CLINICAL NURSING EXPERIENCE ASSESSMENT REPORT FORM

 

NURSES’ AND MIDWIVES’ TRAINING COLLEGE TAMALE

CLINICAL NURSING EXPERIENCE ASSESSMENT REPORT FORM

NAME OF STUDENT:…………………………………………..

REG.NUMBER:………… YEAR GROUP:…………………….

ACADEMIC YEAR:……… SEMESTER:………………………

NAME OF INSTITUTION:……………… WARD/UNIT:………

PERIOD OF EXPERIENCE: FROM………..TO…………………

 

NMTC, BOX 565, TAMALE

NAME/SIGNATURE OF SUPERVISING NURSE:……………………………………

FIRST-YEAR RGN COMPETENCIES (FIRST SEMESTER)

NURSES’ AND MIDWIVES’ TRAINING COLLEGE, TAMALE

CLINICAL EVALUATION CHECKLISTS

 

CLINICAL EVALUATION CHECKLISTS (FIRST YEAR RGN STUDENTS)

  

NAME OF STUDENT:………………………………………………………

NAME OF SUPERVISOR: ……………………………………………………

NAME OF HOSPITAL:…………………......  WARD/UNIT………………..

 

KEY TO PERFORMANCE LEVELS

S = Satisfactory

U = Unsatisfactory

NI = Need improvement

NO = No opportunity to observe

 

PLEASE TICK THE APPROPRIATE COLUMN WITH A CHECKMARK

S/#	ACTIVITY	S	NI	U	NO
1.	Making beds, positioning patients, lifting use of body mechanics
2.	Admission of patients
3.	Assessing temperature, pulse, respiration, blood pressure and weight
4.	Serving of meals and feeding of patients
5.	Mouth care, bathing patients in bed, assisting patients to bath in bed or in the bathroom.
6.	Treatment of pressure areas
7.	Care of the hair, nails, feet, hands, Treatment of infested hair.
8.	Caring for the incontinent patient
9.	Serving and removal of bedpans and urinal, Sterilization of bedpans and urinal, recording intake and output of fluids,
10.	collection  of a specimen; stool, urine, sputum and their disposal,;, taking a blood film
11.	Administration of enemata, insertion of rectal suppositories rectal washout.

 

 

FINAL EVALUATION /COMMENTS:…………………………………………

SIGNATURE OF SUPERVISOR:………………….. DATE:……………………

RANK: ………………………

FIRST-YEAR RGN COMPETENCIES (SECOND SEMESTER)

NURSES’ AND MIDWIVES’ TRAINING COLLEGE, TAMALE

CLINICAL EVALUATION CHECKLISTS

NAME OF STUDENT:………………………………………………………

NAME OF SUPERVISOR: ……………………………………………………

NAME OF HOSPITAL:…………………......  WARD/UNIT………………..

 

KEY TO PERFORMANCE LEVELS

S = Satisfactory

U = Unsatisfactory

NI = Need improvement

NO = No opportunity to observe

 

PLEASE TICK THE APPROPRIATE COLUMN WITH A CHECKMARK

S/#	ACTIVITY	S	NI	U	NO
1.	Preparing for and administering medications(all routes)
2.	Calculating fractional dosages of drugs.
3.	Care of medicine trolley and cabinet.
4.	Administering oxygen.
5.	Local applications.
6.	Sterilization –instrument, dressing, towels.
7.	Wearing of masks, gowns and gloves.
8.	The setting of sterile trays and trolleys
9.	Handwashing technique
10.	Dressing of simple wound: preparation and procedure, Diluting solutions, disposal of soiled dressing, Taking wound swab, Preventing nosocomial infections.
11.	Caring for the dying the dead and their relatives, Last offices.
12.	Assisting  at child welfare  clinics, including immunization
13.	Monitoring of patients with Blood transfusion
14.	The passing of IV cannulas and monitoring of patients on IV therapy
15.	Recording intake and output

 

FINAL EVALUATION /COMMENTS: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………....................................................................................................................................................

SIGNATURE OF SUPERVISOR: DATE:………………………………………………..

RANK: ………………………………………………………..

 

 

 

 

 

SECOND-YEAR RGN STUDENTS

NURSES’ MIDWIVES TRAINING COLLEGE, TAMALE

CLINICAL EVALUATION CHECKLISTS

  

NAME OF STUDENT:………………………………………………………

NAME OF SUPERVISOR: ……………………………………………………

NAME OF HOSPITAL:…………………......  WARD/UNIT………………..

 

KEY TO PERFORMANCE LEVELS

S = Satisfactory

U = Unsatisfactory 

NI = Need improvement

NO = No opportunity to observe

 

PLEASE TICK THE APPROPRIATE COLUMN WITH A CHECKMARK

S/#	ACTIVITY	S	NI	U	NO
1.	Urine  collection and testing
2.	Catheterizing patients.
3.	Vulval  swabbing
4.	Sterilizing instruments
5.	Setting up I.V. Infusions /blood transfusion, subcutaneous infusion.
6.	Administering oxygen
7.	Feeding of patients; nasogastric feeding.
8.	Managing patients with conditions of the cardiovascular and genitourinary systems
9.	Preparing patients for surgery and caring for their post–operatively.
10.	Setting trays and preparing patients for digestive, respiratory, cardiovascular, gynaecological and genitourinary investigations and examination.
11.	Care and management of patients with tracheostomy tubes
12.	Care and management of patients with colostomy bags
13.	Care and management of patients with underwater seal drainage
14	Removal of stitches and clips

 

 

FINAL EVALUATION /COMMENTS:…………………………………………

SIGNATURE OF SUPERVISOR:………………….. DATE:……………………

RANK: ………………………

NURSES’ & MIDWIVES’ TRAINING COLLEGE, TAMALE

CLINICAL EVALUATION CHECKLISTS

 (SECOND YEAR MIDWIFERY STUDENTS)

 

NAME OF STUDENT:………………………………………………………

NAME OF SUPERVISOR: ……………………………………………………

NAME OF HOSPITAL:…………………......  WARD/UNIT………………..

 

KEY TO PERFORMANCE LEVELS

S = Satisfactory

U = Unsatisfactory

NI = Need improvement

NO = No opportunity to observe                                                             

 

 

PLEASE TICK THE APPROPRIATE COLUMN WITH A CHECKMARK

S/#	ACTIVITY- ANTENATAL CLINIC	S	NI	U	NO
1.	Take past obstetric history of a pregnant woman
2.	Identify presumptive, probable and positive signs and symptoms of pregnancy.
3.	Request for various laboratory investigations
4.	Perform general examination of the pregnant client at the antenatal clinic
5.	Conduct abdominal examination  on (PALPATE) a  pregnant client
6.	Examine the breast of a pregnant client
7.	Give health education on  exercise, rest and sleep to a pregnant client.
8.	Give health education on danger signs to the pregnant client
9.	Give health education on nutrition  to a pregnant client
10.	Give health education on the prevention of malaria to a pregnant woman
11.	Give health education on birth preparedness and complications readiness plan to a pregnant client.
12.	Prevention of mother-child transmission (PMTCT)

 

 

SECOND-YEAR RM STUDENTS

NURSES’ AND MIDWIVES TRAINING COLLEGE

TAMALE

CLINICAL EVALUATION CHECKLISTS

  

NAME OF STUDENT:………………………………………………………

NAME OF SUPERVISOR: ……………………………………………………

NAME OF HOSPITAL:…………………......  WARD/UNIT………………..

 

KEY TO PERFORMANCE LEVELS

S = Satisfactory

U = Unsatisfactory

NI = Need improvement

NO = No opportunity to observe                                                             

 

PLEASE TICK THE APPROPRIATE COLUMN WITH A CHECKMARK

S/#	ACTIVITY- ANTENATAL CLINIC	S	NI	U	NO
1.	Take past obstetric history of a pregnant woman
2.	Identify presumptive, probable and positive signs and symptoms of pregnancy.
3.	Request for various laboratory investigations
4.	Perform general examination of the pregnant client at the antenatal clinic
5.	Conduct abdominal examination  on (PALPATE) a  pregnant client
6.	Examine the breast of a pregnant client
7.	Give health education on exercise, rest and sleep to a pregnant client.
8.	Give health education on danger signs to the pregnant client
9.	Give health education on nutrition  to a pregnant client
10.	Give health education on the prevention of malaria to a pregnant woman
11.	Give health education on birth preparedness and complications readiness plan to a pregnant client.
12.	Prevention of mother-child transmission (PMTCT)
	LABOUR WARD, NURSERY AND MATERNITY
	Admit client in labour
	Monitor Client in the first STAGE OF LABOUR using the partograph
14.	Manage client in second stage-deliver at least 10 clients, third and fourth stage of labour.
15.	Perform vulva swabbing of a puerperal client
16.	Perform vulva toileting of a puerperal client
17.	Make an observation  of the client’s vulva  and report to ward  in charge
		S	NI	U	NO
18.	Help mother on how to fix and breastfeed baby
19	Examine the newborn baby in the lying inward
20.	Bath at least 5 babies and dress  their cord
	GYNAEC WARD
	Identify causes /predisposing factors, signs and symptoms, medical/surgical management, complications and prevention of these conditions.
	Pregnancy-induced hypertension
	Abortion
	Placenta previa
	Placenta abruption
	Ectopic pregnancy
	Hyperemises gravidarium
	Fibroids
	fistula
	Cancer of organs of the reproductive system cervix, breast etc.
	Malaria in pregnancy
	Anaemia in pregnancy
	Diabetes in pregnancy
	Urinary tract infection
	OTHERS
	Drugs used in obstetrics including
	I Magnesium
	ii hydrazine
	Iii calcium gluconate
	Iv  syntocinon
	V misopristol and mefpristol
	Obstetrics protocols eg MgSO4

 

 

FINAL EVALUATION /COMMENTS:…………………………………………

SIGNATURE OF SUPERVISOR:………………….. DATE:……………………

RANK: ………………………

 

 

 

 

 

 

 

 

 

 

THIRD-YEAR
NURSES’ AND MIDWIVES’ TRAINING COLLEGE, TAMALE
CLINICAL EVALUATION CHECKLISTS

  

NAME OF STUDENT:………………………………………………………

NAME OF SUPERVISOR: ……………………………………………………

NAME OF HOSPITAL:…………………......  WARD/UNIT………………..

 

KEY TO PERFORMANCE LEVELS

S = Satisfactory

U = Unsatisfactory

NI = Need improvement

NO = No opportunity to observe

 

PLEASE TICK THE APPROPRIATE COLUMN WITH A CHECKMARK

S/#	ACTIVITY	S	NI	U	NO
1.	1.     Manage the cold chain a.      Packing of vaccines into a fridge b.      Packing of vaccine into vaccine carrier c.       Concept of integrated disease surveillance and response(IDSR) d.      Components of IDSR
2.	2.     Observe and participate in health team activities a.      community  level b.      sub-district level c.       districts
3.	3.     Prepare and carry out home visits a.      Normal family b.      Family with special problems c.       Home supervision of families with a different health needs d.      Clients with communicable diseases e.      Needs of the disabled family and the aged. f.        Total family care.
4.	Observe and participate in prevention of communicable diseases using the epidemiological approach. a. Administration of TB drugs(DOTS) b. Administration of leprosy drugs c. principles of disease prevention and control d. disease surveillance f. immunity – types
5.	Community study a. Community entry b. transect walk c. interview
6.	Observe and participate in health education activities
7.	Nursing process approach in caring for the family
8.	Reproductive health Family planning i.                    Concept of demography and population ii.                   Beliefs and misconceptions of family planning iii.                 Family planning methods HIV, STI, RTI
9.

 

 

FINAL EVALUATION /COMMENTS: ………………………

SIGNATURE OF SUPERVISOR: DATE:……………………

RANK: ………………………

 

 

 

 

 

 

 

 

NURSES TRAINING COLLEGE, TAMALE
CLINICAL EVALUATION CHECKLISTS
  

NAME OF STUDENT:………………………………………………………

NAME OF SUPERVISOR: ……………………………………………………

NAME OF HOSPITAL:…………………......  WARD/UNIT………………..

 

KEY TO PERFORMANCE LEVELS

S = Satisfactory

U = Unsatisfactory

NI = Need improvement

NO = No opportunity to observe

 

 

PLEASE TICK THE APPROPRIATE COLUMN WITH A CHECKMARK

S/#	ACTIVITY	S	NI	U	NO
1.	Setting trays/ trolleys for incision and drainage.
2.	Removing stitches and clips.
3.	Dressing wounds.
4.	Identifying nursing problems of various patients and families.
5.	Planning and giving care according to patient’s needs.
6.	Preparing patients physically and psychologically for special therapies, observing for side effects of drugs and therapies and report
7.	Identifying stages of the grieving process and giving support appropriately.
8.	Setting trays and trolleys for I.V therapy including blood transfusion
9.	Serving appropriate diet
10.

 

 

FINAL EVALUATION /COMMENTS:…………………………………………

SIGNATURE OF SUPERVISOR:………………….. DATE:……………………

RANK: ………………………

 

 

 

NURSES’ AND MIDWIVES’ TRAINING COLLEGE, TAMALE

CLINICAL EVALUATION CHECKLISTS

 

YEAR GROUP: THIRD YEAR   

NAME OF STUDENT:………………………………………………………

NAME OF SUPERVISOR: ……………………………………………………

NAME OF HOSPITAL:…………………......  WARD/UNIT………………..

 

KEY TO PERFORMANCE LEVELS

S = Satisfactory

U = Unsatisfactory

NI = Need improvement

NO = No opportunity to observe

 

OBSTETRIC COMPETENCIES

ACTIVITY- ANTENATAL CLINIC

Take past obstetric history of a pregnant woman

Identify presumptive , probable and  positive signs and symptoms of pregnancy.

Request for various laboratory investigations

Perform general examination of the pregnant client at the antenatal clinic

Conduct abdominal examination  on (PALPATE) a  pregnant client

Examine the breast of a pregnant client

Give health education on  exercise, rest and sleep to a pregnant client.

Give health education on danger signs to the pregnant client

Give health education on nutrition  to a pregnant client

Give health education on prevention of malaria to a pregnant woman

Give health education on birth preparedness and complications readiness plan to a pregnant client.

Prevention of mother child transmission (PMTCT)

LABOUR WARD, NURSERY AND MATERNITY

Admit client in labour

Monitor Client in first STAGE OF LABOUR using the partograph

Mange client in  second stage-deliver at least 10 clients ,third and fourth stage of labour.

Perform vulva swabbing of a puerperal client

Perform vulva toileting of a puerperal client

Make observation  of the client’s vulva  and report  to ward  in charge

Help mother on how to fix and breast feed baby

Examine the new born baby in the lying in ward

Bath at least 5 babies and dress  their cord

GYNAEC WARD

Identify causes /predisposing factors ,signs and symptoms ,medical/surgical management , complications and prevention of these conditions.

Pregnancy induced hypertension

Abortion

Placenta previa

Placenta abruption

Ectopic pregnancy

Hyperemises gravidarium

Fibroids

fistula

Cancer of organs of the reproductive system cervix , breast etc.

Malaria in pregnancy

Anaemia in pregnancy

Diabetes in pregnancy

Urinary tract infection

OTHERS

Drugs used in obstetrics including

I Magnesium

ii hydrazine

Iii calcium gluconate

Iv  syntocinon

V misopristol and mefpristol

Obstetrics protocols eg MgSO4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NURSES’ AND MIDWIVES’ TRAINING COLLEGE, TAMALE

CLINICAL EVALUATION CHECKLISTS

 

YEAR GROUP: THIRD YEAR   

NAME OF STUDENT:………………………………………………………

NAME OF SUPERVISOR: ……………………………………………………

NAME OF HOSPITAL:…………………......  WARD/UNIT………………..

 

KEY TO PERFORMANCE LEVELS

S = Satisfactory

U = Unsatisfactory

NI = Need improvement

NO = No opportunity to observe

 

PLEASE TICK THE APPROPRIATE COLUMN WITH A CHECKMARK

S/#	ACTIVITY	S	NI	U	NO
1.	4.      Manage the cold chain e.       Packing of vaccines into a fridge f.        Packing of vaccine into vaccine carrier g.      Concept of integrated disease surveillance and response(IDSR) h.      Components of IDSR
2.	5.      Observe and participate in health team activities d.      community  level e.       sub district level f.        districts
3.	6.      Prepare and carry out home visits g.      Normal family h.      Family with special problems i.        Home supervision of families with different health need j.        Clients with communicable diseases k.      Needs of the disabled family and the aged. l.        Total family care.
4.	Observe and participate in prevention of communicable diseases using the epidemiological approach. a. Administration of TB drugs(DOTS) b. Administration of leprosy drugs c. principles of disease prevention and control d. disease surveillance f. immunity – types
5.	Community study a. Community entry b. transect walk c. interview
6.	Observe and participate in health education activities
7.	Nursing process approach in caring for the family
8.	Reproductive health Family planning iv.                Concept of demography and population v.                  Beliefs and misconceptions of family planning vi.                Family planning methods HIV, STI, RTI
9.	Health education Activities a.       Occupation health i.                    Explanation ii.                  History iii.                Objectives iv.                Reasons v.                  Health and welfare acts vi.                Occupational hazards in Ghana vii.              Role of the nurse in occupational health
10.	Community based rehabilitation a.       The role of the nurse in rehabilitation and disability prevention.

 

 

FINAL EVALUATION /COMMENTS: ……………………………………………………..

SIGNATURE OF SUPERVISOR:…………………………………………………………….

DATE:…………………………..

RANK: …………………………