University of San Agustin

College of Nursing, Nutrition and Dietetics

Nursing Program
Performance Rating Scale
NCM 116a: CARE OF THE CLIENTS WITH PROBLEMS IN NUTRITION,AND GASTRO –INTERNAL, METABOLISM AND ENDOCRINE,PERCEPTION AND COORDINATION,
ACUTE AND CHRONIC

Name: ______________________________________________________ Year & Section: Raw Score: Rating: Grade:

Area of Exposure: Date of Exposure: ____________ Rotation:

INSTRUCTION: Indicate your rating to the item by checking appropriate cell for each task.
Legend:
(5) Excellent: Performs task effectively and correctly without Clinical Instructor's supervision
(4) Very Satisfactory: Performs task effectively and correctly with minimal Clinical Instructor's supervision
(3) Satisfactory: Performs task effectively with full supervision
(2) Needs Improvement: Finds difficulty in performing task
(1) Poor: Initiated to do task but failed
A. BEGINNING PRACTITIONER ROLE (50%) 5 4 3 2 1
1. Practices in accordance with the Code of Ethics in making personal and professional judgment
1. Specifies the ethico-legal bases for providing safe, quality and professional nursing care.
2. Makes professional decisions within ethical and legal parameters.
3. Applies legal and ethical principles to advocate for human and societal well being and preferences
4. Decides on cases based on ethical reasoning.
5. Maintain confidentiality of client and staff.
6. Implements strategies/interventions to protect client’s rights guided by the “Patient’s Bill of Rights and Obligations”.
7. Demonstrates an understanding of informed consent as it applies in multiple contexts.
8. Validates with client if informed consent is clear, complete, taken wholly voluntarily, and signed by legally competent representative.
2. Utilizes the nursing process in the interdisciplinary care of client's that empowers the clients and promotes safe quality care
1. Establishes a nurse-client relationship
2. Introduces self and addresses clients, other individuals as they prefer to be addressed.
3. Performs correct client identification by asking the client's full name, birth date, and ID bands.
4. Shows respect to others regardless of background.
5. Picks out essential data in nursing history relevant to client's condition.
 6. Applies the nursing process in the care of client with problems in gastro, metabolism and endocrine...
6.1. Performs physical assessment using the IPPA method
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
7. Determines the significance of laboratory and diagnostic findings of client's condition.
8. Analyzes client's data utilizing the appropriate theoretical framework
9. Identify appropriate nursing diagnoses of client's condition.
10. Prioritizes the nursing diagnoses of client's with problems in gastro, metabolism and endocrine
11. Formulates a plan of care of client's condition.
11.1. Identifies goals/objectives
11.2. Specifies appropriate nursing interventions
11.3. Defines evaluation criteria
12. Implements appropriate interventions of client's condition.
12.1. Observes principles of safety, privacy, and comfort when providing care.
12.2. Gives full attention to client when giving care.
12.3. Provides nursing care based on individual's needs.
12.4. Adapts to environment to make it conducive for healing/pleasing to the client.

12.5 Provides necessary curative measures (gastro, metabolism and endocrine, correct drug administration, corrects fluid and electrolyte imbalance.)

12.6. Provides restorative/rehabilitative measure e.g. dietary regimen, prescribed exercises, lifestyle modification.
12.7. Utilizes appropriate technology to perform safe and efficient nursing interventions
12.8. Utilizes bio behavioral strategies (e.g. mind-body-spirit paradigm and reflective holism) to client’s condition.
12.9. Performs evidence-based nursing procedures/activities safely and effectively.
a. With ease and confidence
b. Correctly
c. Systematically
d. Performs after-care
13. Evaluates client's response/outcomes of care.
14. Adheres to policies, procedures, and protocols on prevention and control of infection especially to clients with problems in gastro, metabolism and
endocrine.
15. Observes proper waste disposal.
3. Maintains complete, accurate, and up-to-date recording and reporting system.
 1. Demonstrate accuracy and honesty in recording and reporting.
1.1. Data is accurate
1.2. Data is complete
1.3. Shows honesty in documentation
2. Explains therapeutic regimen of the client with the indications and corresponding nursing responsibilities observing the 14 R's in medication
administration.
3. Confirms information given by the doctor for the informed consent to diagnostic and surgical procedures to clients in crisis.
4. Checks the completeness of informed consent and other legal forms.
5. Secures waiver of responsibility for refusal to undergo treatment or procedure (MRI/CT Scan/CVP/Surgery, etc.)
6. Completes updated documentation of client care.
7. Utilizes the use of KARDEX/Care Plan, client's charts, therapeutic sheet, medication card and other hospital forms.
8. Maintains an organized system of filing and keeping client's records.
9. Maintains confidentiality in the safekeeping of records and other information.
10. Releases records and information based on protocol and principle of confidentiality.
4. Establishes collaborative relationship with colleagues and other members of the team to enhance nursing and other health care services.
1. Utilizes all forms of communication: verbal, non-verbal, use of electronics
2. Creates rapport, trust and confidence to client's significant others and members of the health team.
3. Participates actively in the care of client.
4. Works hand and hand with other members of the health team, family, and significant others.
5. Acts as client advocate/liaison to other members of the health team, family, and significant others.
5. Promotes professional and personal growth and development.
1. Manifest self-direction
1.1. Reports to duty on time
1.2. Submits requirements on time
1.3. Shows initiative in activities/tasks
2. Seek proper guidance from clinical instructor and other authorities
3. Accepts feedback from CI and corrects personal deficiencies
4. Display neatness and good grooming.
5. Maintains calm disposition under pressure.
6. Identifies strength and weaknesses.

B. BEGINNING MANAGER-LEADER ROLE (30%)

1. Demonstrates management and leadership skills to provide safe and quality care.
1. Identifies needs/concerns/issues related with multiple interventions for clients with co-morbidities and complex, rapidly changing health status.

2. Uses conflict resolution to resolve health team member's differences and transform these differences into healthier and positive personal interactions.

3. Analyzes results/outcomes of care with nursing and health care team members.
4. Participates actively in the creation of a preventive maintenance program to ensure proper function of equipment.
5. Adopts measures to work within the budget allocation without compromising related principles and standards.
6. Maintains a harmonious and collegial relationship among members of the health team for effective, efficient and safe client care.
7. Utilizes various avenues for open communication.
8. Listens to suggestions and recommendations.
9. Utilizes critical thinking in solving problems/address issues that arise in practice using current information input from clients and colleagues.
10. Carries out strategies and actions to ensure a safe environment of care in partnership with the health team, the client and other support staff.

2. Demonstrates accountability for safe nursing practice.

1. Reports near misses and errors of self/others
2. Institutes appropriate corrective actions to prevent or minimize harm arising from adverse effects
2.1. Specifies appropriate corrective actions.
2.2. Executes judiciously corrective actions.
2.3. Determines effectiveness of implemented corrective actions.
3. Accomplishes assigned workload within a given time frame.
4. Performs task willingly in consonance with the policies of the affiliated institution.
5. Assumes responsibilities for own actions.

3. Demonstrates basic management and leadership skills to deliver health programs and services effectively to clients in Critical Care/Cris.
1. Applies basic management and leadership principles in providing direction to manage clients with problems in gastro, metabolism and endocrine.
2. Executes appropriate activities based on basic management and leadership principles.
3. Determines effectiveness of implemented management activities.

4. Manages care of client condition

1. Collaborates with other members of the health team.
2. Reports promptly any outcomes or responses of interventions given.
3. Shows honesty in data gathering, problem identification, implementing interventions, reporting, recording, and evaluating outcomes.
4. Considers the nature of the client/learner in relation to: social, cultural, political, economic, educational, and religious factors.
 5. Teaches appropriately client's and significant others of health care needed at the level of their understanding.
6. Displays critical thinking in the analysis of the health problems of the client/family.
7. Maintains a positive practice environment.

5. Demonstrates ability to lead and supervise nursing support staff.

1. Applies basic principles of supervision for effective and efficient delivery of health programs and services.
2. Participates in the planning and implementation of staff development activities to enhance performance of nursing support staff.
3. Provides nursing support staff with appropriate information/data on policies, regulations, circulars, and programs

6. Utilizes appropriate mechanisms for networking, linkage building and referrals.

1. Uses appropriate principles of partnership and collaboration which would improve health service delivery
2. Determines resources available for networking, linkage building, and referral necessary for improving delivery of health services.
3. Uses appropriate strategies for networking, linkage building and referral.
4. Implements appropriate advocacy strategies to address health related concerns and policy adoption to foster growth and development of the nursing
profession.

C. BEGINNING NURSE'S ROLE ON RESEARCH (20%)

1. Evaluate research study/report utilizing guidelines in the conduct of a written research critique
1. Analyzes the research study/report for completeness, clarity of presentation, and logical organization.
2. Analyzes a clear link between the theoretical framework /conceptual model and research question /purpose.
3. Explains if the concepts in the framework are clear and consistent with the operational definition
4. Establishes if the interpretation, implications, and recommendations are consistent with the results considering the limitations of the study
5. Analyzes if the rights of the human subjects were protected and ethical principles in nursing research had been followed.

2. Applies the research process in improving patient care in partnership with a quality improvement/quality assurance/nursing audit team.
1. Utilizes knowledge and practice triggers in identifying performance improvement opportunities.
2. Identifies opportunities for improvement of systems or processes in the delivery of health care services.
3. Prioritizes identified opportunities for continuous quality improvement taking into consideration those which occur frequently and affect large number
of clients, high risk problems, and aspects of care that produce problems to clients and staff.
4. Conducts collection and analysis of data with the team members based on the agreed plan.
4.1. Collects data using appropriate methods and tools.
4.2. Analyses with the team data gathered using appropriate methods/models. examples include:
a. Flow charts for laboratory data, test results and medication review.
b. Performs daily check of client's records/condition
 4.3. Evaluates with the team, the identified variations that requires investigation.
5. Identifies and reports variances in the performance of practice standards.

Comments: A (50%)
B (30%)
C (20%)
Final
Grade

Student's Name and Signature:

Clinical Instructor’s Name and Signature:

Date of Evaluation: