EMILIO AGUINALDO COLLEGE

1113-1117 San Marcelino, St. Paco Manila

School of Nursing

PERFORMANCE EVALUATION TOOL

ACHIEVING COMPETENCY IN Performing 3 WAY CATHETER IRRIGATION
Procedure:
NAME OF STUDENT: ____________________________________________________________
SECTION/GROUP

: _________________________________ Date: _______________________

PREPARATION
LEGEND:
5

Gathers corrects and complete supplies and equipment.

Collects 1 inappropriate supply and equipment and/or lacks 1 supply and equipment.

Collects 2 inappropriate supplies and equipment and/or lacks 2 supplies and equipment.

Collects 3 or more inappropriate supplies and equipment and/or lacks 3 or more supplies and
equipment.

Fails to gather correct and complete supplies/equipment.

Preparation
1.

Gather equipment

Non sterile gloves

Personal protective equipment (PPE)
0.9% sodium Chloride irrigation bags as
per facility policy
Chlorhexidine 0.5% with 70% alcohol
wipes
Continuous bladder irrigation set,
closed urinary drainage bag with antireflux valve.
3-way catheter
Underpad
IV pole

REMARKS

PROCEDURE

LEGEND:
4

Very Satisfactorily Performed

(Student performs consistently in an effective and efficient manner)

Satisfactorily Performed
(Performance is usually effective and efficient but not always)

Fairly performed
(Progress in performanceis too slow to judge satisfactorily; task performanceis not properly for majority
of the time)

Poorly performed
(No progress in performance has been demonstrated, and or performance is consistently inefficient)

Prcodeure
1.

Introduce yourself,and verify the clients identity. Explain to the

client what you are going to do, why it is necessary and how the
client can cooperate.

Perform hand hygiene, and observe other appropriate infection

control procedures

Provide client privacy.

2.
Position the patient for easy access to the catheter whilst maintaining
patient comfort

3.

Ensure that the patient has a three-way urinary catheter.

4. Hang irrigation flasks on IV pole and prime irrigation set maintaining

asepsis of irrigation set.
5. Put on goggles and impermeable gown, place underpad beneath the
catheter connection. In order to maintain sterility and keep from

REMARKS

contamination.
6..Wash hands and put on non sterile gloves. To decrease the risk of
spreading bacteria and contamination.
7

.Swab the IDC irrigation as well as catheter ports with

chlorhexidine swabs and let dry. To prevent contamination.

8. Open the irrigation lumen of the catheter

9. . Connect the irrigation set to the irrigation lumen of the catheter,

maintaining clean procedure
10.Ensure urine is draining freely before commencing continuous irrigation
11 Unclamp the irrigation flask that was used to prime the irrigation set and
set the rate of administration by adjusting the roller clamp
11 Document procedure done and include urine color, level of
hematuria, urine output, and patients reaction.
Grading system
Performance Score

_______x 90%=______

Punctuality and Grooming

_______x 10%=______
Total = ______

Evaluated by:
_______________________________
Faculty's Signature over printed name

Confirmed by:
___________________________
Student's Signature over printed name