Ateneo de Zamboanga University

College of Nursing

Summary Performance Evaluation

Achieving Intraoperative Care Competency
In accordance with PRC Board of Nursing Memorandum No. 01 Series 2009

OR Scrub Case (Major)

Name of Student: LADORES, CARMELA ISABEL SAAVEDRA

Legend: (Rating Criteria)

4 Competent (Students performs efficiently in an effective and efficient manner)
3 Progress Acceptable (performance is usually effective and efficient but not always)
2 Needs Improvement (progress in performance is too slow to judge satisfactorily; task
Performance is not most of the time)
1 Progress Unacceptable (no progress in performance has been demonstrated, and or performance
Is consistently ineffective and inefficient)

Name of Patient (Initials only) / Clinical Instructors Signature:

Case No.1 ___________________________________

Case No.2 ___________________________________
Case No.3 ___________________________________
1st 2nd 3rd Average
INTRA-OPERATIVE CARE COMPETENCIES Case Case Case Rating
I. Safe and Quality Nursing Care
1. Conducts pre-operative visit of patient for surgery
(preferably the day before/hours before surgery)
2. Receives endorsement of patient for surgery from ward nurse.
3. Assess client for surgery.
4. Checks/validates the competencies and accuracy of the pre-operative
checklist.
5. Observes universal precautions in handling body fluids.
6. Observes surgical asepsis in her role as a circulating nurse.
7. Transfers patient to/from the stretcher to OR table/bed.
8. Assists in proper positioning and strapping patient on the OR table.
9. Protects the client from electrical, thermal and/chemical injuries
- Proper placement and monitoring of cautery pad/ground
- Appropriate blending of temperature of saline for lavage
- Rinsing of instruments/tubing soaked in chemicals before serving
them to sterile surgical team.
10. Provides needed blankets and sheets to prevent hypothermia/ provide
privacy to the patient.
Performs various roles and functions of a scrub nurse
11. Performs surgical scrub correctly
12. Dons gowns and gloves aseptically
13. Sets up sterile field, mayo stand and prep table.
14. Performs timely surgical count accurately with the circulator.
15. Assists surgeons with gowning/gloving.
16. Assists surgeons with draping and passes off suctions/cautery line
17. Serves correct instruments and other surgical supplies in anticipation of
the needs of the surgeon.
18. Performs aftercare of surgical instruments, needles and blades used.

19. Applies sterile dressing

 1st 2nd 3rd Average
INTRA-OPERATIVE CARE COMPETENCIES
Case Case Case Rating
20. Secures specimen and labels it properly.
Performs appropriate nursing intervention to intra-operative patients
21. Assignment: Summarizes important information about anesthesia
drugs and other common OR drugs in 4x6 index cards (to be brought
every duty day as ready reference)
22. Administers medications as ordered following all principles in drug
administration
23. Executes legal orders of the surgeon/anaesthesiologist timely and
accurately.
24. Evaluates outcomes of acre and adjust nursing interventions as
appropriate
25. Monitors patient continuously during surgery and immediate post-
operative phase
26. Presents a comprehensive case study of an assisted surgical patient.
II. Management Of Resources, Environment, And Equipment
27. Ensures availability, completeness and functionality, storage of OR
equipment and other resources.
28. Observes organization of work and proper budgeting of time and
resources.
29. Observes OR policies, procedures and protocol on infection control and
waste disposal.
30. Performs proper disinfection and sterilization.
31. Disposes hazardous and non-hazardous waste properly per agency
policy.
32. Conducts inventory of OR resources.
III. Health Education
33. Reinforces pre-operative health teaching to surgical client.
34. Provides health education based on identified learning needs of the
intra-operative/post-operative patient and his significant others.
IV. Legal Responsibilities
35. Checks and validates the completeness of the informed consent and
other legal forms.
36. Validates information documented in the endorsed chart of client for
surgery.
V. Ethico-Moral Responsibilities
37. Respect the Patients Bill of Rights.
38. Adheres to the Code of Ethics for Nurses.
VI. Personal and Professional Development
39. Accepts criticisms and recommendations.
40. Courteous and works actively with the OR staff, Clinical Instructor,
other members of the health team.
41. Prompt in reporting to RLE/duty.
42. Prompt in submitting requirements.
VII. Quality Improvement
43. Identifies deviation of practice from the standards of care of patient in
the OR.
44. Participates in ward audit in the OR.
VIII. Research
45. Utilizes and shares relevant research findings related to intraoperative
nursing.
IX. Records Management
46. Maintains legible, complete, accurate and update documentation of
patient care in the patients chart and other OR forms.
47. Submits timely, complete and accurate surgical slips/OR write-ups for
cases handled
X. Communication
48. Communicates therapeutically with patient and their significant others.
 49. Utilizes proper channels of communication
XI. Collaboration And Teamwork
50. Maintains a collaborative relationship with colleagues and other
members of the health team.
TOTAL SCORE: 200

Certified True and Correct:

CARMELA ISABEL SAAVEDRA LADORES

(Signature over Printed Name)

OR SCRUB CASE No.1 OR SCRUB CASE No. 2 OR SCRUB CASE No. 3

____________________________ _______________________________ ____________________________

Clinical Instructor Clinical Instructor Clinical Instructor

PRC License No. _____________ PRC License No. _____________ PRC License No. ______________
Valid until: __________________ Valid until: __________________ Valid until: ___________________

Noted By: ______________________________________

BS Nursing Level Coordinator

License No. _________________

Valid Until: _________________