NAME: DATE:

YEAR LEVEL: RLE GROUP:

NUMERICAL RATING QUALITATIVE DESCRIPTION

3 Outstanding
2 Very Satisfactory
1 Satisfactory
0 Unsatisfactory
 Carries out expected tasks in a
consistent manner with minimal
guidance and supervision
 Carries out expected tasks in a
moderately consistent manner with
frequent guidance and supervision
 Carried out expected tasks in a rarely
consistent manner with close guidance
and supervision
 Does not carry out expected tasks even
with close guidance and supervision

GOWN TECHNIQUE

PERFORMANCE Excellent Very Satisfactory Unsatisfactory

(3) Satisfactory (1) (0)
(2)
1. Applies face mask and cap
2. Performs surgical hand scrub
3. With one hand, picks up the entire
folded gown from the wrapper by
grasping the gown through all layers
being careful to touch only the inside
top layer, which is exposed. Steps
back from the table to allow other
team members room to maneuver.
4. Holds the gown near the gown’s neck,
and allows it to unfold, being careful
that it does not touch either your
body or other unsterile objects.
5. Allows the gown to unfold while
suspending it high enough that it will
not come in contact with the floor
6. Grasps the inside shoulder seams
unopen the gown with armholes
facing you
7. Slides the arms partway into the
sleeves of the gown, keeping your
hands at shoulder level away from
the body
8. With assistance of a circulator, slides
the arms further into the gown’s
sleeves (when the fingertips are even
with the proximal edge of the cuff,
grasp the inside seams at the juncture
 of gown’s sleeve and cuff using your
thumb and index finger.
9. The circulator must continue to assist
in this point. Positions the gown over
your shoulders by grasping the inside
surface at the gown at the shoulder
seams.

TOTAL

REMARKS: _________________________________________________________________

__________________________________________________________________

EVALUATED BY: CONFORME:

_______________________________ ____________________________

CLINICAL INSTRUCTOR’S NAME AND SIGNATURE STUDENT’S NAME AND SIGNATURE

 CREDE’S PROPHYLAXIS

PERFORMANCE 3 2 1 0
1. Identify the patient.
2. Prepares necessary equipment.
3. Position the infant properly in lying position
4. Perform hand hygiene and put on gloves.
5. Gently cleans the eyelids with a sterile cotton ball
moistened with sterile NSS from the inner to outer
canthus of each eye
6. Retract the lower eyelids using the thumb
7. Applies prescribed amount of the prescribed antibiotic
ointment to the lower conjunctival sac from the inner to
outer canthus of the eye. Gently presses on periorbital
ridges.
8. Wipes off excess medication with sterile cotton balls.
9. Do the same thing to the other eye
10. Observe and document the condition of the eyes. Note
any swelling, redness or irritation.

TOTAL

VITAMIN K ADMINISTRATION

PERFORMANCE/PROCEDURE 3 2 1 0
1. Prepare necessary equipment
2. Perform hand hygiene and put on personal protective
equipment
3. Assess the vastus lateralis for muscle mass, lesions and
deformities.
4. Prepare the vitamin K 0.5mg or 1mg (depending on
doctor’s order) in 1cc syringe
5. Select the site for injection
6. Using cotton balls soak in 70% alcohol, clean the site in
circular motion from inside to the outside.
7. Compress or hold the muscle tissue between your
fingers with your non-dominant hand.
8. At a 90-degree angle, pierce the skin straight down into
the top of the thigh.
9. Check for blood backflow by aspirating. If there are
none, administer the injection slowly.
10. Quickly remove the needle and apply a cotton ball on
the site and press firmly to avoid bleeding.
11. Discard syringe in appropriate sharps container
12. Discard supplies, remove gloves, and perform hand
 hygiene
13. Observe and document any signs of bleeding from the
injection site

TOTAL

REMARKS: _________________________________________________________________

__________________________________________________________________

EVALUATED BY: CONFORME:

_______________________________ ____________________________

CLINICAL INSTRUCTOR’S NAME AND SIGNATURE STUDENT’S NAME AND SIGNATURE