blood or the
blood components to be transfused.
8.3 Close the clamp on the Y-site the main flow
rate clamp and both Y-line clamps.
8.4 Using a twisting motion, insert the piercing
pin (spike) into a container of 0.9% saline
solution.
8.5 Hang the container on the IV pole about 1m
(3ft) above the venipuncture site.
9. Prime the tubing:
9.1 Open the upper clamp on the normal saline
tubing and squeeze the drip chamber until
covers the filter and of the drip chamber
above the filter.
9.2 Tap the filter chamber to expel any residual
air in the filter.
9.3 Remove the adapter cover at the tip of the
blood administration set.
9.4 Open the main flow rate clamp and prime the
tubing with saline.
9.5 Close both clamps.
10. Start the saline solution:
10.1 If an IV solution incompatible with blood is
infusing, STOP the infusion and discard the
solution and tubing, according to agency
policy.

Score
2
(2)
1
1
(8)
1
1
1
1
1
1
1
1
2
2
2
2
(10)
2
2
2
2
2
(10)
2
2
2
2
2
(6)
2

Yes

No

Remarks

10.2 Attach the blood tubing primed with

Normal saline to the intravenous catheter.
10.3 Open the saline and main flow rate
clamps, and adjust the flow rate. Allow a
small amount of solution to infuse, to make
sure there are no problems with the flow or
with the venipuncture site.
11. Prepare the blood bag:
11.1 Invert the blood bag gently several times
to mix the cells with plasma.
11.2 Expose the port on the blood bag by
pulling back the tabs. Insert the remaining Yset spike into the blood bag.
11.3 Suspend the blood bag.
11.4 Close the upper clamp below the IV saline
solution on the Y-set.
12. Establish the blood transfusion:
12.1 The blood flow will run into the salinefilled drip chamber. If necessary, squeeze the
drip chamber to re-establish the liquid level
with drip chamber full.
12.2 Re-adjust the flow rate with the main
clamp.
13. Observe the client closely for the first 5-10
minutes:
13.1 Run the blood slowly for the first 15
minutes at 20 drops/minute. Note adverse
reactions, such as chilling, nausea, vomiting,
skin rash or tachycardia.
13.2 Remind the client to call a nurse
immediately if any unusual symptoms are felt
during the transfusion. If any of these
reactions occur, report them to the nurse in
charge, and take appropriate nursing action.
14. Document relevant data. RECORD:
14.1 Starting the blood
14.2 Vital signs
14.3 Type of blood
14.4 Blood unit number
14.5 Sequence number
14.6 Site of the venipuncture
14.7 Size of the needle
14.8 Drip rate
15. Monitor the client:
15.1 Fifteen minutes after initiating the
transfusion, check the vital signs of the
client. If there are no signs of reaction,
establish the required flow rate. Do not
transfuse a unit of blood for longer than 4
hours.
15.2 Assess the client, including vital signs,
every 30 minutes or more often, depending
on the health status, until 1 hour posttransfusion. If the client has a reaction and
the blood is discontinued, send the blood
bag to the laboratory for investigation of the
blood.
16. Terminate the transfusion:
16.1 Put on clean gloves.
16.2 If no infusion is to follow, clamp the blood
tubing and remove the needle. If another
transfusion is to follow, clamp the blood
tubing and open the saline infusion arm.
16.3 If the primary IV is to be continued, flush
the maintenance line with saline solution.
Disconnect the blood tubing system and
reestablish the intravenous infusion using

2
(8)
2
2
2
2
(4)
2
2
(4)
2

2
(8)
1
1
1
1
1
1
1
1
(6)
3

(12)
2
2

new tubing. Adjust the drip to the desired

rate.
16.4 Discard the administration set, according
to agency practice. Needle should be placed
in a labeled, puncture-resistant container
designed for such disposal. Blood bags and
administration sets should be bagged and
labeled before being sent for decontamination
and processing.
16.5 Remove gloves.
16.6 Monitor vital signs again.
17. Dispose off appropriately:
17.1 On the requisition attached to the blood
unit, fill in the time the transfusion was
completed and the amount transfused.
17.2 Attach one copy of the requisition to the
clients record and another to the empty
blood bag.
17.3 Return the blood bag and requisition to
the blood bank.
18. Document relevant data. Record:
18.1 Completion of the transfusion.
18.2 The amount of blood absorbed.
18.3 The blood unit number.
18.4 Vital signs
18.5 If the primary intravenous infusion was
continued, record connecting it.
18.6 Record the transfusion on the IV flow
sheet, and intake and output record.
TOTAL

Students Signature
Date:_____________________

/meemafmrep09

2
2
(6)
2
2
2
(6)
1
1
1
1
1
1
100

Clinical Instructors Printed Name over Signature

SAINT FRANCIS OF ASSISI COLLEGE

045 Admiral Street, Admiral Village, Talon 3, LPC

COLLEGE OF NURSING
Name of Student:__________________________________
Year and Section:__________________________________

Score:____________

Clinical Performance Evaluation Checklist

NCM 101: Monitoring an IV Solution

1.
2.

3.

4.

5.

6.

Procedure
Verify written doctors order.
Assess:
2.1 Appearance of infusion site.
2.2 Patency of system.
2.3 Type of fluid being infused.
2.4 Rate of flow.
2.5 Response of the client
Ensure that the correct solution is being
infused:
3.1 Check IV tag (Patients name, room #,
IVF,
drug incorporation, bottle sequence and
duration, time and date) against doctors
order and IVF sheet.
Observe the rate of flow every hour:
4.1 Compare the rate of flow regularly against the
infusion schedule.
4.2 If the rate is too fast, slow it so that the
infusion will be completed at the planned
time. Assess the client for manifestations of
hypervolemia and its complications.
4.3 If the rate is too slow, regulate on desired
rate.
Inspect the patency of the IV tubing and needle:
5.1 Observe the position of the solution
container. If it is less than 1m (3 feet) above
the IV site, readjust it to the correct height of
the pole.
5.2 Observe the drip chamber. If it is less than
half full, squeeze the drip chamber to allow
the correct amount of fluid to flow in.
5.3 Open the drip regulator and observe for a
rapid flow of fluid from the solution container
into the drip chamber. Then partially close the
drip regulator to reestablish prescribed flow
rate.
5.4 Inspect the tubing for pinches, kinks or
obstructions to flow.
5.5 Lower the solution container below the level
of the infusion site. Observe for the return
flow of blood from the vein.
5.6 Determine whether the bevel of the catheter is
blocked against the wall of the vein. If it is
blocked, adjust accordingly to reestablish
flow.
5.7 If there is leakage, locate the source. If the
leak is at the catheter connection, tighten the
tubing into the catheter. If the leak cannot be
stopped, replace the tubing with a new sterile
set.
Inspect the insertion site for complications:
6.1 Assess for:
6.1.1 Swelling
6.1.2 Coolness
6.1.3 Pallor
6.1.4 Discomfort

Score
5
(5)
1
1
1
1
1
(10)
10
(15)
5
5
5
(35)
5

5
5
5
5

5
(15)
1
1
1
1

Yes

No

Remarks

6.1.5 Pain
6.2 If a complication is present, stop the infusion.
Restart the infusion at another site.
6.3 Apply warm compress to the affected site.
7. If complication is not evident, calibrate the IV
solution as ordered.
8. Document and endorse accordingly.
TOTAL

Students Signature
Date:_____________________

/meemafmrep09

1
5
5
5
10
100

Clinical Instructors Printed Name over Signature

SAINT FRANCIS OF ASSISI COLLEGE

045 Admiral Street, Admiral Village, Talon 3, LPC

COLLEGE OF NURSING
Name of Student:__________________________________
Year and Section:__________________________________

Score:____________

Clinical Performance Evaluation Checklist

NCM 102: Changing a Bowel Diversion Ostomy Appliance: Colostomy Care:
Procedure
1. Assess:
1.1 Identify the type of ostomy and its location.
1.2 Note the appearance of the stoma.
1.3 Check the skin integrity.
1.4 Note the quantity and quality of the fecal material.
2. Prepare the equipment:
2.1 Pouch
2.2 Warm water
2.3 Mild soap
2.4 Washcloth
2.5 Clean gloves
2.6 Kidney Basin
2.7 Pair of Clean Gloves
3. Perform hand hygiene and observe other appropriate infusion
control procedures.
4. Introduce yourself and verify the clients identity.
5. Explain to the client what you are going to do, why it is
necessary, and how the client can cooperate.
6. Provide for client privacy.
7. Assist the client to a comfortable, sitting or lying position in
bed or, preferably, a sitting or standing position in the
bathroom.
8. Empty and remove the ostomy skin barrier:
8.1 Put on clean gloves.
8.2 Empty the contents of the pouch through the bottom
opening into a kidney basin or toilet. Do not throw away
the clamp.
8.3 Assess the consistency and the amount of effluent.
8.4 Peel the skin barrier off slowly, beginning at the top and
working downward, while holding the clients skin taut.
8.5 Discard the disposable pouch in a moisture-proof bag.
9. Clean and dry the peristomal skin and stoma:
9.1 Use toilet tissue to remove excess stool.
9.2 Use warm water, mild soap, and a wash cloth to clean the
skin and stoma.
9.3 Dry the area thoroughly by patting with a wash cloth.
10. Assess the stoma and peristomal skin:
10.1 Inspect the stoma for color, size, shape and bleeding.
10.2 Inspect the peristomal skin for any redness, ulceration
or irritation.
11. Place a piece of tissue over the stoma, and change it as
needed.
12. Prepare and apply the skin barrier:
12.1 Use the guide to measure the size of the stoma.
12.2 On the backing of the skin barrier, trace a circle the
same size as the stomal opening.
12.3 Cut out the traced stoma pattern to make an opening
in the skin barrier. Make the opening no more than 1/8-1/4
inches larger than the stoma.
12.4 Remove the backing to expose the sticky adhesive
side.
13. Apply the clean appliance:
13.1 Center the skin barrier over the stoma, and gently
press it onto the clients skin, smoothing out any wrinkles

Score
(4)
1
1
1
1
(8)
2
1
1
1
1
1
1
5
5
5
5
5
(18)
3
5
4
3
3
(9)
3
3
3
(6)
3
3
3
(14)
3
3
5
3

(5)

Yes

No

Remarks

or bubbles.

14. Dispose equipment properly.

15. Document the procedure in the clients record:
15.1 Amount
15.2 Consistency
15.3 Color of the stool
TOTAL

Students Signature
Date:_____________________

/meemafmrep09

5
(3)
1
1
1
100

Clinical Instructors Printed Name over Signature

SAINT FRANCIS OF ASSISI COLLEGE

045 Admiral Street, Admiral Village, Talon 3, LPC

COLLEGE OF NURSING
Name of Student: ____________________________________________
Year and Section: ____________________________________________

Score: ______________

Clinical Performance Evaluation Checklist

NCM 102: Performing Gastrostomy/Jejunostomy Feeding
Procedure
1. Verify the doctors order.
2. Prepare the equipment needed:
2.1 Feeding solution with right amount
2.2 Asepto syringe
2.3 Calibrated glass
2.4 Water

Score
5
(5)
2
1
1
1

3. Explain to the client what you are going to do, why it is

necessary and how he can cooperate.

4. Wash hands and other appropriate infection control

procedure.

5. Provide client privacy.

6. Check the patency of a tube that is sutured in place:

6.1. Determine placement of the tube.
6.2. Remove the tube clamp. Pour 15 to 30 ml of water to
the syringe and allow the water to flow into the tube.
6.3. If the water does not flow freely, notify the nurse in
charge and/or physician.

(15)
5
5
5

7. Check for residual formula:

7.1. Attach the bulb to the syringe and compress the
bulb.
7.2. Attach the syringe to the end of the feeding tube,
withdraw and measure stomach contents.
7.3. Hold the feeding if there is more that 100 ml or 50%
of feeding.
7.4. Notify the physician if a large residual feeding is
aspirated.

(20)
5

8. Administer the feeding:

8.1. Hold the syringe 7 to 15 cm (3-6 in) above the
ostomy opening.
8.2. Slowly pour the solution into the asepto syringe and
allow it to flow through the tube by gravity.
8.3. Just before all the formula has run through and the
syringe is empty, add 30ml of water.
8.4. If the tube is sutured in place, hold it upright,
remove the syringe and then clamp the tube to
prevent leakage.

(20)
5

5
5
5

5
5
5

9. Ensure client comfort and safety.

10. After the feeding, ask the client to remain in the sitting
position or a slightly elevated right lateral position for at
least 30 minutes.

11. Observe for common complications of enteral

feedings:
aspiration,
hyperglycemia,
abdominal
distention, diarrhea, and fecal impaction.

Yes

No

Remarks

12. Document all assessments and interventions.

5
TOTAL

Students Signature
Date:_____________________
/meemafmrep09

100

Clinical Instructors Printed Name over Signature