Our Lady of Fatima University College of Nursing - Cabanatuan City

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OUR LADY OF FATIMA UNIVERSITY

College of Nursing – Cabanatuan City


PROGRAM Bachelor of Science in Nursing STUDENT NAME

COURSE NCMB-312 YEAR & SECTION


Care of Clients with Problem in
Oxygenation, Fluids & INSTRUCTOR
Electrolytes, Infectious,
Inflammatory & Immunologic DATE
Response, Cellular Aberrations
(Acute & Chronic)
(SKILLS LABORATORY)
PROCEDURE :BREAST SELF EXAMINATION
EXPECTED OUTCOME : The student should be able to perform breast self examination correctly.
ASSESSMENT TASK : Return Demonstration
Assessment Exceptional Good Average Poor SCOR
Dimension (4) (3) (2) (1) E
1. Clearly verified Verified the Verified the Failed to
Verify the doctor’s the presence of presence of presence of verified the
order and secure doctor’s written doctors doctors written presence of
consent if necessary orderand ritten order with order incorrectly doctors written
secured minimal and secured order.
consent if error and consent if
necessary. secured necessary.
consent if
necessary.
2. Performed Performed Performed Medical hand
Hand washing medical hand medical hand medical hand washing not
washing wash- ing with washing with performed
properly. least error. most error
3. Gathered all With lacking of With lacking Failed to
Gather all the the necessary 12 materials. of 3 or more gather
necessary materials materials materials. necessary
needed. (drape, ruler completely. materials
in centimeter, (Drape, ruler completely.
marker, in
gloves) centimeter,
marker,
glove)
4 Greeted and Performed at Performed one Failed to greet
Identify the patient identified least two (2) (1) way of and identify
patient ways of identifying the the patient.
by asking his/her identifying the patient.
name and patient.
checking his/her
ID band and bed
tag.
5. Explained Explained Explained Failed to explain
Explanation the procedure to the procedure but procedure but in procedure.
procedure patient clearly and lacks details. an unclear
completely with manner.
patient’s approval.
6. Provided privacy Privacy and Provided Failed to
Privacy and position and position positioning of the privacy but provide
appropriately and patient was not unable to privacy and
comfortably maintained all position patient position the
throughout the throughout the comfortably patient.
procedure. procedure. and
appropriately
or vice versa.
7. Performed breast Performed Performed Performed
Perform Breast inspection incomplete breast incomplete incomplete
Inspection. Note its completely. inspection with at breast inspection breast
size and symmetry, Taking note all its least 1-2 details with at inspection with
color and texture, details. missing. least 3-4 details at least 5-6
superficial venous missing details missing
patterns, retraction
and dimpling, areola
and nipples.

8. Performed breast Performed Performed Performed


Perform Breast inspection incomplete breast incomplete incomplete
Palpation. Note its completely. inspection with at breast inspection breast
texture and elas- Taking note all its least 1-2 details with at least 3-4 inspection with
ticity, tenderness and details. missing. details missing. at least 5-6
temperature, masses, details missing.
nipples.
9. Documented the Some of the Most of the Failed to
Documentation information about details of details of document the
the procedure, procedure were procedure were procedure.
date and time not documented. not documented.
properly and
completely.
OVERALL SCORE: _____

Target Raw Score: 21 out of 36. If raw score is less than 36, repeat the return demonstration.

FACULTY SIGNATURE OVER PRINTED NAME

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