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University of San Jose-Recoletos

COLLEGE OF NURSING

Corner P. Lopez St. and Magallanes St., Cebu City Philippines 6000

Phone: 032 2537900 loc 543; Fax: 032 2 541720; www.usjr.edu.ph

SUMMARY PERFORMANCE EVALUATION ACHIEVING INTRA-PARTAL CARE COMPETENCY

In Accordance with PRC Board of Nursing Memorandum No.01 Series 2009

Signature Over Printed Name of Student: _________________________________________

INTRAPARTAL COMPETENCIES DESIRED RATING ACTUAL RATING

I. SAFE AND QUALITY NURSING CARE (SQC)1. Obtains obstetrical history including parity, gravid score, LMP, EDC, AOG, BOW onset of true labor. 42. Checks vital signs. 13. Conducts physical examination. 24. Performs leopolds maneuver. 25. Checks fetal heart rate and fundic height. 26. Monitor progress of labor/uterine contractions as to:

y Frequencyy Durationy Intensityy Interval

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7. Observes for the timely rupture of membrane. 18. Coaches mother on process of labor. 2

PERFORMS FUNSTIONS DURING ACTUAL LABOR 1

1. Transport clients safely while providing privacy. 12. Places mother in lithotomy position. 13. Performs perineal care using sterile technique correctly. 14. Performs proper hand scrub. 15. Wears gown and gloves according to hospital policy. 26. Performs Ritgens maneuver safely. 17. Coaches mother on breathing and pushing technique. 18. Delivers baby and placenta carefully.

y Checks and manages cord recoil correctly.y Clamps and cuts the c ord correctly.y Identify signs of placental separation.y Checks the characteristic/completeness of the placenta.

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Assesses amount of blood loss (Normal:

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University of San Jose-Recoletos

COLLEGE OF NURSING

Corner P. Lopez St. and Magallanes St., Cebu City Phil ippines 6000

Phone: 032 2537900 loc 543; Fax: 032 2541720; www.usjr.edu.ph

SUMMARY PERFORMANCE EVALUATION ACHIEVING

IMMEDIATE CARE OF THE NEWBORN COMPETENCY

In Accordance with PRC Board of Nursing Memorandum No.01 Series 2009

Signature Over Printed Name of Student: _________________________________________

NEWBORN COMPETENCIES DESIRED RATING ACTUAL

RATING

I. SAFE AND QUALITY NURSING CARE (SQC)1. Establishes and maintains patent airway. 32. Puts the newborn in Trendelenburg position.3. Suctions mouth and nose of the newborn gently. 24. Dries newborn and wraps warmly.

y Places under droplight as needed.5. Performs and interprets APGAR scoring correctly.

y Immediately after delivery.y After 5 minutes 22

6. Ensures proper identification of newborn (name tag: name of mother, date and time of delivery, gender and name of attending physician.) 27. Performs physical assessment including anthropometric measurements including weight, height, head, chest, abdominal circumference. 48. Takes vital signs (temperature per rectum to check patency) 19. Gives oil/water and soap bath according to institutional policy. 110. Latches newborn tot he mothers breast immediately after birth. 111. Applies CREDEs prophylaxis on the eyes. 112. Performs cord dressing aseptically.

y Disinfects area properly according to hospital policy.y Clamps and cuts c ord 1 inch from the abdomen.y Checks for the presence of 2 arteries and 1 vein.y Dresses cord aseptically according to hospital policy.

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13. Administers vitamin K (1mg/M) into the lateral anterior this or vastus lateralis. 114. Keeps baby wrapped warmly under floor lamp or beside mother according to institutional policy until discharge. 115. Records pertinent observations and nursing care done. 116. Reports any signs of deviation/abnormality to the paediatrician. 1

II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE)1. Prepares instrument and equipment needed.

y Suction bulb, cord clamp, gauze, cotton balls, dis infectant, blanket, droplight, vitamin K, antimicrobial ophthalmic ointment. 42. Ensures use of sterile equipment during immediate care of the newborn. 13. Maintain adequacy of supplies as newborn care is rendered. 14. Maintains orderliness of the working area. 15. Observes precautionary measures related to use of electrical equipment. 16. Ensures a warm and quite environment. 17. Uses supplies diligently. 18. Ensures proper disposal of hospital waste. 1

III. HEALTH EDUCATION (HE)1. Provides instructions to the mother on daily cord care and prevention of cord infection. 22. Provides discharge instructions to the mother on when to expect cord to fall or to report signs of infection. 13. Provides information regarding newborn screening, immunization, feeding, etc. 24. Responds to questions of mother and relatives regarding expections. 1

IV. LEGAL RESPONSIBILITIES (LR)1. Identifies newborn by comparing ID band with data in the chart. 22. Documents all pertinent data correctly and completely. 13. Reports accurately any deviations/abnormal findings and nursing interventions rendered. 14. Ensures that birth certificate and other civil registration forms are accomplished filled out according to institutional policy. 25. Performs foot printing according to hospital policy. 1

V. ETHICO-MORAL RESPONSIBILITIES (EMR)1. Respects the religious, cultural and ethnic practices of the family of the newborn. 12. Maintains privacy and confidentially of findings of assessments. 1

VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)1. Updates oneself with the latest trends and developments in newborn care. 12. Projects a professional image of the pediatric nurse. 13. Accepts criticisms and recommendations. 14. Performs functions according to standards. 1

VII. QUALITY IMPROVEMENT (QI)1. Identifies deviation of practice from the standards. 12. Participates (whenever possible) in audit practices in the nursery unit. 13. Recommends corrective and preventive measures for the identified deviations. 1

VIII. RESEARCH (R)1. Identifies researcheable problems related to immediate care of the newborn. 22. Utilizes findings of research studies in the immediate care of the newborn. 2

IX. RECORDS MANAGEMENT (RM)1. Documents accurately relevant data about the newborn. 12. Maintains an organized system of filing and record keeping. 1

X. COMMUNICATION (Comm)1. Utilizes appropriately all forms of communication; verbal, non-verbal, electronic. 12. Maintains an open line of communication with the mother and other family members. 13. Informs mother of relevant information about the newborn. 14. Listens attentively to queries and requests of mothers and family members. 1

XI. COLLABORATION AND TEAMWORK (CTM)1. Functions effectively as a team player in the nursery. 12. Communicates findings as assessment to all concerned. 13. Establishes a collaborative relationship with members of the health team and family of the newborn. 1

TOTAL SCORE 75

Certified True and Correct:

(Signature over Printed Name)

_______________________________ Mr. Janus S. Fuertes, RN, MAN

________

Clinical Instructor RLE CoordinatorLicense Number: _________________ License Number: 0346339

PRC Card Validity date: ___________ PRC Card Validity Date: November 1, 2012

Dr. Aurora Q. Pestao 2011-2012

DEAN Academic Year Graduated

License Number: 0186407

PRC Card Validity Date: April 23, 2014_

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University of San Jose-Recoletos

COLLEGE OF NURSING

Corner P. Lopez St. and Magallanes St., Cebu City Philippines 6000

Phone: 032 2537900 loc 543; Fax: 032 2541720; www.usjr.edu.ph

SUMMARY PERFORMANCE EVALUATION ACHIEVING

INTRAOPERATIVE CARE COMPETENCY

In Accordance with PRC Board of Nursing Memorandum No.01 Series 2009

Signature Over Printed Name of Student: _________________________________________

INTRAOPERATIVE CARE COMPETENCIES DESIRED

RATING

1ST

RLE 2ND

RLE

3RD

RLE

AVERAGE

RATING

I. SAFE AND QUALITY NURSING CARE (SQC)1. Utilizes the nursing process in the care of OR client:

a. Obtains comprehensive clients information by checking complete accomplishment of thepreoperative checklist/clients chart.

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b. Identifies priority needs of the client at the Operating Room. 4c. Provides needed nursing interventions based on identified needs. 4d. Monitors clients responses to surgery. 2

2. Promotes safety and comfort of patients inside the OR. 23. Performs the functions of the scrub nurse:

a. Performs surgical scrub correctly. 4b. Wears sterile gowns and gloves aseptically. 2c. Prepares surgical instruments, sponges, sutures and other supplies in functional

arrangement. 2d. Hands instruments, sponges, sutures and other needed materials according to surgeons

preference. 2

e. Performs surgical count accurately. 24. Performs the functions of the circulating nurse.

a. Anticipates the needs of the surgical team. 2b. Sets up the OR room and needed equipment. 2c. Receives client for surgery/endorses client postoperatively. 2d. Assists in skin preparation and draping of client. 2

5. Administers medications and other health therapeutics safely. 2II. MANAGEMENT OF RESOURCES AND ENVIRONMENT (MRE)

1. Organizes work load to facilitate timely patient care. 42. Utilizes adequate and appropriate resources to support the OR team. 23. Ensures functionality of OR resources. 24. Maintains a safe environment at the OR by observing the principles of asepsis. 2

III.

HEALTH EDUCATION (HE)1. Implements appropriate health education activities to client based on needs assessment. 2

IV. LEGAL RESPONSIBILITIES1. Adheres to legal and institutional protocols regarding informed consent. 2

V. ETHICO-MORAL RESPONSIBILITIES (EMR)1. Respects the rights of the OR client. 22. Accepts responsibility and accountability for own decisions and actions as an OR nurse. 2VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)1. Performs Or functions according to professional standards. 42. Possesses positive attitude towards learning surgical and Or-related knowledge and skills. 2VII. QUALITY IMPROVEMENT (QI)1. Participates in quality improvement activities related to infection control and successful OR

operations.

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2. Identifies and reports variances in sterility and other OR activities. 2VIII. RESEARCH (R)1. Disseminates results of Or-related research findings to clinical group and other members of theOR team as appropriate. 2IX. COMMUNICATION (Comm)1. Establishes rapport with patients, significant others and members of the health team. 12. Uses appropriate information mechanisms to facilitate communication inside the OR and with

other departments in the hospital.

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X. COLLABORATION AND TEAM WORK (CTM)1. Collaborates plan of care with other members of the health team 2

TOTAL SCORE 75

Certified True and Correct:

(Signature over Printed Name)

_______________________________ Mr. Janus S. Fuertes, RN, MAN

________

Clinical Instructor RLE Coordinator

License Number: _________________ License Number: 0346339

PRC Card Validity date: ___________ PRC Card Validity Date: November 1, 2012

Dr. Aurora Q. Pestao 2011-2012

DEAN Academic Year Graduated

License Number: 0186407

PRC Card Validity Date: April 23, 2014_