DR. YANGA’S COLLEGES, INC. (Formery Or. Yanga Francisco Balagts Colleges) Wakas, Bocaue, Bulacan COLLEGE OF HEALTH SCIENCES CCinical Performance Evaluation Tool ‘0B Ward Name of Student: Date: __ Year Gown: — [T= Safe and Quality Nursing Care os 1. Obtains obstetical history including pati, oravida EDC. AOG. : 1 hes as ond penneue ora — 5. Checks size, consistency and location of wits. 5 Employs infervenions to achieve and meinain 2 | ‘wel contracted ulers to prevent hemorrhage © Uterine massage 1 © _Comect administration of oxytocin "7, Mentor posipartum patent accurately. _Perlorms perineal care an appies pad corecy. qurce and Environment Maintains orderiness of the room - Ensures a quit environment i Performs ater care of the materials and equipments | used. Ensures proper disposal of hospital waste including blood and other fi T=Hoalth Education (eaeui ea 5, Gives instuctons to parents regarding infant care j before discharge sas sso | & Provides cischarge instuctons a to feeding, | bathing adminisieion of ordered metications, appointment dates for post natal and well baby _check up. ail 7 Responds to questions of clients and relaies regarding expectations. _ = ed ae W= Legal Responsibility _ z : 8 Secures informed consent inal procedures related to postpartum. SO Reports accurately and honesty the health care || T _gven. “70: Ensures proper identification ofthe patent a 1. Documents all perinent data comedy and completely. : | V=Etico-Moral Resporsibifty ae 72. Respecs the religious, cultural and ethnic practices ofthe family of the patient hes: oe___,developmentin postpartum __ aes 2 Projects @ professional image of @ postpartum | Wdentfies researcheable problems related to | { - postpartum patient, oo aia nea [2 initiates 2 research study on an identified | i Erie feseuchesbie petleeh ets eg ee eee eee eed ecco =} 3 Partcpates as a member ofa veserch eam inthe ‘conduction of a esearch study. i a “4 Uiiize findings of research studies in postpartum. | 1K= Records Management. [7 1Documents accurately relevant data about cient 2. Maintains an organized system of ing and keeping Communication ae | 1. Utilizes “appropriately all forms of communication; verbal, non-erbal Z Listens attentively 10 chen and familes queries | | andrequests. a _ W=Collaboration and Teamwork “1. Functions eflectvely as ateam pleyerin the ward | ila 2 ‘2. Establishes collaboration relationship with members ofthe heath team and family members. Tooen 4 Capote (Sutin potas crit n noc and ele ares) 3 Crregese seep (Pororane uly oecivand ocala) 3 Nees mgrovenent Preapesin paomance soso ge slack patmanco Tt done prepay x maori ein) 1 -Pogest nowcapltie fro ropes hpeferance hasbeen danse are promanes ‘nation ills and nicer). ie ae Tae OR a 7 Signe oC oer ped rare DateDr. Yanga's Colleges, Inc Wakas, Bocaue, Bulacan College of Health Sciences Clinical Performance Evaluation Tool Labor Room and Delivery Room Caro Name of Student: Date: Year! Group: 1 Safe and Quality Nursing Care Z ‘Obtains Ob history including paily, gravid score, LWP, EDC, ACG, BOW ‘onset of tue labor. (Checks vital signs. ‘Conducts Physical Examination. Performs Leopold's Maneuver ‘Check fetal heart rate and fundic height. Monitor Progress of Labor! Uterine conractons | + Frequency Duration Intensity Interval 7. Observes for the time, color of rupture of BOW @. Ensure the mother inher position of choice while in labor. 9. Ask the mother if she wishes to eal dink or oi. | 10. Communicate withthe mother ~ infor her of progress of labor, gave reassurance and encou ‘PERFORMS FUNCTIONS DURING ACTUAL LABOR T Transports cents safely while providing privacy. 2. Check the temperature in DR area to be 25 - 28 degree Celsius; eliminated at drat. '3._Ask woman if she is comforiable in the semi upright positon 4._Ensure the woman's pivecy. Remove al jewelry then wash hands thoroughly observing the WHO 1-2- 3.45 procedure. Prepare the @ clear, clean newbom resuscitation area, Check the ‘equipment ifclean, funcional and within easy reach, “7. Arrange materials/supplies in near sequence, 8. Gloves, dry linen, bonet, oxylocin injection, plastic clamp, instrument ‘lamp, scissors, 2 kidney basins in @ seperate sequence, for afer the first breastfeed. Eye ointment, (stethoscope to symbolize PE), wiamin K, hepaiis B and [BCG vaccines (pus cotton bal) 70. Performs perineal cae using sterile technique correctly “1, Performs proper hand sorub. 712. Wears stole gown and gloves according to hospital policy. 713. Encourage the woman to push as desired ] “14, Drape the clean, dry linen over the mother’s abdomen or arms in reparation fr crying the baby 75. Applied perineal support end did contclled dalvery of the head. 46. Caled out time of bith and sex of baby. 77_Infom the mother of outcome. [4a (First 30 minutes) thoroughly dry The Baby Tor at Teast 30 seccnds, | starting from the face and head, going tothe unk and exremebes while‘performing a quick check for breathing i 7G. (1-3 minutes) Remove the wet clot. "20. Plane baby in sino skin contact on he mothers abdomen or chest. 21. Cover baby with the dry cloth and the baby’s head wth bonet. 22. Excluded a second baby by palpating the abdomen in preparaion for giving oytocin sai "25. Give IM onyfcin within one minute of babys bith. ‘24. Palpated umbilical cord to check for pulsations. 26. After pulsations stopped, clamp cord using the plastic clamp or cord te in 2cm from the base. ae 26. Place the instrument clamp 5 om from the base. 27._Out near plastic clamp (not midway) i 28. Perform the remaining steps ofthe AMTSL "2. Wait for strong uterine conracions then apply contol cord action and counter racton onthe uterus, continuing unit placenta was delivered. ‘30, Massage the uterus untl itis fim. | _ 31. Inspect the tower vagina and perineum for leoerationsiears and repair ~ __lacorationstears as- necessary. ‘32, Examine the placenta for completeness and abnomalles. ‘33. Clean the mother, fush perineum and applied perineal pad/ cloth, ‘34. Check baby’s color and breathing; check that mother was comfortable, uterus contracted. ‘35, Dispose of the placenta ina leak — proof container or plastic bag. 38. Deconiaminato tho instuments befor caning (soak in 0.5% channe | solution) staling that decontamination lasts for atleast 10 minutes. _| 37. Advise the mather to maintain skin fo skin contact. Baby should be prone | ‘on mother’s chest/in batwoen the breasts with head tur o one side. '36, (15 - 90 mins) advise the mother to observe for feeding cues and cied |__ examples of feeding cues. | 38. Support mother, instructed her on posiioning and attachment. ‘40, Wait for full breastleed to_be completed “1. Afler a complete breastieed, administer eye oiniment (ist) thorough physical examination, then Vi K, hepaiis Bend BCG Injections/simutanoously explain purpose ofeach intervention). 42, Advise optionally bathing of baby expan the rationale) 43. Advise breastfeeding par demand. “A Inthe first hour, check baby's breathing and color, and check mothers |. __ vital signs and massage uterus every 15 minutes. | ~4B-1n the second hour, check mother baby dyad every 30 minutos for 1 hour. [6 Evaluates patients conditon and records parinent data accordingly. [AT Prepares patient or ansfr to wardioom. | W=Communication 11. Utlizes appropriately all forms of communication; verbal, non vert, electronics. Inform client's signifcant others of fhe progress of labor and deve. 33_Listens attentively to cients and familes queries and requests Til= Collaboration and Teamwork. 1 Funes fac satan jee dei oo Wa 2. Communicates the progress of labor! delivery to significant others. and family members. ei 3 Sansa ctetone tee wh mento oe tal [1 Hem Econ eran rg brad darn an | TTeaches clent on basic preparation during labor and delivery (can be done inthe labor room). FiV= Health Education [‘Coach the woman to push as desire ‘Demonstrate proper breastfeeding technique (done postpartum period) ‘Give instruction o parents regarding infant care before discharge. Provides discharye instructions 2s to feeding, bathing, administration of ‘ordered macications, appointment dates for post natal and well baby check up. Responds to questions of chenis and relatives regarding expectations, { T= Loa Rnpnstes 7. Secutes informed consent in all procedures related 16 labor and delivery 2, Reports accurately and honestly the gender, ime of delivery ofthe baby and placenta — Ensures proper identification ofthe mother and newoom. ‘Documents all pertinent data and correctly and completely i= Een = Moral Responses “Respects the retgious, culual and efhric practices of the family ate] ‘woman in labor and delivery. 2 Promotes emotional secuty by supporing needs. — '3._Ensures privacy and confidently ‘vu= Research (preferably done during post conference) “,_Identies researchable problems related to labor and delivery. 2_Uiilze findings of research studies in intra — pata care, Vill Management of Resources, Environment and Equipment 1. Prepares room, instruments and equipment needed. T ‘= Siete drape | ‘© Sterle instruments and equipment (scissors, forces, bu _syringe, gauze, suture, needle holder, catheter (Optional) Performs sterilization procedure. ‘Maintain adequacy of supplies as the delivery progresses. ‘Maintains ordetiness ofthe ster table. ‘Qaserves precautionary measures related fo use of electrical equipment Ensures a quel environment. Uses supplies dligenty Performs aftor car ofthe materials and equipments used. 0] >| ~s]o»|e>] 20} Ensures proper disposal of hospital waste including blood and other fuids. T= Personal and Professional Development 4. Updates oneself with the latest trends and development in labor and Lo delvery. Projects a professional image ofa delivery room nurse. ‘Accepts crisms and recommendations. 2 3 “Performs functions according to standards. ‘Quality improvement 1._denifes deviation of prastice fom the standards. 2. Pa in audit practies in the delivary room! ying in “3. Recommends corrective and preventive measures for the identified deviations. I~ Records Mani “1. Documents accurately relevant date about cient. 2, Maintains an organized system offing and keeping records ofthe cent. | Total Score FELegend: 4 Competent (student performs consistently in an effective and efficient manner) 3 Progress acceplable (Performance is usualy effective and efficient but not always) 2 Needs improvement (Progress in performance is {00 slow to judge satisfactory; task performance is ‘at done propery for majority of the time). {| Progress unacceptable (no progress in performance has been demonstrated, and performance is consistently ineffective and ineffciont) CPET FORMULA:__Raw Score or Actual Score _X50-+ 50 Highest Soore ‘Total CPET Grade. x 00% SLA: 20% 100% ‘Supplemental Leaming Activities (SLA: 20% of RLE Grade) ATTENDANCE, Total number of days absent: Reason: a Total number of days tardy: Reason: