WESTERN MINDANAO STATE UNIVERSITY College of Nursing Normal Road, Baliwasan, Zamboanga City, Philippines Telephone No.

(062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.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: _______________________ Academic Year Graduated: _____________ Name of Patient (Patients initials only) 1st RLE: ______________________ 2nd RLE: ______________________ 3rd RLE: ______________________ INTRAPARTAL COMPETENCIES I. SAFE AND QUALITY NURSING CARE (SQC) 1. Checks obstetrical history including parity, gravida score, LMP, EDC, AOG, BOW, onset of true labor. 2. Checks vital signs. 3. Conducts physical examination. 4. Performs Leopolds maneuver. 5. Checks Fetal Heart Rate and Fundic height. 6. Monitor progress of labor / uterine contractions as to: Frequency Duration Intensity Interval 7. Observes for the timely rupture of membrane. 8. Inform mother on process of labor. PERFORMS FUNCTIONS DURING ACTUAL LABOR 1. Transports clients safely while providing privacy. 2. Places mother in lithotomy position. 3. Performs perineal care using sterile technique correctly. 4. Performs proper hand scrub.
Wears gown and gloves according to hospital policy. Performs Ritgens maneuver safely. Coaches mother on breathing and pushing techniques. Delivers baby and placenta carefully. Checks and manages cord recoil correctly Clamps and cuts the cord correctly and safely Identify signs of placental separation Checks the characteristic / completeness of the placenta 9. Assesses amount of blood loss (Normal: <500 cc) 10. Employs interventions to achieve and maintain a well contracted uterus to prevent / control hemorrhage. Uterine massage Correct administration of oxytocin Cold compress 11. Assesses presence and degree of laceration. 12. Assist in episiorrhaphy. 13. Checks size, consistency and location of uterus. 14. Performs perineal care and applies pad correctly. 15. Provides emotional support to the mother throughout labor and delivery. 16. Evaluates patients condition and records pertinent data accordingly. 17. Prepares patient for transfer to recovery room / ward. II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE) 1. Prepares room, instruments and equipment needed. Sterile drape Sterile instruments and equipment [Forceps, scissors, bulb, syringe, gauze, suture, needle holder, catheter (optional)] Kelly pad 2. 3. 4. 5. 6. 7. 8. 9. Performs sterilization procedure Maintains adequacy of supplies as the delivery progresses. Maintains orderliness of the sterile table. Observes precautionary measures related to use of electrical equipment. Ensures a quiet environment Uses supplies appropriately Perform after care of the materials and equipments used. Ensures proper disposal of hospital waste including blood and other fluids. 5. 6. 7. 8.
DESIRED RATING

1st RL E

2nd RLE

3rd RL E

AVERAGE RATING

3 1 2 2 2 2 2 2 2 1 2 1 1 1 1
1 2 2 3 2 1 1 2 2 3 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1

III. HEALTH EDUCATION (HE) 1. Teaches client on basic preparation during labor and delivery (can be done in the labor
room).

1 2 2 1 2

2.

Coaches client on breathing / bearing down technique.

3. Demonstrates proper latch- on breast feeding technique (done post-partum period). 4. Gives instructions to parents regarding infant care before discharge (done post-partum
period).

5. Provides discharge instructions as to feeding, bathing, administration of ordered

6. medications, appointment dates for post natal and well baby check up (done postpartum period). Responds to questions of clients and relatives regarding expectations.

1 1 2 2 2 1 1 1 1 1 1 1 1 1 1

IV. LEGAL RESPONSIBILITIES (LR) 1. Secures informed consent in all procedures related to labor and delivery. 2. Reports accurately and honestly the gender, time of delivery of the baby and the placenta. 3. Ensures proper identification of the mother and newborn. 4. Documents all pertinent data correctly and completely. V. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Respects the religious, cultural and ethnic practices of the family of the woman in labor and delivery. 2. Promotes emotional security by supporting needs. 3. Ensures privacy and confidentiality. VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. Updates oneself with the latest trends and development in labor and delivery. 2. Projects a professional image of a delivery room nurse. 3. Accepts criticisms and recommendations. 4. Performs functions according to standards. VII. QUALITY IMPROVEMENT (QI) (preferably done during post conferences) 1. Identifies deviation of practice from the standard. 2. Participates in audit practices in the delivery room / lying in. 3. Recommends corrective and preventive measures for the identified deviations. VIII. RESEARCH (R) (preferably done during post conferences) 1. Identifies rersearchable problems related to labor and delivery. 2. Utilize findings of research studies in intra-partal care. IX. RECORDS MANAGEMENT (RM) 1. Documents accurately relevant data about client. 2. Maintains an organized system of filing and keeping records of the client. X.COMMUNICATION (Comm) 1. Utilizes appropriately all forms of communication; verbal, non-verbal; electronic. 2. Inform clients significant others of the progress of labor and delivery. 3. Listens attentively to clients and families queries and requests. XI.COLLABORATION AND TEAMWORK (CTW) 1. Functions effectively as a team player in the delivery room / lying in. 2. Communicates the progress of labor / delivery to significant others. 3. Establishes collaborative relationship with members of the health team and family members. TOTAL SCORE: Certified True and Correct: ___________________________ Clinical Instructor (1st RLE) License Number:_________________ PRC Card Validity Date: __________

2 2 1 1 1 1 1 1 1 1

100

____________________________ Clinical Instructor (2nd RLE) License Number:_______________ PRC Card Validity Date: ________

_____________________________________ Clinical Instructor (3rd RLE) License Number: _______________________ PRC Card Validity Date: ________________ Noted by: Approved by:

SARAH S. TAUPAN, RN, MN, DPA Clinical Coordinator License Number: 0150766 PRC Card Validity Date: January 17, 2015 2013

_________________________________ DEAN License Number: ___________________ PRC Card Validity Date: January 3,

WESTERN MINDANAO STATE UNIVERSITY College of Nursing Normal Road, Baliwasan, Zamboanga City, Philippines Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.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: _____________________________________ Academic Year Graduated: ________________ Name of Patient (Patients initials only) 1st RLE: ________________________________ 2nd RLE: _______________________________ 3rd RLE: ________________________________ NEWBORN COMPETENCIES
DESIRED RATING

1st RL E

2nd RL E

3rd RL E

AVERAGE RATING

I. SAFE AND QUALITY NURSING CARE (SQC) 1. Establishes and maintains patent airway. 2. Puts the newborn in Prone position. 3. Dries newborn and wraps warmly. Places under droplight as needed. 4. Performs and interprets APGAR scoring correctly. Immediately after delivery After 5 minutes 5. Ensures proper identification of newborn (name tag: name of mother, date and time of delivery, gender and name of the attending physician). 6. Performs physical assesment including anthropometric measurements including weight, height, head, chest, abdominal circumference. 7. Takes vital signs (temperature per rectum to check patency) 8. Latches newborn to the mothers breast immediately after birth. 9. Applies CREDEs prophylaxis on the eyes. 10. Performs cord dressing aseptically. Disinfects area properly according to hospital policy Clamps and cuts cord 1 inch from the abdomen Checks for the presence of 2 arteries and 1 vein Dresses cord aseptically according to hospital policy 11. Administers Vitamin K (1 mg/M) into the lateral anterior thigh or vastus lateralis. 12. Keeps baby wrapped warmly under floor lamp or beside mother according to institutional policy until discharge. 13. Records pertinent observations and nursing care done. 14. Reports any signs of deviation / abnormality to the pediatrician. II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE) 1. Prepares instruments and equipment needed. Suction bulb, cord clamp, gauze, cotton balls, disinfectant, blanket, droplight, vitamin K, antimicrobial opthalmic ointment, 2. Ensures use of sterile equipment during immediate care of the newborn. 3. Maintains adequacy of supplies as newborn care is rendered. 4. Maintains orderliness of the working area. 5. Observes precautionary measures related to use of electrical equipment. 6. Ensures a warm and quiet environment. 7. Uses supplies diligently. 8. Ensures proper disposal of hospital waste III. HEALTH EDUCATION (HE) 1. Provides instructions to the mother on daily cord care and prevention of cord infection 2. Provides discharge instructions to the mother on when to expect cord to fall off or to report signs of cord infection. 3. Provides information regarding newborn screening, immunization, feeding, etc. 4. Responds to questions of mother and relatives regarding expectations.

3 2 3

2 2 2 4 2 3 3 2 2 2 2 3 3 2 2 4 2 2 2 1 2 2 2 2 2 2 1

IV. LEGAL RESPONSIBILITIES (LR) 1. Identifies newborn by comparing ID band with data in the chart. 2. Documents all pertinent data correctly and completely. 3. Reports accurately any deviations / abnormal findings and nursing interventions rendered. 4. Ensures that birth certificate and other civil registration forms are accomplished / filled out according to institutional policy. V. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Respects the religious, cultural and ethnic practices of the family of the newborn. 2. Maintains privacy and confidentiality of findings of assessments. VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. Updates oneself with the latest trends and development in newborn care. 2. Projects a professional image of the pediatric nurse. 3. Accepts criticisms and recommendations. 4. Performs functions according to standards. VII. QUALITY IMPROVEMENT (QI) 1. Identifies deviation of practice from the standard. 2. Participates (whenever possible) in audit practices in the nursery. 3. Recommends corrective and preventive measures for the identified deviations. VIII. RESEARCH (R) 1. Identifies researchable problems related to immediate care of newborn. 2. Utilizes findings of research studies in immediate care of the newborn IX. RECORDS MANAGEMENT (RM) 1. Documents accurately relevant data about the newborn. 2. Maintains an organized system of filing and record keeping. X.COMMUNICATION (Comm) 1. Utilizes appropriately all forms of communication; verbal, non-verbal; electronic. 2. Maintains an open line communication with the mother and other family members. 3. Informs mother of relevant information about the newborn. 4. Listens attentively to queries and requests of mothers and family members. XI.COLLABORATION AND TEAMWORK (CTW) 1. Functions effectively as a team player in the nursery. 2. Communicates findings of assessment to all concerned. 3. Establishes collaborative relationship with members of the health team and family of the newborn. TOTAL SCORE:

2 2 2 2 1 1 1 1 1 1 1 1 1 2 2 2 1 1 2 1 1 1 1 1 100

Certified True and Correct: _________________________ Clinical Instructor (1st RLE) License Number: ______________ PRC Card Validity Date: ________ \

_____________________________ Clinical Instructor (2nd RLE) License Number: ______________ PRC Card Validity Date: ________

___________________________ Clinical Instructor (3rd RLE) License Number: ______________ PRC Card Validity Date: _________

Noted by: SARAH S. TAUPAN, RN., MN.,DPA Clinical Coordinator License Number: 0150766 PRC Card Validity Date: January 17, 2015

Approved by: ___________________________________ DEAN License Number:_____________________ PRC Card Validity Date: January 3, 2013

WESTERN MINDANAO STATE UNIVERSITY College of Nursing Normal Road, Baliwasan, Zamboanga City, Philippines Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph /Web-Site: www.wmsu.edu.ph SUMMARY PERFORMANCE EVALUATION ACHIEVING INTRA-OPERATIVE COMPETENCY In Accordance with PRC Board of Nursing Memorandum No. 01 Series 2009 Signature over Printed Name of Student: _____________________________________ Academic Year Graduated: _________________ Name of Patient (Patients initials only) 1st RLE: ________________________________ 2nd RLE: _______________________________ 3rd RLE: ________________________________

INTRAOPERATIVE COMPETENCES (CIRCULATING NURSE)

Desir ed Ratin g

1st RLE

2nd RLE

3rd RL E

Avera ge Rating

I. SAFE AND QUALITY NURSING CARE (SQC) A.Utilizes the Nursing process in the care of O.R. client 1. Obtains comprehensive clients information by checking complete 2. Accomplishment of the preoperative checklist/clients chart.
3. Makes sure theater is clean 4. Provides a clean kick bucket and pail

5. Identifies priority needs of the client upon admission to the Operating Room 6. Provides needed nursing interventions based on identified needs. 1. Patient transfer to stretcher. 2. Patient transfer to O.R. table 3. Allay patients anxiety & questions. 4. Patients comfort. (Serving of bedpan, etc.) B.FUNCTIONS AS A CIRCULATING NURSE 1. DURING THE INDUCTION OF ANESTHESIA
1. Turns on OR light 2. Assists in positioning the patient

2 2 4

1 1 1 1

1 2 2 2 2 2 2 2 2 2 1 5 5 5 2 4 2 5

2. AFTER THE PATIENT IS ANESTHETIZED

1. Assists in Repositioning of the patient per anesthesiologist order 2. Attaches anesthesia screen and places the patients arms on the arm boards 3. Applies restraints on the patient 4. Exposes the area for skin preparation 5. Observes skin preparation

3. DURING OPERATION
1. Remains in theater throughout the procedure 2. Focuses the OR light as needed 3. Connects equipment/machines (cautery machine, suction machine) 4. Positions kick buckets on the operating side 5. Replenishes and records sponge/sutures 6. Ensures the theater door remains close and patients dignity is upheld 7. Maintains a safe environment at the OR by observing the principles of asepsis and sterility 8. Monitors clients responses to surgery. 9. Initiates and assists with final sponge and instruments count 4. AFTER OPERATION 1. Helps remove and dispose drapes

2. Assists the scrub nurse, with after care of instruments and equipment 3. Ensures that the theater is ready for the next case II. MANAGEMENT OF RESOURCES, ENVIRONMENT and EQUIPMENT (MRE) 1. Organizes work load to facilitate timely patient care 2. Utilizes adequate and appropriate resources to support the OR team 3. Ensures functionality of OR resources

2 2

4 2 2

III. HEALTH EDUCATION (HE) 1. Implements appropriate education activities to client based on needs assessment IV. LEGAL RESPONSIBILITIES (LR) 1. Adheres to legal and institutional protocols regarding informed consent. V. ETHICO MORAL RESPONSIBILITIES 1. Respects the rights of the OR client 2. Accepts responsibility and accountability for own decisions and actions as an OR nurse. VI. PERSONAL AND PROFESSIONAL DEVELOPMENT 1. Performs OR functions according to professional standards 2. Possesses positive attitude towards learning surgical and OR related knowledge and skills. VII. QUALITY IMPROVEMENT 1. Participates in quality improvement activities related to infection control and successful OR operations 2. Identifies and reports variances in sterility and other OR activities VIII. RESEARCH 1. Disseminates results of OR-related research findings to clinical group and other members of the OR team as appropriate. 2. Utilize findings of research studies in immediate care of the newborn. IX. RECORD MANAGEMENT 1. Maintain accurate and updated documentation of the patient care X. COMMUNICATION (Comm) 1. Establishes rapport with patients, significant others, and members of the health team 2. Uses appropriate information mechanisms to facilitate communication inside the OR and with other departments in the hospital. XI. COLLABORATION AND TEAMWORK 1. Collaborates plan of care with other members of the health team TOTAL

2 2 2

4 2

2 2

2 2

1 2

2 100

Certified True and Correct: _______________________________ Clinical Instructor (1st RLE) License Number:_________________ Number:_________________ PRC Card Validity Date: __________ __________

________________________________ Clinical Instructor (2nd RLE) License PRC Card Validity Date:

_____________________________________ Clinical Instructor (3rd RLE) License Number: _______________________ PRC Card Validity Date: ________________

Noted by:

Approved by:

SARAH S. TAUPAN, RN, MN, DPA Clinical Coordinator License Number: 0150766 PRC Card Validity Date: January 17, 2015 2013

_________________________________ DEAN License Number: ___________________ PRC Card Validity Date: January 3,

Western Mindanao State University COLLEGE OF NURSING Zamboanga City SUMMARY PERFORMANCE EVALUATION ACHIEVING INTRA-OPERATIVE COMPETENCY In Accordance with PRC Board of Nursing Memorandum No. 01 Series 2009 Signature over Printed Name of Student: _______________________________ Academic Year Graduated: ___________________________________________ Name of Patient (Patients initials only) 1st RLE: ______________________ nd 2 RLE: ______________________ 3rd RLE: ______________________

INTRA-OPERATIVE COMPETENCIES FOR A SCRUB NURSE

I. SAFE AND QUALITY NURSING CARE (SQC)
A. DEMONSTRATES PROPER PROCEDURE PREOPERATIVELY 1. Performs surgical hand scrub correctly 2. Dons sterile gown aseptically 3. Dons sterile gloves aseptically 4. Drapes operative field correctly a. Mayo Stand b. Patient 5. Prepares surgical instruments, sponges, sutures and other supplies in functional arrangement 6. Performs initial surgical count with circulator B. UTILIZES BASIC SKILLS INTRAOPERATIVELY 1. Observes principles of strict surgical aseptic techniques within the work area at all times 2. Demonstrates proper handling and serving of instruments, sutures and accessories 3. Demonstrates proper preparation of sutures and needles 4. Anticipates the surgeons needs (supplies and equipment) 5. Maintains internal count of sponges, needles, and instruments 6. Maintains orderly sterile field C. IMMEDIATE POSTOPERATIVE CARE 1. Performs surgical counts with circulator at proper intervals 2. Organizes suture and dressings for wound closure 3. Assists in the application of postoperative sterile dressing 4. Prepares for terminal cleaning of instruments and non-disposable supplies 5. Demonstrates proper disposal of sharps, body fluids and other wastes

Desire d Rating

1st RLE

2nd RL E

3rd RL E

Average rating

5 5 5 3 5 5 5 2 5 3 2 5 2 5 2 2 2 2

II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE) 1. Organizes workload to facilitate timely patient care 2. Utilizes adequate and appropriate resources to support the OR team 3. Ensures functionality of OR resources 4. Maintains a safe environment at the OR by observing the principles of asepsis III. HEALTH EDUCATION (HE) 1. Implements appropriate health education activities to the client based on needs assessment IV. LEGAL RESPONSIBILITIES (LR) 1. Adheres to legal and institutional protocols regarding informed consent. V. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Respects the rights of the OR client. 2. Accepts responsibility and accountability for own decisions and actions as an OR nurse. VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. Performs OR functions according to professional standards 2. Possesses positive attitude towards learning surgical and OR related knowledge and skills

2 2 2 2

2 2 2 2 2 2

VI. QUALITY IMPROVEMENT (QI) 1. Participates in quality improvement activities related to infection control and successful OR operations 2. Identifies and reports variances in sterility and other OR activities VIII. RESEARCH (R) 1. Disseminates results of OR related findings to clinical group and other member of the OR team as appropriate 2. Utilizes findings of research studies of a post-surgical patient IX. RECORDS MANAGEMENT (RM) 1. Maintains accurate and updated documentation of patient care X. COMMUNICATION (COMM) 1. Establishes rapport with patients, significant others and members of the health team 2. Uses appropriate information mechanisms to facilitate communication inside the OR and with other departments in the hospital XI. COLLABORATION AND TEAMWORK (CW) 1. Collaborates plan of care with other members of the health team TOTAL SCORE

2 2 2 2 2 1 2 2 100

Certified True and Correct: _______________________________ Clinical Instructor (1st RLE) License Number:_________________ PRC Card Validity Date: __________ __________

________________________________ Clinical Instructor (2nd RLE) License Number:______________ PRC Card Validity Date:

_____________________________________ Clinical Instructor (3rd RLE) License Number: _______________________ PRC Card Validity Date: ________________

Noted by:

Approved by:

SARAH S. TAUPAN, RN, MN, DPA Clinical Coordinator License Number: 0150766 PRC Card Validity Date: January 17, 2015 2013

_________________________________ DEAN License Number: ___________________ PRC Card Validity Date: January 3,