Republic of the Philippines

NORTHERN NEGROS STATE COLLEGE OF SCIENCE & TECHNOLOGY

College of Nursing and Allied Health Sciences
Brgy. Rizal, Sagay City, Negros Occidental
(034)722-4120, www.nonescost.edu.ph
ISO 9001:2015
Certified

LEVEL III and LEVEL IV

SUMMARY PERFORMANCE EVALUATION ACHIEVING

INTRA-OPERATIVE CARE COMPETENCY

Signature over Printed Name of Student: _____________________________________

INTRA-OPERATIVE CARE COMPETENCIES DESIRED 1ST 2ND 3RD AVERAGE

RATING RLE RLE RLE RATING
I. SAFE AND QUALITY NURSING CARE (SQC)
1. Utilizes the nursing process in the care of OR
client.
 Obtains comprehensive client’s information
by checking complete accomplishment of 4
the preoperative checklist/client’s chart.
 Identifies priority needs of the client at the
4
Operating Room.
 Provides needed nursing interventions
4
based on identified needs.
 Monitor client’s response to surgery. 2
2. Promotes safety and comfort of patient inside
2
the OR.
3. Performs functions of the scrub nurse.
 Performs surgical scrub correctly. 4
 Wears sterile gowns and gloves aseptically. 2
 Prepares surgical instruments, sponges,
sutures, and other supplies in functional 2
arrangement.
 Hands instruments, sponges, sutures, and
other needed materials according to 2
surgeon’s preference.
 Performs surgical count accurately. 2
4. Performs the functions of the circulating nurse.
 Anticipates the needs of the surgical team.
2

 Sets up the OR room and needed

2
equipment.
 Receives client for surgery/endorses client
2
post-operatively.
 Assists in skin preparation and draping of
2
client.
5. Administers medications and other health
2
therapeutics safely.
II. MANAGEMENT OF RESOURCES AND ENVIRONMENT (MRE)
1. Organizes work load to facilitate timely patient
4
care.
2. Utilizes adequate and appropriate resources to
2
support the OR Team.
3. Ensures functionality of OR resources. 2
4. Maintains a safe environment at the OR by
2
observing the principles of asepsis.
III. HEALTH EDUCATION (HE)
1. Implements appropriate health education
2
activities to client based on needs assessment.
IV. LEGAL RESPONSIBILITIES (LR)
1. Adheres to legal and institutional protocols
2
regarding informed consent.
V. ETHICO-MORAL RESPONSIBILITIES (EMR)
1. Respects the rights of the OR client. 2
2. Accepts responsibility and accountability for own
2
decisions and actions as an OR nurse.
 VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
1. Performs OR functions according to professional
4
standards.
2. Possesses positive attitude towards learning
2
surgical and OR-related knowledge and skills.
VII. QUALITY IMPROVEMENT (QI)
1. Participates in quality improvement activities
related to infection control and successful OR 2
operations.
2. Identifies and reports variances in sterility and
2
other OR activities.
VIII. RESEARCH (R)
1. Disseminates results of OR-related research
findings to clinical group and other members of 2
the OR team as appropriate.
IX. RECORD MANAGEMENT (RM)
1. Maintain accurate and updated documentation of
2
patient care.
X. COMMUNICATION (Comm)
1. Establishes rapport with patients, significant
1
others and members of the health team.
2. Uses appropriate information mechanisms to
facilitate communication inside the OR and with 2
other departments in the hospital.
XI. COLLABORATION AND TEAMWORK (CTM)
1. Collaborates plan of care with other members of
2
the health team.
TOTAL SCORE 75

When Graded RLE’s Were Performed (Specify Academic Year and Semester)

First Graded RLE : Academic Year ___________ 1st Sem. ___ 2nd Sem. ___ Summer ____
Clinical Instructor : Name ___________________________________________ Signature ________________________
License Number: _____________ Validity: ___________________

Second Graded RLE: Academic Year __________ 1st Sem. ___ 2nd Sem. ___ Summer ____
Clinical Instructor : Name ___________________________________________ Signature ________________________
License Number: _____________ Validity: ___________________

Third Graded RLE: Academic Year ____________ 1st Sem. ___ 2nd Sem. ___ Summer ____
Clinical Instructor : Name ___________________________________________ Signature ________________________
License Number: _____________ Validity: ___________________

Verified True and Correct:

(Signature over Printed Names)

__NATASHA KAY V. CHAN, RN, MN_____

Clinical Coordinator License Number: ____0378902_______ Validity Date: _July 30, 2023___

____________________________________
Academic Year Graduated

_____AILEEN G. SYPONGCO, RN, RM, MN_____

DEAN

License Number: ___198131_________ Validity Date: _March 17, 2024_____

 Republic of the Philippines
NORTHERN NEGROS STATE COLLEGE OF SCIENCE & TECHNOLOGY
College of Nursing and Allied Health Sciences
Brgy. Rizal, Sagay City, Negros Occidental
(034)722-4120, www.nonescost.edu.ph
ISO 9001:2015
Certified

LEVEL III and LEVEL IV

SUMMARY PERFORMANCE EVALUATION ACHIEVING

INTRA-PARTAL CARE COMPETENCY

Signature over Printed Name of Student: _____________________________________

INTRA-PARTAL COMPETENCIES DESIRED 1st 2nd 3rd AVERAGE

RATING RLE RLE RLE RATING
I. SAFE AND QUALITY NURSING CARE (SQC)
1. Obtains obstetrical history including parity, gravida score, 4
LMP, EDC, AOG, BOW onset of true labor.
2. Checks vital signs. 1
3. Conducts physical examination. 2
4. Performs Leopold Maneuver. 2
5. Checks Fetal Heart Rate and Fundic Height. 2
6. Monitor progress of labor/uterine contractions as to:
 Frequency 1
 Duration 1
 Intensity 1
 Interval 1
7. Observes for the timely rupture of membrane. 1
8. Coaches mother on process of labor. 2
PERFORMS FUNCTIONS DURING ACTUAL LABOR
1. Transports clients safely while providing privacy. 1
2. Places mother in lithotomy position. 1
3. Performs perineal care using sterile technique correctly. 1
4. Performs proper hand scrub. 1
5. Wears gown and gloves according to hospital policy. 1
6. Performs Ritgen’s Maneuver safely. 2
7. Coaches mother on breathing and pushing techniques. 1
8. Delivers baby and placenta carefully. 1
 Checks and manages cord recoil correctly. 1
 Clamps and cut the cord correctly. 1
 Identify signs of placental separation. 1
 Checks the characteristic/completeness of the 2
placenta.
9. Assesses amount of blood loss (Normal: <500 cc). 1
10. Employs interventions to achieve and maintain a well 1
contracted uterus to prevent/control hemorrhage.
 Uterine massage 1
 Correct administration of oxytocin 1
1
 Cold compress
1
11. Assesses presence and degree of laceration.
1
12. Assist in episiorrhaphy.
1
13. Checks size, consistency and location of uterus.
2
14. Performs perineal care and applies pad correctly.
2
15. Provides emotional support to the mother throughout labor
and delivery.
3
16. Evaluates patient’s condition and records pertinent data
accordingly.
3
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 1
 Sterile instruments and equipment [forceps, scissors, 1
bulb syringe, gauze, suture, needle holder, catheter
(optional)].
 Kelly pad 1
 Disinfectant 1
2. Performs sterilization procedure. 1
3. Maintains adequacy of supplies as the delivery progresses. 1
4. Maintains orderliness of the sterile table.
5. Observes precautionary measures related to use of 1
electrical equipment. 1
6. Ensures a quite environment.
7. Uses supplies diligently. 1
8. Performs after care of the materials and equipment used. 1
9. Ensures proper disposal of hospital waste including blood 1
and other fluids. 1
III. HEALTH EDUCATION (HE)
1. Teaches client on basic preparation during labor and 1
delivery (can be done in the labor room).
2. Coaches’ client on breathing/bearing down technique. 2
3. Demonstrates proper “latch-on” breastfeeding technique 1
(done post-partum period).
4. Gives instruction to parents regarding infant care before 1
discharge (done post-partum period).
5. Provides discharge instructions as to feeding, bathing, 1
administration of ordered medications, appointment dates
for post-natal and well-baby check-up (done post-partum
period).
6. Responds to questions of clients and relatives regarding 1
expectations.
IV. LEGAL RESPONSIBILITIES (LR)
1. Secures informed consent in all procedures related to labor 1
and delivery.
2. Reports accurately and honestly the gender, time of 2
delivery of the baby and placenta.
3. Ensures proper identification of the mother and newborn. 2
4. Documents all pertinent data correctly and completely. 1
V. ETHICO-MORAL RESPONSIBILITIES (EMR)
1. Respects the religious, cultural, and ethnic practices of the 1
family of the woman in labor and delivery.
2. Promotes emotional security by supporting needs. 1
3. Ensures privacy and confidentiality. 1
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
1. Updates oneself with the latest trends and development in 1
labor and delivery.
2. Projects a professional image of a delivery room nurse. 1
3. Accepts criticisms and recommendations. 1
4. Performs functions according to standards. 1
VII. QUALITY IMPROVEMENT (QI) (preferably done during post conferences)
1. Identifies deviation of practice from the standards. 1
2. Participates in audit practices in the delivery room/lying in. 1
3. Recommends corrective and preventive measures for the 1
identified deviations.
VIII. RESEARCH (R) (preferably done during post conferences)
1. Identifies researchable problems related to labor and 2
delivery.
2. Utilize findings of research studies in intra-partal care. 2
IX. RECORDS MANAGEMENT (RM)
1. Documents accurately relevant data about client. 1
2. Maintains and organized system of filing and keeping 1
records of the client.
X. COMMUNICATION (Comm)
1. Utilizes appropriately all forms of communication; verbal, 1
non-verbal, electronic.
2. Inform client’s significant others of the progress of labor and 1
delivery.
3. Listens attentively to clients and families queries and 1
requests.
XI. COLLABORATION AND TEAMWORK (CTW)
1. Functions effectively as a team player in the delivery 1
room/lying in.
2. Communicates the progress of labor/delivery to significant 1
others.
3. Establishes collaborative relationships with members of the 1
health team and family members.
TOTAL SCORE 100
When Graded RLE’s Were Performed (Specify Academic Year and Semester)

First Graded RLE : Academic Year ___________ 1st Sem. ___ 2nd Sem. ___ Summer ____
Clinical Instructor : Name ___________________________________________ Signature ________________________
License Number: _____________ Validity: ___________________

Second Graded RLE: Academic Year __________ 1st Sem. ___ 2nd Sem. ___ Summer ____
Clinical Instructor : Name ___________________________________________ Signature ________________________
License Number: _____________ Validity: ___________________

Third Graded RLE: Academic Year ____________ 1st Sem. ___ 2nd Sem. ___ Summer ____
Clinical Instructor : Name ___________________________________________ Signature ________________________
License Number: _____________ Validity: ___________________

Verified True and Correct:

(Signature over Printed Names)

__NATASHA KAY V. CHAN, RN, MN_____

Clinical Coordinator License Number: ____0378902_______ Validity Date: _July 30, 2023___

____________________________________
Academic Year Graduated

_____AILEEN G. SYPONGCO, RN, RM, MN_____

DEAN

License Number: ___198131_________ Validity Date: _March 17, 2024_____

 Republic of the Philippines
NORTHERN NEGROS STATE COLLEGE OF SCIENCE & TECHNOLOGY
College of Nursing and Allied Health Sciences
Brgy. Rizal, Sagay City, Negros Occidental
(034)722-4120, www.nonescost.edu.ph
ISO 9001:2015
Certified

LEVEL III and LEVEL IV

SUMMARY PERFORMANCE EVALUATION ACHIEVING

IMMEDIATE CARE OF THE NEWBORN COMPETENCY

Signature over Printed Name of Student: _____________________________________

NEWBORN COMPETENCIES DESIRED 1st 2nd 3rd AVERAGE

RATING RLE RLE RLE RATING
I. SAFE AND QUALITY NURSING CARE (SQC)
1. Establishes and maintain patent airway. 3
2. Puts the newborn in Trendelenburg Position. 1
3. Suctions mouth and nose of the newborn gently. 2
4. Dries newborn and wraps warmly. 1
 Places under droplight as needed 2
5. Performs and interpret APGAR scoring correctly. 2
 Immediately after delivery 2
 After 5 minutes 4
6. Ensures proper identification of newborn (name tag: name 1
of mother, date and time of delivery, gender and name of
attending physician).
7. Performs physical assessment including anthropometric 1
measurements including weight, height, head, chest,
abdominal circumference.
8. Takes vital signs (temperature, per rectum to check 1
patency).
9. Gives oil/water and soap bath according to institutional 1
policy.
10. Latches newborn to the mother’s breast immediately after 1
birth.
11. Applies CREDE’S prophylaxis on the eyes. 1
12. Performs cord dressing aseptically. 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
1
 Dresses cord aseptically according to hospital policy.
13. Administers Vit. K (1 mg/M) Into the lateral anterior thigh or
1
vastus lateralis.
14. Keep baby wrapped warmly under floor lamp or beside
2
mother according to institutional policy until discharge.
2
15. Records pertinent observations and nursing care done.
1
16. 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, 4
disinfectant, blanket, droplight, Vitamin K, antimicrobial
ophthalmic ointment.
2. Ensures use of sterile equipment during immediate care of 1
the newborn.
3. Maintain adequacy of supplies as newborn care is 1
rendered.
4. Maintains orderliness of the working area. 1
5. Observes precautionary measures related to use of 1
electrical equipment.
6. Ensures a warm and quiet environment. 1
7. Uses of supplies diligently. 1
8. Ensures proper disposal of hospital waste. 1
III. HEALTH EDUCATION (HE)
1. Provides instructions to the mother on daily cord care and 2
prevention of cord infection.
2. Provides discharge instructions to the mother on when to 1
expect cord to fall off or to report signs of cord infection.
3. Provides information regarding newborn screening,
 immunization, feeding, etc. 2
4. Responds to questions of mother and relatives regarding
expectations. 1
IV. LEGAL RESPONSIBILITIES (LR)
1. Identifies newborn by comparing ID band with data in the 2
chart.
2. Documents all pertinent data correctly and completely. 1
3. Reports accurately any deviations/abnormal findings and 1
nursing interventions rendered.
4. Ensures the birth certificate and other civil registration 2
forms are accomplished/filled out according to institutional
policy.
5. Performs foot printing according to hospital policy. 1
V. ETHICO-MORAL RESPONSIBIITIES (EMR)
1. Respects the religious, cultural and ethnic practices of the 1
family of the newborn.
2. Maintains privacy and confidentiality of findings of 1
assessments.
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
1. Updates oneself with the latest trends and developments 1
in newborn care.
2. Projects a professional image of the pediatric nurse. 1
3. Accepts criticisms and recommendations. 1
4. Performs functions according to standards. 1
VII. QUALITY IMPROVEMENT (QI)
1. Identifies deviation of practice from the standards. 1
2. Participates (whenever possible) in audit practices in the 1
nursery.
3. Recommends corrective and preventive measures for the 1
identified deviations.
VIII. RESEARCH (R)
1. Identifies researchable problems related to immediate care 2
of newborn.
2. Utilizes findings of research studies in the immediate care 2
of the newborn.
IX. RECORDS MANAGEMENT (RM)
1. Documents accurately relevant data about newborn. 1
2. Maintains an organized system of filing and record 1
keeping.

X. COMMUNICATION (Comm)
1. Utilizes appropriately all forms of communication; verbal, 1
non-verbal, electronic.
2. Maintains an open line communication with the mother and 1
other family members.
3. Informs mother of relevant information about newborn. 1
4. Listens attentively to queries and requests of mother and 1
family members.
XI. COLLABORATION AND TEAMWORK (CTW)
1. Functions effectively as a team player in the nursery. 1
2. Communicates findings of assessment to all concerned. 1
3. Establishes a collaborative relationship with members of 1
the health team and family of the newborn.
TOTAL SCORE 80

When Graded RLE’s Were Performed (Specify Academic Year and Semester)

First Graded RLE : Academic Year ___________ 1st Sem. ___ 2nd Sem. ___ Summer ____
Clinical Instructor : Name ___________________________________________ Signature ________________________
License Number: _____________ Validity: ___________________

Second Graded RLE: Academic Year __________ 1st Sem. ___ 2nd Sem. ___ Summer ____
Clinical Instructor : Name ___________________________________________ Signature ________________________
License Number: _____________ Validity: ___________________

Third Graded RLE: Academic Year ____________ 1st Sem. ___ 2nd Sem. ___ Summer ____
Clinical Instructor : Name ___________________________________________ Signature ________________________
License Number: _____________ Validity: ___________________
Verified True and Correct:
(Signature over Printed Names)

__NATASHA KAY V. CHAN, RN, MN_____

Clinical Coordinator License Number: ____0378902_______ Validity Date: _July 30, 2023___

____________________________________
Academic Year Graduated

_____AILEEN G. SYPONGCO, RN, RM, MN_____

DEAN

License Number: ___198131_________ Validity Date: _March 17, 2024_____