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 (Patient’s 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 Leopold’s 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 Ritgen’s 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 patient’s 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. 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. 5. 6. 7. 8.
DESIRED RATING

1st RL E

2nd RL E

3rd RL E

ACTUAL 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

7. 1 1 1 1 .6. Ensures proper disposal of hospital waste including blood and other fluids. 8. Ensures a quiet environment Uses supplies appropriately Perform after care of the materials and equipments used. 9.

2. 2. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. Utilizes appropriately all forms of communication. Recommends corrective and preventive measures for the identified deviations. HEALTH EDUCATION (HE) 1. Ensures privacy and confidentiality. 4. Teaches client on basic preparation during labor and delivery (can be done in the labor room). electronic. 2. 3. 3.COMMUNICATION (Comm) 1. 2. 3. Identifies rersearchable problems related to labor and delivery. Accepts criticisms and recommendations. Provides discharge instructions as to feeding. Ensures proper identification of the mother and newborn. QUALITY IMPROVEMENT (QI) (preferably done during post conferences) 1. XI. Maintains an organized system of filing and keeping records of the client. 2. VII. 3. Communicates the progress of labor / delivery to significant others. IV. 2. V. Functions effectively as a team player in the delivery room / lying in. Documents accurately relevant data about client. verbal. non-verbal. Secures informed consent in all procedures related to labor and delivery. appointment dates for post natal and well baby check up (done postpartum period). 6. 3. 2. 3. RECORDS MANAGEMENT (RM) 1. 2. Performs functions according to standards.on” breast feeding technique (done post-partum period). Respects the religious. Utilize findings of research studies in intra-partal care.III. VIII. Gives instructions to parents regarding infant care before discharge (done post-partum period). bathing. administration of ordered medications. Identifies deviation of practice from the standard. 4. Promotes emotional security by supporting needs.COLLABORATION AND TEAMWORK (CTW) 1. VI. 4. cultural and ethnic practices of the family of the woman in labor and delivery. X. Documents all pertinent data correctly and completely. 1 2 2 1 2 1 1 2 2 2 1 1 1 1 1 1 1 1 1 1 2. IX. LEGAL RESPONSIBILITIES (LR) 1. 5. Establishes collaborative relationship with members of the health team and family members. 3. Projects a professional image of a delivery room nurse. TOTAL SCORE: Certified True and Correct: 2 2 1 1 1 1 1 1 1 1 100 _________________________________ _________________________________ _________________________________ Clinical Instructor (1st RLE) Clinical Instructor (2nd RLE) Clinical Instructor (3rd RLE) License Number:_________________ License Number:_______________ License Number:_______________ PRC Card – Validity Date: __________ PRC Card – Validity Date: ________ PRC Card – Validity Date: ________ . Participates in audit practices in the delivery room / lying in. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Updates oneself with the latest trends and development in labor and delivery. Coaches’ client on breathing / bearing down technique. RESEARCH (R) (preferably done during post conferences) 1. Demonstrates proper “latch. Reports accurately and honestly the gender. Responds to questions of clients and relatives regarding expectations. Inform client’s significant others of the progress of labor and delivery. time of delivery of the baby and the placenta. Listens attentively to clients and families queries and requests.

SAFE AND QUALITY NURSING CARE (SQC) 1. Records pertinent observations and nursing care done. 2. Takes vital signs (temperature per rectum to check patency) Latches newborn to the mother’s breast immediately after birth. (062) 992-4238 / E-mail: cn@wmsu. 13. (062) 992-0315 / Fax No. . 3. 14.edu. Puts the newborn in Prone position. date and time of delivery. 3 2 3 DESIRED RATING 1st RL E 2nd RL E 3rd RL E ACTUAL RATING 2 2 2 4 2 3 3 2 2 2 2 3 3 2 2 Performs cord dressing aseptically. Applies CREDE’s prophylaxis on the eyes. RN. head. DPA Clinical Coordinator License Number: 0150766 PRC Card – Validity Date: January 17.Noted by: Approved by: SARAH S. Performs and interprets APGAR scoring correctly.edu. 01 Series 2009 Signature over Printed Name of Student: ________________________________ Academic Year Graduated: ________________ Name of Patient (Patient’s initials only) 1st RLE: ________________________________ 2nd RLE: _______________________________ 3rd RLE: ________________________________ NEWBORN COMPETENCIES I. • 4. 6. Keeps baby wrapped warmly under floor lamp or beside mother according to institutional policy until discharge. 10. 8.ph / Web-Site: www. height. Dries newborn and wraps warmly. Establishes and maintains patent airway. 12. Baliwasan. Zamboanga City. 9.wmsu. • • 5. Places under droplight as needed.ph SUMMARY PERFORMANCE EVALUATION ACHIEVING IMMEDIATE CARE OF THE NEWBORN COMPETENCY In Accordance with PRC Board of Nursing Memorandum No. Philippines Telephone No. 7. • • • • 11. 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 Administers Vitamin K (1 mg/M) into the lateral anterior thigh or vastus lateralis. gender and name of the attending physician). Performs physical assesment including anthropometric measurements including weight. MN. Reports any signs of deviation / abnormality to the pediatrician. TAUPAN. Immediately after delivery After 5 minutes Ensures proper identification of newborn (name tag: name of mother. abdominal circumference. chest. 2015 DEAN License Number: PRC Card – Validity Date: WESTERN MINDANAO STATE UNIVERSITY College of Nursing Normal Road.

RESEARCH (R) 1. Identifies researchable problems related to immediate care of newborn. 2. TOTAL SCORE: . MANAGEMENT OF RESOURCES. Informs mother of relevant information about the newborn. 4. Listens attentively to queries and requests of mothers and family members. immunization. cotton balls. Responds to questions of mother and relatives regarding expectations. Reports accurately any deviations / abnormal findings and nursing interventions rendered. droplight. VIII.COMMUNICATION (Comm) 1. Communicates findings of assessment to all concerned. HEALTH EDUCATION (HE) 1. blanket. 4. Observes precautionary measures related to use of electrical equipment. Prepares instruments and equipment needed. cultural and ethnic practices of the family of the newborn. 2. Maintains orderliness of the working area. QUALITY IMPROVEMENT (QI) 1. 4. Respects the religious. 4. disinfectant.II. 2. Documents all pertinent data correctly and completely. Maintains adequacy of supplies as newborn care is rendered. Identifies deviation of practice from the standard. LEGAL RESPONSIBILITIES (LR) 1. Maintains an organized system of filing and record keeping. Utilizes findings of research studies in immediate care of the newborn IX. 3. 2. feeding. Performs functions according to standards. 3. Accepts criticisms and recommendations. XI. 5. 6. 2 2 2 1 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 IV. Establishes collaborative relationship with members of the health team and family of the newborn. 3. Maintains an open line communication with the mother and other family members. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. VI. 7. non-verbal. 2. Provides instructions to the mother on daily cord care and prevention of cord infection Provides discharge instructions to the mother on when to expect cord to fall off or to report signs of cord infection. • 2. Utilizes appropriately all forms of communication. Provides information regarding newborn screening. antimicrobial opthalmic ointment. ENVIRONMENT AND EQUIPMENT (MRE) 1. 3. 4.COLLABORATION AND TEAMWORK (CTW) 1. 3. cord clamp. verbal. Recommends corrective and preventive measures for the identified deviations. 2. Uses supplies diligently. Ensures use of sterile equipment during immediate care of the newborn. 3. 2. Ensures proper disposal of hospital waste 4 2 2 2 1 2 2 2 III. Functions effectively as a team player in the nursery. Suction bulb. 2. Ensures a warm and quiet environment. 3. RECORDS MANAGEMENT (RM) 1. V. etc. gauze. Maintains privacy and confidentiality of findings of assessments. vitamin K. X. VII. Identifies newborn by comparing ID band with data in the chart. 2. electronic. Participates (whenever possible) in audit practices in the nursery. Ensures that birth certificate and other civil registration forms are accomplished / filled out according to institutional policy. Projects a professional image of the pediatric nurse. Documents accurately relevant data about the newborn. 8. Updates oneself with the latest trends and development in newborn care. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1.

ph /Web-Site: www.edu. MN.R. 01 Series 2009 Signature over Printed Name of Student: ________________________________ Academic Year Graduated: _________________ Name of Patient (Patient’s initials only) 1st RLE: ________________________________ 2nd RLE: _______________________________ 3rd RLE: ________________________________ De sir ed Ra tin g INTRAOPERATIVE COMPETENCES (CIRCULATING NURSE) 1st RL E 2nd RL E 3rd RL E Avera ge Rating I. table 2 2 4 1 1 . 2015 DEAN License Number: PRC Card – Validity Date: WESTERN MINDANAO STATE UNIVERSITY College of Nursing Normal Road. RN. Patient transfer to stretcher.Utilizes the Nursing process in the care of O. client 1. SAFE AND QUALITY NURSING CARE (SQC) A. Accomplishment of the preoperative checklist/clients chart. 2. 1. Philippines Telephone No. Makes sure theater is clean 4. (062) 992-0315 / Fax No.wmsu. Provides needed nursing interventions based on identified needs.edu. TAUPAN. Obtains comprehensive client’s information by checking complete 2.Certified True and Correct: _________________________________ _________________________________ _________________________________ Clinical Instructor (1st RLE) Clinical Instructor (2nd RLE) Clinical Instructor (3rd RLE) License Number:_________________ License Number:_______________ License Number:_______________ PRC Card – Validity Date: __________ PRC Card – Validity Date: ________ PRC Card – Validity Date: ________ Noted by: Approved by: SARAH S. (062) 992-4238 / E-mail: cn@wmsu. 3. DPA Clinical Coordinator License Number: 0150766 PRC Card – Validity Date: January 17.R. Provides a clean kick bucket and pail 4 5. Patient transfer to O. Baliwasan. Zamboanga City.ph SUMMARY PERFORMANCE EVALUATION ACHIEVING INTRA-OPERATIVE COMPETENCY In Accordance with PRC Board of Nursing Memorandum No. Identifies priority needs of the client upon admission to the Operating Room 6.

Assists the scrub nurse.) B. with after care of instruments and equipment 3. 9.3. Applies restraints on the patient 4. VI. IX. (Serving of bedpan.FUNCTIONS AS A CIRCULATING NURSE 1. V. Utilize findings of research studies in immediate care of the newborn. Accepts responsibility and accountability for own decisions and actions as an OR nurse. Identifies and reports variances in sterility and other OR activities VIII. Implements appropriate education activities to client based on needs assessment IV. etc. Focuses the OR light as needed 3. ETHICO – MORAL RESPONSIBILITIES 1. Performs OR functions according to professional standards 2. Initiates and assists with final sponge and instruments count 4. Exposes the area for skin preparation 5. Utilizes adequate and appropriate resources to support the OR team 3. Disseminates results of OR-related research findings to clinical group and other members of the OR team as appropriate. Attaches anesthesia screen and places the patient’s arms on the arm boards 3. PERSONAL AND PROFESSIONAL DEVELOPMENT 1. RECORD MANAGEMENT 1. Observes skin preparation 3. AFTER OPERATION 1. AFTER THE PATIENT IS ANESTHETIZED 1. Ensures that the theater is ready for the next case II. Monitors client’s responses to surgery. Adheres to legal and institutional protocols regarding informed consent. ENVIRONMENT and EQUIPMENT (MRE) 1. DURING THE INDUCTION OF ANESTHESIA 1. HEALTH EDUCATION (HE) 1. Allay patient’s anxiety & questions. Turns on OR light 2. DURING OPERATION 1. 2. Replenishes and records sponge/sutures 6. Ensures the theater door remains close and patient’s dignity is upheld 7. VII. LEGAL RESPONSIBILITIES (LR) 1. MANAGEMENT OF RESOURCES. Participates in quality improvement activities related to infection control and successful OR operations 2. suction machine) 4. Possesses positive attitude towards learning surgical and OR related knowledge and skills. Maintain accurate and updated documentation of the 4 2 2 2 2 2 2 4 2 2 2 2 2 2 . Organizes work load to facilitate timely patient care 2. Assists in positioning the patient 1 1 1 2 2 2 2 2 2 2 2 2 1 5 5 5 2 4 2 2 2 5 2. RESEARCH 1. Maintains a safe environment at the OR by observing the principles of asepsis and sterility 8. Respects the rights of the OR client 2. Remains in theater throughout the procedure 2. Helps remove and dispose drapes 2. Positions kick buckets on the operating side 5. Assists in Repositioning of the patient per anesthesiologist order 2. Ensures functionality of OR resources III. Patient’s comfort. 4. QUALITY IMPROVEMENT 1. Connects equipment/machines (cautery machine.

significant others. RN. 01 Series 2009 Signature over Printed Name of Student: ________________________________ Academic Year Graduated: ___________________________________________ Name of Patient (Patient’s initials only) 1st RLE: ______________________ 2nd RLE: 3 rd ______________________ ______________________ RLE: INTRA-OPERATIVE COMPETENCIES FOR A SCRUB NURSE I. COLLABORATION AND TEAMWORK 1. XI. 2015 DEAN License Number: PRC Card – Validity Date: 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. TAUPAN. SAFE AND QUALITY NURSING CARE (SQC) Desire d Rating 1st RLE 2nd RL E 3rd RL E Average rating . COMMUNICATION (Comm) 1. DPA Clinical Coordinator License Number: 0150766 PRC Card – Validity Date: January 17. Establishes rapport with patients. MN.patient care X. Collaborates plan of care with other members of the health team TOTAL 1 2 2 100 Certified True and Correct: _________________________________ _________________________________ _________________________________ Clinical Instructor (1st RLE) Clinical Instructor (2nd RLE) Clinical Instructor (3rd RLE) License Number:_________________ License Number:_______________ License Number:_______________ PRC Card – Validity Date: __________ PRC Card – Validity Date: ________ PRC Card – Validity Date: ________ Noted by: Approved by: SARAH S. and members of the health team 2. Uses appropriate information mechanisms to facilitate communication inside the OR and with other departments in the hospital.

sponges. QUALITY IMPROVEMENT (QI) 1. Patient 5. Maintains orderly sterile field C. Uses appropriate information mechanisms to facilitate 2 2 2 2 2 1 2 . Respects the rights of the OR client. VI. RECORDS MANAGEMENT (RM) 1. Dons sterile gown aseptically 3. Possesses positive attitude towards learning surgical and OR related knowledge and skills 5 5 5 3 5 5 5 2 5 3 2 5 2 5 2 2 2 2 2 2 2 2 2 2 2 2 2 2 VII. body fluids and other wastes II. Organizes suture and dressings for wound closure 3. Demonstrates proper preparation of sutures and needles 4. DEMONSTRATES PROPER PROCEDURE PREOPERATIVELY 1. LEGAL RESPONSIBILITIES (LR) 1. Utilizes findings of research studies of a post-surgical patient IX. Dons sterile gloves aseptically 4. V. COMMUNICATION (COMM) 1. and instruments 6. Mayo Stand b. Performs OR functions according to professional standards 2. ENVIRONMENT AND EQUIPMENT (MRE) 1. UTILIZES BASIC SKILLS INTRAOPERATIVELY 1.A. Establishes rapport with patients. Demonstrates proper handling and serving of instruments. sutures and other supplies in functional arrangement 6. sutures and accessories 3. IMMEDIATE POSTOPERATIVE CARE 1. significant others and members of the health team 2. Performs surgical hand scrub correctly 2. Demonstrates proper disposal of sharps. Anticipates the surgeon’s needs (supplies and equipment) 5. Drapes operative field correctly a. Performs initial surgical count with circulator B. Maintains internal count of sponges. Participates in quality improvement activities related to infection control and successful OR operations 2. Ensures functionality of OR resources 4. Observes principles of strict surgical aseptic techniques within the work area at all times 2. Organizes workload to facilitate timely patient care 2. Utilizes adequate and appropriate resources to support the OR team 3. needles. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Prepares for terminal cleaning of instruments and nondisposable supplies 5. Accepts responsibility and accountability for own decisions and actions as an OR nurse. Prepares surgical instruments. 2. Identifies and reports variances in sterility and other OR activities VIII. Maintains accurate and updated documentation of patient care X. RESEARCH (R) 1. MANAGEMENT OF RESOURCES. HEALTH EDUCATION (HE) 1. Assists in the application of postoperative sterile dressing 4. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. Disseminates results of OR related findings to clinical group and other member of the OR team as appropriate 2. Adheres to legal and institutional protocols regarding informed consent. Maintains a safe environment at the OR by observing the principles of asepsis III. Implements appropriate health education activities to the client based on needs assessment IV. Performs surgical counts with circulator at proper intervals 2.

RN. TAUPAN. 2015 DEAN License Number: PRC Card – Validity Date: . DPA Clinical Coordinator License Number: 0150766 PRC Card – Validity Date: January 17. MN. COLLABORATION AND TEAMWORK (CW) 1. Collaborates plan of care with other members of the health team TOTAL SCORE 2 100 Certified True and Correct: _________________________________ _________________________________ _________________________________ Clinical Instructor ( 1st RLE) Clinical Instructor (2nd RLE) Clinical Instructor (3rd RLE) License Number:_________________ License Number:_______________ License Number:_______________ PRC Card – Validity Date: __________ PRC Card – Validity Date: ________ PRC Card – Validity Date: ________ Noted by: Approved by: SARAH S.communication inside the OR and with other departments in the hospital XI.

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