UNIVERSITY OF LA SALETTE COLLEGE OF NURSING Santiago City, Isabela 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 I. SAFE AND QUALITY NURSING CARE (SQC) 1. Obtains 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. Coaches 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. 5. Wears gown and gloves according to hospital policy. 6. Performs Ritgen’s maneuver safely. 7. Coaches mother on breathing and pushing techniques. 8. Delivers baby and placenta carefully. • Checks and manages cord recoil correctly • Clamps and cuts the cord correctly • 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. Assists 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. DESIRED 1st 2nd 3rd AVERAGE RATING RLE RLE RLE RATING 4 1 2 2 2 1 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1

2 1 1 1

1 1 1 1 1 2 1

MANAGEMENT OF RESOURCES. ENVIRONMENT AND EQUIPMENT (MRE) .II.

needle holder. Provides discharge instructions as to feeding. 1 8. 1 3. Maintains adequacy of supplies as the delivery progresses. Projects a professional image of a delivery room nurse. Reports accurately and honestly the gender. IV. 1 administration of ordered medications. cultural and ethnic practices of the family of the woman in labor and delivery. Observes precautionary measures related to use of electrical 1 equipment. 6. Coaches’ client on breathing/ bearing down technique. 1 V. Participates in audit practices in the delivery room/lying in. LEGAL RESPONSIBILITIES (LR) 1. Respects the religious. III.) 5. Maintains orderliness of the sterile table. 3. 1 • Sterile drape 1 • Sterile instruments and equipment [Forceps. VIII. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. instruments and equipment needed. 2. 1 7. 1 3. Promotes emotional security by supporting needs. Performs functions according to standards. 2 IX. 1 5. Performs after care of the materials and equipments used. gauze. 2 2. Teaches client on basic preparation during labor and deliver (can be done in the labor room) 2. HEALTH EDUCATION (HE) 1 1.) 6. ETHICO-MORAL RESPONSIBILITIES (EMR) 1 1. 1 VII. 1 4. 2 3. Demonstrates proper “latch-on” breast feeding technique (done 1 post-partum period). Updates oneself with the latest trends and development in labor 1 and delivery. Utilize findings of research studies in intra-partal care. Performs sterilization procedure. RECORDS MANAGEMENT (RM) 1. catheter (optional)] 1 • Kelly pad 1 • Disinfectant 2. 1 3. Identifies deviation of practice from the standards. 1 4. suture. Documents accurately relevant data about client. Ensures a quiet environment. time of delivery of 2 the baby and placenta. 2 4. Responds to questions of clients and relatives regarding 1 expectations. QUALITY IMPROVEMENT (QI) (preferably done during post conferences) 1. Prepares room. 1 VI. Uses supplies diligently. 1 3. Accepts criticisms and recommendations. Ensures privacy and confidentiality. bulb syringe. Gives instructions to parents regarding infant care before discharge (done post-partum period. Identifies researchable problems related to labor and delivery. 1 9. 1 . RESEARCH (R) (preferably done during post conferences) 1. bathing. 1 2. 1 4. Recommends corrective and preventive measures for the 1 identified deviations. 2.1. 2. appointment dates for post natal and well baby check up (done post-partum period. scissors. Ensures proper disposal of hospital waste including blood and 1 other fluids. Documents all pertinent data correctly and completely. Secures informed consent in all procedures related to labor and 1 delivery. Ensures proper identification of the mother and newborn.

Establishes collaborative relationship with members of the health team and family members.___ Summer____ Signature________________________ Validity: ________________________ Verified True and Correct: ________________________________ (Signature Over Printed Name) Clinical Coordinator License Number _________________ Validity ________________________ Academic Year Graduated: ________________________________ ______________________________________ DEAN Signature Over Printed Name License Number ___________________ Validity Date _____________________ UNIVERSITY OF LA SALETTE COLLEGE OF NURSING . Functions effectively as a team player in the delivery room/lying in.___ 2nd Sem. XI. 2.2. Listens attentively to clients and families queries and requests.___ 2nd Sem. Inform client’s significant others of the progress of labor and delivery.___ 2nd Sem. Maintains an organized system of filing and keeping records of the client. COLLABORATION AND TEAMWORK (CTW) 1. 3. 2. electronic. COMMUNICATION (Comm) 1.___ Summer____ Signature________________________ Validity: ________________________ 1st Sem. Utilizes appropriately all forms of communication.___ Summer____ Signature________________________ Validity: ________________________ 1st Sem. X. nonverbal. verbal. TOTAL SCORE: 1 1 1 1 1 1 1 90 First Graded RLE Clinical Instructor Second Graded RLE Clinical Instructor Third Graded RLE Clinical Instructor : Academic Year____________ : Name____________________ License Number: __________ : Academic Year____________ : Name____________________ License Number: __________ : Academic Year____________ : Name____________________ License Number: __________ 1st Sem. Communicates the progress of labor/delivery to significant others. 3.

Maintains orderliness of the working area. chest. Takes vital signs (temperature per rectum to check 1 patency) 9. 10. MANAGEMENT OF RESOURCES.Santiago City. Administers Vitamin K (1 mg/M) into the lateral 1 anterior thigh or vastus lateralis. date and time of delivery. 1 16. 1 12. Vitamin K. Gives oil/ water and soap bath according to institutional 1 policy. Ensures proper identification of newborn (name tag: name 2 of mother. II. Reports any signs of deviation/abnormality to the 1 pediatrician. Applies CREDE’s prophylaxis on the eyes. cotton balls. 2 4. 1 3. droplight. head. Suctions mouth and nose of the newborn gently. Isabela SUMMARY PERFORMANCE EVALUATION ACHIEVING IMMEDIATE CARE OF THE NEWBORN COMPETENCY In Accordance with PRC Board of Nursing Memorandum No. 2 2 • Immediately after delivery • After 5 minutes 6. 8. gender and name of attending physician). 15. Latches newborn to the mother’s breast immediately 1 after birth. 01 Series 2009 Signature over Printed Name of Student: ___________________________________________ NEWBORN COMPETENCIES DESIRED 1st 2nd 3rd AVERAGE RATING RLE RLE RLE RATING I. 14. SAFE AND QUALITY NURSING CARE (SQC) 1. 2. 11. abdominal circumference. Dries newborn and wraps warmly. Establishes and maintains patent airway. antimicrobial ophthalmic ointment. 1 • Disinfects area properly according to hospital policy 1 • Clamps and cuts cord 1 inch from the abdomen 1 • Checks for the presence of 2 arteries and 1 vein 1 • Dresses cord aseptically according hospital policy 13. 1 • Places under droplight as needed 5. Maintain adequacy of supplies as newborn care is rendered 1 4. Puts the newborn in Trendelenburg position. gauze. 7. 3 2. Keeps baby wrapped warmly under floor lamp or 1 beside mother according to institutional policy until discharge. cord clamp. blanket. ENVIRONMENT AND EQUIPMENT (MRE) 1. Ensures use of sterile equipment during immediate care of 1 the newborn. Performs cord dressing aseptically. Prepares instrument and equipment needed 4 • Suction bulb. Performs physical assessment including anthropometric 4 measurements including weight. 3. height. Records pertinent observations and nursing care done. Performs and interprets APGAR scoring correctly. 1 . disinfectant.

5. 1 . Observes precautionary measures related to use of electrical equipment.

2. Communicates findings of assessment to all concerned. Updates oneself with the latest trends and developments in 1 newborn care. Reports accurately any deviations/abnormal findings and 1 nursing interventions rendered. 2. 1 VII. Functions effectively as a team player in the nursery. Provides information regarding newborn screening. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. RECORDS MANAGEMENT (RM) 1. Informs mother of relevant information about the newborn. QUALITY IMPROVEMENT (QI) (preferably done during post conferences) 1. Respects the religious. 1 8. COMMUNICATION (Comm) 1. VI. 1 3. 4. electronic. RESEARCH (R) (preferably done during post conferences) 1.6. Maintains an open line of communication with the mother and 1 other family members. Maintains an organized system of filing and record keeping. Provides discharge instructions to the mother on when to 2 expect cord to fall off or to report signs of cord infection. 2. Ensures a warm and quiet environment. Participates in audit practices in the delivery room/lying in. Documents all pertinent data correctly and completely. 1 2. 1 non-verbal. 1 1 . verbal. Performs functions according to standards. 3. 1 7. Identifies deviation of practice from the standards. 1 4. 2 immunization. 1 3. 1 3. Ensures that birth certificate and other civil registration forms 2 are accomplished/ filled out according to institutional policy. 2. 2. 3. XI. 4. Maintains privacy and confidentiality of findings of 1 assessments. 1 V. Identifies newborn by comparing ID band with data in the 2 chart. HEALTH EDUCATION (HE) 1. IV. Utilizes findings of research studies in the immediate care of 2 the newborn. 1 III. Responds to questions of mother and relatives regarding 1 expectations. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. Recommends corrective and preventive measures for the 1 identified deviations. Uses supplies diligently. etc. 5. LEGAL RESPONSIBILITIES (LR) 1. 1 4. 2. Provides instructions to the mother on daily cord care and 2 prevention of cord infection. Accepts criticisms and recommendations. 1 2. Listens attentively to queries and requests of mothers and 1 family members. IX. 1 X. Ensures proper disposal of hospital waste. 2. Projects a professional image of the pediatric nurse. Documents accurately relevant data about the newborn. VIII. cultural and ethnic practices of the 1 family of the newborn. feeding. Identifies researchable problems related to immediate care of 2 newborn. COLLABORATION AND TEAMWORK (CTW) 1. Performs foot printing according to hospital policy. Utilizes appropriately all forms of communication.

___ Summer____ Signature________________________ Validity: ________________________ 1st Sem.___ Summer____ Signature________________________ Validity: ________________________ Verified True and Correct: ________________________________ (Signature Over Printed Name) Clinical Coordinator License Number _________________ Validity ________________________ Academic Year Graduated: ________________________________ ______________________________________ DEAN Signature Over Printed Name License Number ___________________ Validity Date _____________________ UNIVERSITY OF LA SALETTE COLLEGE OF NURSING Santiago City.___ 2nd Sem. Isabela .___ 2nd Sem.3. TOTAL SCORE: 1 75 First Graded RLE Clinical Instructor Second Graded RLE Clinical Instructor Third Graded RLE Clinical Instructor : Academic Year____________ : Name____________________ License Number: __________ : Academic Year____________ : Name____________________ License Number: __________ : Academic Year____________ : Name____________________ License Number: __________ 1st Sem.___ 2nd Sem.___ Summer____ Signature________________________ Validity: ________________________ 1st Sem. Establishes a collaborative relationship with members of the health team and family of the newborn.

LEGAL RESPONSIBILITIES (LR) 1. HEALTH EDUCATION (HE) 1. Assists in skin preparation and draping of client 2 5. Implements appropriate health education activities to client 2 based on needs assessment IV. Promotes safety and comfort of patients inside the OR 2 3. Receives client for surgery / endorses client post – 2 operatively d. Hands instruments. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1.SUMMARY PERFORMANCE EVALUATION ACHIEVING INTRA-OPERATIVE CARE COMPETENCY In Accordance with PRC Board of Nursing Memorandum No. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Performs the functions of the circulating nurse 2 a. Identifies priority needs of the client at the Operating 4 Room c. Prepares surgical instruments. Administers medications and other health therapeutics 2 safely II. Maintains a safe environment at the OR by observing the 2 principles of asepsis III. MANAGEMENT OF RESOURCES. Accepts responsibility and accountability for own 2 decisions and actions as an OR nurse VI. Sets up the OR room and needed equipment 2 c. 01 Series 2009 Signature over Printed Name of Student: ___________________________________________ INTRA-OPERATIVE CARE COMPETENCIES DESIRED 1st 2nd 3rd AVERAGE RATING RLE RLE RLE RATING I. Performs surgical count accurately 2 4. Obtains comprehensive client’s information by checking complete accomplishment of the preoperative checklist/client’s chart b. Organizes work load to facilitate timely patient Care 4 2. Wears sterile gowns and gloves aseptically 2 c. sponges. SAFE AND QUALITY NURSING CARE (SQC) 1. Utilizes the nursing process in the care of OR client 4 a. Performs OR functions according to professional standards 4 . ENVIRONMENT AND EQUIPMENT (MRE) 1. Provides needed nursing interventions based on 4 identified needs d. Performs the functions of the scrub nurse 4 a. Performs surgical scrub correctly b. Ensures functionality of OR resources 2 4. Monitors client’s responses to surgery 2 2. sutures and other needed 2 materials according to surgeon’s preference e. Respects the rights of the OR client 2 2. sutures and 2 other supplies in functional arrangement d. Anticipates the needs of the surgical team b. Adheres to legal and institutional protocols regarding 2 informed consent V. sponges. Utilizes adequate and appropriate resources to support the 2 OR team 3.

___ Summer____ Signature________________________ Validity: ________________________ 1st Sem.2. Uses appropriate information mechanisms to facilitate 2 communication inside the OR and with other departments in the hospital XI. Disseminates results of OR-related research findings to 2 clinical group and other members of the OR team as appropriate IX. Collaborates plan of care with other members of the health 2 team TOTAL SCORE: 75 First Graded RLE Clinical Instructor Second Graded RLE Clinical Instructor Third Graded RLE Clinical Instructor : Academic Year____________ : Name____________________ License Number: __________ : Academic Year____________ : Name____________________ License Number: __________ : Academic Year____________ : Name____________________ License Number: __________ 1st Sem.___ Summer____ Signature________________________ Validity: ________________________ 1st Sem. Establishes rapport with patients. Identifies and reports variances in sterility and other OR 2 activities VIII.___ 2nd Sem. significant others and 1 members of the health team 2. COMMUNICATION (Comm) 1. Participates in quality improvement activities related to 2 infection control and successful OR operations 2. COLLABORATION AND TEAMWORK (CTW) 1. Maintain accurate and updated documentation of patient 2 care X.___ 2nd Sem. RESEARCH (R) (preferably done during post conferences) 1.___ 2nd Sem.___ Summer____ Signature________________________ Validity: ________________________ Verified True and Correct: ________________________________ (Signature Over Printed Name) Clinical Coordinator License Number _________________ Validity ________________________ Academic Year Graduated: ________________________________ ______________________________________ DEAN Signature Over Printed Name License Number ___________________ Validity Date _____________________ . Possesses positive attitude towards learning surgical and 2 OR-related knowledge and skills VII. QUALITY IMPROVEMENT (QI) (preferably done during post conferences) 1. RECORDS MANAGEMENT (RM) 1.

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