Republic of the Philippines

TARLAC STATE UNIVERSITY

COLLEGE OF NURSING
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300 Tel. No.: (045) 982-6062 Fax: (045) 982-0110 website: www.tsu.edu.ph

Performance Evaluation Checklist NEBULIZATION Name of Student: ________________________________________ Year/Clinical Group: ______________________________________ School Year: _____________________________________________ Semester: ___First ___Second ___Summer Inclusive Dates of Clinical Rotation: ___________________________ Instructor: _______________________________________________ STEPS I. SAFE & QUALITY NURSING CARE 1. Demonstrate knowledge of the procedure by identifying health needs of the patient. Review medical orders and obtain information on drug/s, dosage/s, specifics of administration, responses to previous treatments and other medical and nursing history. Explain to client the procedure, its purpose. II. MANAGEMENT OF RESOURCES ENVIRONMENT AND EQUIPMENT 1. Prepares instrument and equipments needed. Prescribed drug/s Patient s medical record/chart Air compressor or Nebulizer 2. Performs safely nursing procedures. A. Preparatory Monitor the heart rate before and after the treatment for patient using bronchodilator drugs. B. Performance Explain the procedure to the patient. Place the patient in a comfortable sitting or a semiFowler s position. Add the prescribed amount of medication and saline to the nebulizer. Connect the tubing to the compressor and turn it on. Instruct the patient to exhale. Tell the patient to take in a deep breath from the mouthpiece and hold breath briefly then exhale. Observe expansion of chest to ascertain that patient is taking deep breaths. Instruct the patient to breathe slowly and deeply until all the medication is nebulized. Observe for adverse effects during administration. On completion of the treatment, encourage the patient to cough after several deep breaths. Assess need for percussion, vibration, postural drainage and suctioning. Record medication used and description of secretions. Disassemble and clean nebulizer after each use. SCORE 0 1 2 REMARKS

III. HEALTH EDUCATION 1. Provides information on the following. Nebulization procedure and its purpose Expected effect of the procedure IV. LEGAL RESPONSIBILITY 1. Adheres to practices in accordance with the law and other relevant legislation. 2. Documents all nursing care performs and assessment findings according to institutional policies. Record the following after the procedure: clinical improvement, improved aeration with decreased work of breathing drugs and dosages administered increase wheezing, increased work of breathing, more limited air entry, cyanosis, agitation, desaturation or other deterioration during or after treatment topics discussed with the patient and his family V. ETHICO-MORAL RESPONSIBILITY 1. Adheres to ethico-moral standards of nursing practice. Respects the religious, cultural and ethnic practices of the client. Maintain privacy and confidentiality of information obtained and encountered. VI. PERSONAL AND PROFESSIONAL DEVELOPMENT 1. Projects a professional image of a nurse 2. Accepts criticisms and recommendations. 3. Performs function according to professional standards by explaining nursing practice when situations call for it. VII. QUALITY IMPROVEMENT 1. Identifies deviation of practice from the standards. 2. Recommends corrective and preventive measures for the identified deviations. VIII. RECORDS MANAGEMENT 1. Documents accurately relevant data about the before, during and after the procedure. 2. Maintains an organized system of filling and record keeping. IX. RESEARCH 1. Utilizes findings in research and readings on chemotherapy. 2. Identifies researchable problems related to respiratory problem. 3. Initiate research study on identified researchable problem. 4. Participates as a member of a research team in the conduct of the study. X. COMMUNICATION 1. Establishes rapport to patient and significant others. 2. Utilizes appropriately all forms of communication: verbal, non-verbal, and electronic. 2. Maintains an open line of communication with the patient and client. 3. Listens attentively to the queries & request of the client.

XI. COLLABORATION AND TEAMWORK 1. Establishes collaborative relationship to colleagues and other members of the health team. 2. Communicates findings to all concerned. TOTAL SCORE TRANSMUTATION EQUIVALENT Evaluated by:

Signature over Printed Name Clinical Instructor

Signature over Printed Name Student

Signature over Printed Name RLE Coordinator