Republic of the Philippines

TARLACSTATEUNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Villa Lucinda Campus, Brgy. Binauganan, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

Performance Evaluation Checklist

LEOPOLD’S MANEUVER

Name of Student: _______________________________________

Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ___First Semester ____Second Semester ___ Summer
Inclusive Dates of Clinical Rotation: __________________
Instructor: _____________________________________________

SCORE REMARKS
Preparation 2 1 0
1. 1. Check doctor’s order
2. Gather equipments (if any)
3. Introduce yourself to the client
4. Identify your client
5.Explain the procedure to the client
6.Provide privacy to your client
7.Ask the client to empty the bladder
8.Place in supine position, head slightly elevated and knees
slightly flexed.
9. Do hand washing and dry hands. (Hold palm and scratch
together before the procedure if bare hand)

Procedure
10. Do the FIRST MANEUVER (fundal grip or presentation)
Purpose:
▪ to determine the fetal part lying in the fundus
Procedure:
▪ Facing the mother, palpate the fundus with both hands.
▪ Assess for shape, size, consistency, and mobility
Findings:
▪ Fetal head should be firm, hard and round.
▪ Breech or buttocks are softer and has bony prominences.

11. Do the SECOND MANEUVER (umbilical grip or fetal lie)

Purpose:
▪ to determine the position of the fetus back and small parts
Procedure:
Still facing the mother, place both palms on the abdomen.
▪ Hold right hand still and with deep and gentle pressure,
use left hand to feel for the firm, smooth back
▪ Once located the back, confirm your findings by
palpating the fetal extremities on the opposite side.
Findings:
▪ back – smooth, hard, resistant
▪ small parts – knees and legs
 12. Do the THIRD MANEUVER (pawlick’s grip or engagement)
Purpose:
▪ To determine if the presenting part has entered the pelvis
Procedure:
▪ Gently grasp the lower portion of the abdomen with the
thumb and fingers of the right hand.
▪ Confirm presenting part
Findings:
▪ Head will feel firm
▪ Buttocks will feel softer and irregular
▪ If it‘s not engaged, it may be gently pushed back and forth
✓ flexion – cephalic prominence is on the same side of
the small parts
✓ extension - cephalic prominence is on the same side of
the fetal back

13. Do the FOURTH MANEUVER (pelvic grip)

Purpose:
▪ To determines fetal head flexion or extension
Procedure:
▪ Turn to face the woman‘s feet
▪ Move fingers of both hands gently down the sides of the
abdomen towards the pubis
▪ Locate brow
▪ Assess descent of the presenting part
Findings:
▪ Prominence on the same side as the small parts
suggest that the head is flexed
▪ Prominence on the same side as the back suggest that the
head is extended
14. Assist the client after the procedure.
15. Document and report the findings.
TOTAL SCORE:

Evaluated by:

________________________________
Signature over Printed Name
Clinical Instructor

________________________________
Signature over Printed Name
Student
 Republic of the Philippines
TARLACSTATEUNIVERSITY
COLLEGE OF NURSING
Lucinda Campus, Brgy. Ungot, Tarlac CityPhilippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

Performance Evaluation Checklist

Name of Student: _______________________________________

Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ___First Semester ____Second Semester ___ Summer
Inclusive Dates of Clinical Rotation: __________________
Instructor: _____________________________________________

Core Competency SCORE REMARKS

2 1 0
A. Safe and quality nursing care
16.
1.

1.

2.

3.

4.
5.
6.
7.
8.

9. .

10.

11.
 B. Management of Resources ,Environment and
Equipments

1. Ensures safe environment. Make sure unnecessary

wires and furnitures are remove from the actual setting
2. Observes precautionary measures related to use of
electrical equipment.
3. Performs after care, proper endorsement to medical
team.
V.LEGAL RESPONSIBILITIES
1. Record all relevant findings about the client and
members of the family.
2. Ensures proper identification of the client
3. Documents all pertinent data correctly and completely
VI. ETHICO-MORAL RESPONSIBILITY
1. Ensures privacy and confidentiality
VII. PERSONAL AND PROFESSIONAL DEVELOPMENT
1. Maintain professionalism ethics in administering First
aid choking treatment
2. Accepts criticism and recommendation
VIII. QUALITY IMPROVEMENT
1. Identifies deviation of practice from the standards
2. Recommends corrective and preventive measures for
the identified deviations
IX. RESEARCH
1. Identifies researchable problems related to bag
technique
2. Initiates a research study on an identified researchable
problems
X.RECORD MANAGEMENT
1. Documents accurately relevant data about the clients
2. Maintain an organized system of filing and keeping
records of the client
XI. COMMUNICATION
1. Listen attentively to clients and families queries and
request
XII. COLLABORATION AND TEAMWORK
12. Establishes collaborative relationship with the
members of the health team and family members

TOTAL SCORE:

Evaluated by:

________________________________
Signature over Printed Name
Clinical Instructor

________________________________
Signature over Printed Name
Student