Republic of the Philippines

CENTRAL MINDANAO UNIVERSITY

College of Nursing

PERFORMANCE CHECKLIST
"Postpartum Exercise"

Name: Sec/Group: Score: Rating: 0

Scale Description Interpretation Assisstance Needed
5 Outstanding Without Direction
Demonstrates exceptional performance and mastery of the procedure. Proficient, coordinated and confident
With occasional physical or verbal
4 Very Satisfactory Able to state and demonstrate the step by step procedure but failed to mention the rationale. Efficient,
direction
coordinated, confident. Expedient use of time.

3 Satisfactory Meets the standards or basic requirements of the procedure. Misses some steps and rationale with partial With frequent verbal and/or direction
demonstration of skills, inefficient, uncoordinated. Delayed time Expenditure

2 Fair Barely meets the requirements of the Performance of the procedure. Unskilled and inefficient. Considerable With continuous verbal and/or physical
and proonged time expenditure. direction
Needs With continuous verbal and physical
1 Improvement
Fails to meet the requirements of the performance of the procedure. Misses most of the steps, without
direction
rationale. Lacks confidence, coordination and efficiency.

Procedure 5 4 3 2 1
Pre-Exercise Phase
1 Assess client's ability to perform the activity
2 Determine the scope of assessment needed. Prepare necessary equipment.
3 Perform hand washing.
4 Introduce self and verify the client's identity.
5 Explain the procedure to the client.
6 Position patient comfortably and provides privacy.
7 Before exercise, instruct client to do warm up:
8 Inform client to stand with equal eight in both legs.
9 Ensure client to maintain good posture during exercise at all times.
Exercise Phase
DAY 1
Raise the abdomen while inhaling deeply. Slowly exhale through pursed lips while contracting
10
abdominal muscle forcibly.
DAY 2
Lie flat on the back with the legs separated slightly. With the abducted arms, raise the arms to midline
13
then lower them slowly to the original position.
DAY 3
Lie flat on the back with the arms at the sides. Raise the buttocks, arch back, and then lower the
14
buttocks slowly.
DAY 4
Lie flat on the back with the legs flexed at the knees and the hip. Contract the buttocks. Press the back
15
flat on the floor. Contract the abdominal muscles. Raise the head and relax.
DAY 5
Lie flat on the back with one leg and both arms touch the floor and raise one knee. Reach towards the
16
raised knee with the opposite hand. Relax and repeat with the other knee and hand.
DAY 6
Lie flat on the back with straightened arms and legs. Flex knee of one leg at the same time flex hip until
17
foot reaches the buttocks. Straighten up and lower the legs slowly.
DAY 7
While lying flat on the back with the legs extended, point toes and raises one leg as high as possible
18
then lower it slowly. Use the abdominal muscle with the hands at the sides.
DAY 8
19 Do pelvic rocking or tilting.
DAY 9
20 Lie flat on the back with arms on the sides. Raise and lower both legs slowly and simultaneously.
DAY 10
21 From the supine position, with hands behind head, contract the abdominal muscles and sit up.
Post-exercise Phase
22 Perform cool down activity
23 Do after care.
24 Perform hand washing.
25 Evaluate client’s response to the procedure.
26 Document the findings in the client’s record.
TOTAL 0 0 0 0 0

Knowledge/Assignment Score 0
Total 130

Skills (Video) Score 0

Comments:

Clinical Instructor:
Signature over printed name Date

Rubrics Return Demonstration Video

Parameter 15 10 8 6 Points

It covers all the topics in depth It includes basic knowledge about It includes essential information
The content includes minor details and it has
Content and with details. The knowledge on the the topic. The content seems to be about the topic, but it has some
several mistakes. Most of the steps have no
Organization topic is excellent. With rationale all good. About 70% of the steps have mistakes. About 40% of the steps
rationale.
throughout the video. rationale. have rationale.

The student use language The student use language The patient minimally understands
Use of The student use language that confuses the
appropriately and understandable understandably to deliver the language being used by the
patient on the information being delivered
Language to deliver the information to the information to the patient with about student to deliver information with
most of the time.
patient with no grammatical error. 70% grammatical error. about 40% grammatical error.
Meets the standards or basic Barely of fails to meet the requirements of the
Demonstrates exceptional Able to state and demonstrate the
requirements of the procedure. performance of the procedure, misses not of
performance and mastery all step-by-step procedure but failed to
Misses some steps and rationale the steps, without rationale. Unskilled and
Execution throughout the procedure. mention the rationale. Efficient,
with partial demonstration of skills, inefficient. Considerable and prolonged time
Proficient, coordinated and coordinated, confident. Expedient
inefficient, uncoordinated. Delayed expenditure. Lacks confidence, coordination
confident use of time.
time Expenditure and efficiency.

Timely Submits the output on or before Submits the output 3 hours LATE Submits the output 5 hours LATE Submits the output more than 5 hours LATE
submission the deadline. form the set time. from the set time. from the set time.

SCORE 0