APPENDIX D

SAMPLE QUESTIONNAIRE
Part I. Profile of the Respondents
Kindly put a check in the box provided for your answer.
AGE:
GENDER:

below 20
Male

CIVIL STATUS:

21-25
Female
Single

Married

26-30

31 above

Appendix C
Questionnaire

I.

Problems in preparing nursing care plan.

Direction: Listed below are the problems encountered by BSN-3 students in

the preparation of nursing care plan. Kindly check the column that
corresponds to your answer.
5 strongly agree
4 agree
3 moderately agree
2 disagree
1 strongly disagree
a.
b.
c.
d.
e.
II.

Item Statement
Insufficient Time
Inadequate knowledge and skills
Insufficient resources
Lack of guidance from the clinical instructors
Others (please specify)

Difficulties in preparing nursing care plan

Direction: Listed below are the problems encountered by BSN-3 students

in the preparation of nursing care plan. Kindly check the column that
corresponds to your answer.
4 to a great extent
3 to a moderate extent
2 to a lesser extent
1 to a least extent

1.

2.

3.

4.

5.

Item Statement
ASSESSMENT
a. Inability to differentiate
b. Poor assessment skills
c. Lack of time in discussing assessment
techniques
d. Others (please specify)
NURSING DIAGNOSIS
a. Inability to identify medical from nursing
diagnosis
b. Indefinite diagnosis
c. Lack of book sources
d. Others (please specify)
PLANNING
a. Inability to differentiate long-term to shortterm goals
b. Difficulty in making specific , measurable,
attainable, realistic, and time-bounded
planning
c. Others (please specify)
IMPLEMENTATION
a. Difficulty in identifying which nursing
intervention is to be prioritized
b. Inadequate knowledge skills
c. Lack of coordination and guidance from the
clinical instructors
d. Others (please specify)
EVALUATION
a. Inability to evaluate if the goals are being
met or not
b. Inability to correlate evaluation to expected
outcome
c. Others (please specify)