ST. ANTHONY COLLEGE OF ROXAS CITY, INC.

College of Nursing San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 SUMMARY PERFORMANCE EVALUATION ACHIEVING INTRAPARTAL CARE COMPETENCY In Accordance with PRC Board of Nursing Memorandum No. 01, Series 2009

Signature over Printed Name of Student:

INTRAPARTAL COMPETENCIES I. 1. 2. 3. 4. 5. 6. SAFE AND QUALITY NURSING CARE (SQC) Obtains obstetrical history including parity, gravida score, LMP, EDC, AOG, BOW onset of true labor. Checks vital signs. Conducts physical examination. Performs Leopolds maneuver. Checks Fetal Heart Rate and Fundic height. Monitor progress of labor/ uterine contractions as to: Frequency Duration Intensity Interval Observes for the timely rupture of membrane. Coaches mother on process of labor. PERFORMS FUNCTIONS DURING ACTUAL LABOR Transports clients safely while providing privacy. Places mother in lithotomy position. Performs perineal care using sterile technique correctly. Performs proper hand scrub. Wears gown and gloves according to hospital policy. Performs Ritgens maneuver safely. Coaches mother on breathing and pushing techniques. Delivers baby and placenta carefully. Checks and manages cord recoil correctly Clamps and cuts the cord correctly Identify signs of placental separation Checks the characteristic/ completeness of the placenta Assesses amount of blood loss (Normal: <500 cc) Employs interventions to achieve and maintain a well contracted uterus to prevent/control hemorrhage. Uterine massage Correct administration of oxytocin Cold compress Assesses presence and degree of laceration. Assists in episiorrhaphy. Checks size, consistency and location of uterus. Performs perineal care and applies pad correctly. Provides emotional support to the mother throughout labor and delivery. Evaluates patients condition and records pertinent data accordingly. Prepares patient for transfer to recovery room/ ward. Prepares room, instruments and equipment needed. Sterile drape Sterile instruments and equipment [Forceps, scissors, bulb syringe, gauze, suture, needle holder, catheter (optional)] Kelly pad Disinfectant INTRAPARTAL COMPETENCIES 2. 3. 4. 5. 6. 7. 8. 9. III. 1. 2. 3. 4. 5. Performs sterilization procedure. Maintains adequacy of supplies as the delivery progresses. Maintains orderliness of the sterile table. Observes precautionary measures related to use of electrical equipment. Ensures a quiet environment. Uses supplies diligently. Performs after care of the materials and equipments used. Ensures proper disposal of hospital waste including blood and other fluids. HEALTH EDUCATION (HE) Teaches client on basic preparation during labor and deliver Coaches client on breathing/ bearing down technique. Demonstrates proper latch-on breast feeding technique Gives instructions to parents regarding infant care before discharge. Provides discharge instructions as to feeding, bathing, administration of ordered medications, appointment dates for post natal and well baby check up. Responds to questions of clients and relatives regarding expectations. LEGAL RESPONSIBILITIES (LR) Secures informed consent in all procedures related to labor and delivery.

DESIRED RATING 4 1 2 2 2 1 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 2

1st RLE

2nd RLE

3rd RLE

AVERAGE RATING

7. 8. 1. 2. 3. 4. 5. 6. 7. 8.

9. 10.

11. 12. 13. 14. 15. 16. 17. II. 1.

1 1 1 1 1 1 1 1 2 1

MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE) 1 1 1 1 DESIRED RATING 1 1 1 1 1 1 1 1

1st RLE

2nd RLE

3rd RLE

AVERAGE RATING

1 2 1 1 1 1

6. IV. 1.

INTRAPARTAL COMPETENCIES 2. 3. XI. 1. 2. 3. Inform clients significant others of the progress of labor and delivery. Listens attentively to clients and families queries and requests. COLLABORATION AND TEAMWORK (CTW) Functions effectively as a team player in the delivery room/lying in. Communicates the progress of labor/delivery to significant others. Establishes collaborative relationship with members of the health team and family members. TOTAL SCORE:

DESIRED RATING 1 1

1st RLE

2nd RLE

3rd RLE

AVERAGE RATING

1 1 1 90

When Graded RLEs Were Performed (Specify Academic Year and Semester) First Graded RLE Clinical Instructor Second Graded RLE Clinical Instructor Third Graded RLE Clinical Instructor : : : : : : Academic Year Name License Number: Academic Year Name License Number: Academic Year Name License Number: 1st Sem. Signature Validity: Sem. Signature Validity: Sem. Signature Validity: 2nd Sem. Summer

1st

2nd Sem.

Summer

1st

2nd Sem.

Summer

Verified True and Correct (Signature over Printed Name) Academic Year Graduated

: Clinical Coordinator :

License Number: Validity:

DEAN Signature over Printed Name

License Number: Validity Date:

ST. ANTHONY COLLEGE OF ROXAS CITY, INC. College of Nursing San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 SUMMARY PERFORMANCE EVALUATION ACHIEVING IMMEDIATE CARE OF THE NEWBORN COMPETENCY In Accordance with PRC Board of Nursing Memorandum No. 01, Series 2009

Signature over Printed Name of Student: DESIRED DESIRED RATING RATING 1 3 1st 1st RLE RLE 2nd 2nd RLE RLE 3rd 3rd RLE RLE AVERAGE AVERAGE RATING RATING

NEWBORN COMPETENCIES I. 2. 1. 2. 3. 3. 4. 4.

SAFE AND QUALITY NURSING CARE (SQC) Provides discharge instructions toairway. Establishes and maintains patent the mother on when to expect cord to fall off or to report signs of cord Puts the newborn in Trendelenburg position. infection. 1 Provides mouth and nose of thenewborn screening, 2 Suctions information regarding newborn gently. 2 immunization, feeding, etc. Dries newborn and wraps warmly. Responds to questions of mother and relatives regarding 1 1 Places under droplight as needed expectations. interprets APGAR scoring correctly. 5. Performs and IV. LEGAL RESPONSIBILITIES (LR) Immediately after delivery 2 1. Identifies newborn by comparing ID band with data in the chart. 2 2 After 5 minutes 2. Documents all pertinent data correctly and completely. 1 6. Ensures accurately any deviations/abnormal findings name of proper identification of newborn (name tag: and 3. Reports 1 mother, interventions rendered. gender and name of 2 nursing date and time of delivery, attendingthat birth certificate and other civil registration forms physician). 4. Ensures 2 7. Performs physical assessment including anthropometric are accomplished/ filled out according to institutional policy. 4 5. measurements including weight, to hospital policy. abdominal Performs foot printing according height, head, chest, 1 circumference. V. ETHICO-MORAL RESPONSIBILITIES (EMR) 8. Takes vital signs (temperature per rectum to check patency) 1 1. Respects the religious, cultural and ethnic practices of the 1 9. Gives oil/the newborn. water and soap bath according to institutional policy. 1 family of 10. Latches newborn to the mothers breastfindings of after birth. immediately 1 2. Maintains privacy and confidentiality of 1 11. Applies CREDEs prophylaxis on the eyes. 1 assessments. 12. Performs cord dressing aseptically. DEVELOPMENT (PPD) VI. PERSONAL AND PROFESSIONAL Disinfects area properly according to developments 1 1. Updates oneself with the latest trends andhospital policy in Clamps and 1 newborn care. cuts cord 1 inch from the abdomen 1 2. Projects a professional imageof 2 arteries andnurse. Checks for the presence of the pediatric 1 vein 3. Accepts criticisms aseptically according hospital policy 1 Dresses cord and recommendations. 4. Administers Vitamin K (1 mg/M) standards. 1 13. Performs functions according to into the lateral anterior thigh or 1 VII. QUALITY IMPROVEMENT (QI) vastus lateralis. 1. Keeps baby wrapped warmly from floor lamp or beside mother 1 14. Identifies deviation of practiceunder the standards. 1 2. Participates (whenever possible) in audit practices in the 1 according to institutional policy until discharge. nursery. 15. Records pertinent observations and nursing care done. 1 3. Reports any signs of deviation/abnormality to the pediatrician. 1 16. Recommends corrective and preventive measures for the 1 identified deviations. RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE) II. MANAGEMENT OF VIII. RESEARCH (R) 1. Prepares instrument and equipment needed 1. Identifies researchable clamp, gauze, cotton balls, disinfectant, 2 4 Suction bulb, cord problems related to immediate care of newborn. blanket, droplight, Vitamin K, antimicrobial ophthalmic 2. Utilizes findings of research studies in the immediate care of 2 ointment. 2. the newborn. of sterile equipment during immediate care of the Ensures use 1 IX. RECORDS MANAGEMENT (RM) newborn. 1. Documents accuratelysupplies as newborn the newborn. 1 3. Maintain adequacy of relevant data about care is rendered 1 2. Maintains an organized system of filing and record keeping. 1 4. Maintains orderliness of the working area. 1 X. COMMUNICATION (Comm) 5. Observes precautionary measures related to use of electrical 1 1. Utilizes appropriately all forms of communication; verbal, nonequipment. verbal, electronic. 6. Ensures a warm and quiet environment. 1 2. Maintains an open line of communication with the mother and 1 7. Uses supplies diligently. 1 other family members. of hospital waste. 8. Ensures proper disposal 1 3. HEALTH EDUCATION (HE) 1 III. Informs mother of relevant information about the newborn. 4. Listens attentively to queries and requests of mothers and 1 1. Provides instructions to the mother on daily cord care and 2 family members. infection. prevention of cord XI. COLLABORATION AND TEAMWORK (CTM) When Graded RLEs Were Performed (Specify Academic Year and Semester) 1. Functions effectively as a team player in the nursery. 1 First Graded RLE : Academic Year 2. Communicates findings of assessment to all concerned. 3. Establishes a collaborative relationship with members of the Clinical Instructor : Name health team and family of the newborn. Number: License TOTAL SCORE: 11 1 75
st

Sem. Signature Validity:

2nd Sem.

Summer

Second Graded RLE Clinical Instructor Third Graded RLE Clinical Instructor

: : : :

Academic Year Name License Number: Academic Year Name License Number:

1st

1st

Sem. Signature Validity: Sem. Signature Validity:

2nd Sem.

Summer

2nd Sem.

Summer

Verified True and Correct (Signature over Printed Name) Academic Year Graduated

: Clinical Coordinator :

License Number: Validity:

DEAN Signature over Printed Name

License Number: Validity Date:

ST. ANTHONY COLLEGE OF ROXAS CITY, INC. College of Nursing San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 SUMMARY PERFORMANCE EVALUATION ACHIEVING INTRA-OPERATIVE CARE COMPETENCY In Accordance with PRC Board of Nursing Memorandum No. 01, Series 2009

Signature over Printed Name of Student: DESIRED DESIRED RATING RATING 2 4 2 4 2 4 1 2 2 2 4 2 2 2 1st 1st RLE RLE 2nd 2nd RLE RLE 3rd 3rd RLE RLE AVERAGE AVERAGE RATING RATING

INTRA-OPERATIVE CARE COMPETENCIES I. 2. 1. VIII. 1. IX. 1. X. 1. 2. 2. 3. XI. 1. SAFE AND QUALITY NURSING CARE (SQC) Identifies and reports variances in sterility and other OR 1. Utilizes the nursing process in the care of OR client activities a. Obtains comprehensive clients information by RESEARCH (R) checking complete accomplishment of the Disseminates results of OR-related research findings to clinical preoperative checklist/clients chart group and other members of the OR team as appropriate b. Identifies priority needs of the client at the Operating RECORDS MANAGEMENT (RM) Maintain Room accurate and updated documentation of patient care c. Provides needed nursing interventions based on COMMUNICATION (Comm) identified needs Establishes rapport with patients, significant others and d. Monitors clients responses to surgery members of the health team Promotes safety and comfort of patients inside the OR Uses appropriate information mechanisms to facilitate Performs the functions of the scrub nurse communication inside the OR and with other departments in a. Performs surgical scrub correctly the hospital b. Wears sterile gowns and gloves aseptically COLLABORATION AND TEAMWORK (CTM) c. Prepares surgical instruments, sponges, sutures and Collaborates plan of care with other members of the health other supplies in functional arrangement team d. Hands instruments, sponges, sutures and other TOTAL SCORE needed materials according to surgeons preference e. Performs surgical count accurately Performs the functions of the circulating nurse a. Anticipates the needs of the surgical team b. Sets up the OR room and needed equipment c. Receives client for surgery / endorses client post operatively d. Assists in skin preparation and draping of client Administers medications and other health therapeutics safely MANAGEMENT OF RESOURCES AND ENVIRONMENT (MRE) Organizes work load to facilitate timely patient Care Utilizes adequate and appropriate resources to support the OR team Ensures functionality of OR resources Maintains a safe environment at the OR by observing the principles of asepsis HEALTH EDUCATION (HE) 1. Implements appropriate health education activities to client based on needs assessment LEGAL RESPONSIBILITIES (LR) 1. Adheres to legal and institutional protocols regarding informed consent ETHICO-MORAL RESPONSIBILITIES (EMR) Respects the rights of the OR client Accepts responsibility and accountability for own decisions and actions as an OR nurse PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) Performs OR functions according to professional standards Possesses positive attitude towards learning surgical and ORrelated knowledge and skills QUALITY IMPROVEMENT (QI) Participates in quality improvement activities related to infection control and successful OR operations

75
2 2 2 2 2 2 4 2 2 2

4.

5. II. 1. 2. 3. 4. III.

IV.

V. 1. 2. VI. 1. 2. VII. 1.

2 2

4 2

When Graded RLEs Were Performed (Specify Academic Year and Semester)

First Graded RLE Clinical Instructor Second Graded RLE Clinical Instructor Third Graded RLE Clinical Instructor

: : : : : :

Academic Year Name License Number: Academic Year Name License Number: Academic Year Name License Number:

1st

1st

1st

Sem. Signature Validity: Sem. Signature Validity: Sem. Signature Validity:

2nd Sem.

Summer

2nd Sem.

Summer

2nd Sem.

Summer

Verified True and Correct (Signature over Printed Name) Academic Year Graduated

: Clinical Coordinator :

License Number: Validity:

DEAN Signature over Printed Name

License Number: Validity Date: