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University of San Jose-Recoletos COLLEGE OF NURSING Corner P. Lopez St. and Magallanes St.

, Cebu City Philippines 6000 Phone: 032 2537900 loc 543; Fax: 032 2541720; www.usjr.edu.ph SUMMARY PERFORMANCE EVALUATION ACHIEVING INTRA-PARTAL CARE COMPETENCY In Accordance with PRC Board of Nursing Memorandum No.01 Series 2009 Signature Over Printed Name of Student: _________________________________________ INTRAPARTAL COMPETENCIES DESIRED RATING ACTUAL RATING

SAFE AND QUALITY NURSING CARE (SQC) 1. Obtains obstetrical history including parity, gravid score, LMP, EDC, AOG, BOW onset of true labor. 2. Checks vital signs. 3. Conducts physical examination. 4. Performs leopold s maneuver. 5. Checks fetal heart rate and fundic height. 6. Monitor progress of labor/uterine contractions as to: y Frequency y Duration y Intensity y Interval 7. Observes for the timely rupture of membrane. 8. Coaches mother on process of labor. PERFORMS FUNSTIONS DURING ACTUAL LABOR 1. Transport clients safely while providing privacy. 2. Places mother in lithotomy position. 3. Performs perineal care using sterile technique correctly. 4. Performs proper hand scrub. 5. Wears gown and gloves according to hospital policy. 6. Performs Ritgen s maneuver safely. 7. Coaches mother on breathing and pushing technique. 8. Delivers baby and placenta carefully. y Checks and manages cord recoil correctly. y Clamps and cuts the cord correctly. y Identify signs of placental separation. y Checks the characteristic/completeness of the placenta. 9. Assesses amount of blood loss (Normal:<500cc) 10. Employs interventions to achieve and maintain a well contracted uterus to prevent/control hemorrhage. y Uterine massage y Correct administration of oxytocin y Cold compress 11. Assesses presence and degree of laceration. 12. Assists in episiorrhaphy. 13. Checks size, consistency and location of uterus. 14. Performs perineal care and applies pad correctly. 15. Provides emotional support to the mother throughout labor and delivery. 16. Evaluates patient s condition and records pertinent data accordingly. 17. Prepares patient for transfer to recovery room/ward. II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE) 1. Prepare room, instruments and equipment needed. y Sterile drape y Sterile instruments and equipment (Forceps, scissors, bulb syringe, gauze, needle holder, catheter (optional) y Kelly pad y Disinfectant 2. Performs sterilization procedure. 3. Maintains adequacy of supplies as the delivery progresses. 4. Maintains orderliness of the sterile table. 5. Observes precautionary measures related to use of electrical equipment. 6. Ensures a quite environment. 7. Uses supplies diligently. 8. Performs after care of the materials and equipments used. 9. Ensures proper disposal of hospital waste including blood and other fluids. III. HEALTH EDUCATION (HE) 1. Teaches client on basic preparation during labor and delivery (can be done in the labor room) 2. Coaches client on breathing/bearing down technique. 3. Demonstrates proper latch-on breast feeding technique (done postpartum period) 4. Gives instructions to parents regarding infant care before discharge (done post-partum period) 5. Provides discharge instructions as to feeding, bathing, administration of ordered medications, appointment dates for post natal and well baby check up (done post partum partum) 6. Responds to questions of clients and relatives regarding expectations. IV. LEGAL RESPONSIBILITIES (LR) 1. Secures informed consent in all procedures related to labor and delivery. 2. Reports accurately and honestly the gender, time of delivery of the baby and the placenta. 3. Ensures proper identification of the mother and newborn. 4. Documents all pertinent data correctly and completely. V. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Respects the religious, cultural and ethnic practices of the family of the woman in labor and delivery. 2. Promotes emotional security by supporting needs. 3. Ensures privacy and confidentiality. VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. Updates onself with the latest trends and development in labor and delivery. 2. Projects a professional image of a delivery room nurse. 3. Accepts criticisms and recommendation. 4. Performs functions according to standards. VII. QUALITY IMPROVEMENT (QI) (preferably done during post conferences) 1. Identifies deviation of practice from the standards. 2. Participates in audit practices in the delivery room/lying in. 3. Recommends corrective and preventive measures for the identified deviations. VIII. RESEARCH (R) (preferably done during post conferences) 1. Identifies reseacheable problems related to labor and delivery. 2. Utilize findings of research studies in intra-partal care. IX. RECORDS MANAGEMENT (RM) 1. Documents accurately relevant data about the client. 2. Maintains an organized system of filing and keeping records of the client. X. COMMUNICATION (C) 1. Utilizes appropriately all forms of communication; verbal, non-verbal, electronic. 2. Inform client s significant others of the progress of labor and delivery. 3. Listens attentively to clients and families queries and requests. XI. COLLABORATION AND TEAMWORK (CTW) 1. Functions effectively as a team player in the delivery room/lying in. 2. Communicates the progress of the labor/delivery to significant others. 3. Establishes collaborative relationship with members of the health team and family members. TOTAL SCORE
When Graded RLE s 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 _____ 2nd Sem _____ Summer _____ __________ Signature: ________________ Validity: _________________ 1st Sem _____ 2nd Sem _____ Summer _____ __________ Signature: ________________ Validity: _________________ 1st Sem _____ 2nd Sem _____ Summer _____ __________ Signature: ________________ Validity: _________________

I.

4 1 2 2 2 1 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 2 1

1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 90

Mr. Janus S. Fuertes, RN, MAN__ RLE Coordinator License No: 0346339 Validity: November 1, 2012 Academic Year Graduated: _____________

Verified True and Correct:

Licence No:

0186407

Dr. Aurora Q. Pestao _____ Dean Validity: April 23, 2014

University of San Jose-Recoletos COLLEGE OF NURSING Corner P. Lopez St. and Magallanes St., Cebu City Philippines 6000 Phone: 032 2537900 loc 543; Fax: 032 2541720; www.usjr.edu.ph 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: _________________________________________ NEWBORN COMPETENCIES SAFE AND QUALITY NURSING CARE (SQC) Establishes and maintains patent airway. Puts the newborn in Trendelenburg position. Suctions mouth and nose of the newborn gently. Dries newborn and wraps warmly. y Places under droplight as needed. 5. Performs and interprets APGAR scoring correctly. y Immediately after delivery. y After 5 minutes 6. Ensures proper identification of newborn (name tag: name of mother, date and time of delivery, gender and name of attending physician.) 7. Performs physical assessment including anthropometric measurements including weight, height, head, chest, abdominal circumference. 8. Takes vital signs (temperature per rectum to check patency) 9. Gives oil/water and soap bath according to institutional policy. 10. Latches newborn tot he mother s breast immediately after birth. 11. Applies CREDE s prophylaxis on the eyes. 12. Performs cord dressing aseptically. y Disinfects area properly according to hospital policy. y Clamps and cuts cord 1 inch from the abdomen. y Checks for the presence of 2 arteries and 1 vein. y Dresses cord aseptically according to hospital policy. 13. Administers vitamin K (1mg/M) into the lateral anterior this or vastus lateralis. 14. Keeps baby wrapped warmly under floor lamp or beside mother according to institutional policy until discharge. 15. Records pertinent observations and nursing care done. 16. Reports any signs of deviation/abnormality to the paediatrician. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE) 1. Prepares instrument and equipment needed. y Suction bulb, cord clamp, gauze, cotton balls, disinfectant, blanket, droplight, vitamin K, antimicrobial ophthalmic ointment. 2. Ensures use of sterile equipment during immediate care of the newborn. 3. Maintain adequacy of supplies as newborn care is rendered. 4. Maintains orderliness of the working area. 5. Observes precautionary measures related to use of electrical equipment. 6. Ensures a warm and quite environment. 7. Uses supplies diligently. 8. Ensures proper disposal of hospital waste. HEALTH EDUCATION (HE) 1. Provides instructions to the mother on daily cord care and prevention of cord infection. 2. Provides discharge instructions to the mother on when to expect cord to fall or to report signs of infection. 3. Provides information regarding newborn screening, immunization, feeding, etc. 4. Responds to questions of mother and relatives regarding expections. LEGAL RESPONSIBILITIES (LR) 1. Identifies newborn by comparing ID band with data in the chart. 2. Documents all pertinent data correctly and completely. 3. Reports accurately any deviations/abnormal findings and nursing interventions rendered. 4. Ensures that birth certificate and other civil registration forms are accomplished filled out according to institutional policy. 5. Performs foot printing according to hospital policy. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Respects the religious, cultural and ethnic practices of the family of the newborn. 2. Maintains privacy and confidentially of findings of assessments. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. Updates oneself with the latest trends and developments in newborn care. 2. Projects a professional image of the pediatric nurse. 3. Accepts criticisms and recommendations. 4. Performs functions according to standards. QUALITY IMPROVEMENT (QI) 1. Identifies deviation of practice from the standards. 2. Participates (whenever possible) in audit practices in the nursery unit. 3. Recommends corrective and preventive measures for the identified deviations. RESEARCH (R) 1. Identifies researcheable problems related to immediate care of the newborn. 2. Utilizes findings of research studies in the immediate care of the newborn. RECORDS MANAGEMENT (RM) 1. Documents accurately relevant data about the newborn. 2. Maintains an organized system of filing and record keeping. COMMUNICATION (Comm) 1. Utilizes appropriately all forms of communication; verbal, non-verbal, electronic. 2. Maintains an open line of communication with the mother and other family members. 3. Informs mother of relevant information about the newborn. 4. Listens attentively to queries and requests of mothers and family members. COLLABORATION AND TEAMWORK (CTM) 1. Functions effectively as a team player in the nursery. 2. Communicates findings as assessment to all concerned. 3. Establishes a collaborative relationship with members of the health team and family of the newborn. TOTAL SCORE I. 1. 2. 3. 4. DESIRED RATING ACTUAL RATING

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2 2 2 4 1 1 1 1 1 1 1 1 1 1 1 1 4 1 1 1 1 1 1 1 2 1 2 1 2 1 1 2 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 75

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When Graded RLE s 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: ____________________ 1 Sem _____ 2 Sem _____ Signature: ________________ Validity: _________________ st nd 1 Sem _____ 2 Sem _____ Signature: ________________ Validity: _________________ st nd 1 Sem _____ 2 Sem _____ Signature: ________________ Validity: _________________
st nd

Summer _____

Summer _____

Summer _____

Verified True and Correct: Mr. Janus S. Fuertes, RN, MAN RLE Coordinator License No: 0346339 Validity: November 1, 2012 Academic Year Graduated: _____________

Dr. Aurora Q. Pestao Dean Licence No: 0186407 Validity: April 23, 2014

University of San Jose-Recoletos COLLEGE OF NURSING Corner P. Lopez St. and Magallanes St., Cebu City Philippines 6000 Phone: 032 2537900 loc 543; Fax: 032 2541720; www.usjr.edu.ph

SUMMARY PERFORMANCE EVALUATION ACHIEVING INTRAOPERATIVE CARE COMPETENCY In Accordance with PRC Board of Nursing Memorandum No.01 Series 2009

Signature Over Printed Name of Student: _________________________________________ INTRAOPERATIVE CARE COMPETENCIES I. SAFE AND QUALITY NURSING CARE (SQC) 1. Utilizes the nursing process in the care of OR client: a. Obtains comprehensive client s information by checking complete accomplishment of the preoperative checklist/client s chart. b. Identifies priority needs of the client at the Operating Room. c. Provides needed nursing interventions based on identified needs. d. Monitors client s responses to surgery. 2. Promotes safety and comfort of patients inside the OR. 3. Performs the functions of the scrub nurse: a. Performs surgical scrub correctly. b. Wears sterile gowns and gloves aseptically. c. Prepares surgical instruments, sponges, sutures and other supplies in functional arrangement. d. Hands instruments, sponges, sutures and other needed materials according to surgeon s preference. e. Performs surgical count accurately. 4. 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 postoperatively. d. Assists in skin preparation and draping of client. 5. Administers medications and other health therapeutics safely. II. MANAGEMENT OF RESOURCES AND ENVIRONMENT (MRE) 1. Organizes work load to facilitate timely patient care. 2. Utilizes adequate and appropriate resources to support the OR team. 3. Ensures functionality of OR resources. 4. Maintains a safe environment at the OR by observing the principles of asepsis. III. HEALTH EDUCATION (HE) 1. Implements appropriate health education activities to client based on needs assessment. IV. LEGAL RESPONSIBILITIES 1. Adheres to legal and institutional protocols regarding informed consent. V. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Respects the rights of the OR client. 2. Accepts responsibility and accountability for own decisions and actions as an OR nurse. VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. Performs Or functions according to professional standards. 2. Possesses positive attitude towards learning surgical and Or-related knowledge and skills. VII. QUALITY IMPROVEMENT (QI) 1. Participates in quality improvement activities related to infection control and successful OR operations. 2. Identifies and reports variances in sterility and other OR activities. VIII. RESEARCH (R) 1. Disseminates results of Or-related research findings to clinical group and other members of the OR team as appropriate. IX. COMMUNICATION (Comm) 1. Establishes rapport with patients, significant others and members of the health team. 2. Uses appropriate information mechanisms to facilitate communication inside the OR and with other departments in the hospital. X. COLLABORATION AND TEAM WORK (CTM) 1. Collaborates plan of care with other members of the health team TOTAL SCORE When Graded RLE s 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: ____________________ 1 Sem _____ 2 Sem _____ Signature: ________________ Validity: _________________ st nd 1 Sem _____ 2 Sem _____ Signature: ________________ Validity: _________________ st nd 1 Sem _____ 2 Sem _____ Signature: ________________ Validity: _________________
st nd

DESIRED RATING

1 RLE

ST

2 RLE

ND

3 RLE

RD

AVERAGE RATING

4 4 4 2 2 4 2 2 2 2 2 2 2 2 2 4 2 2 2 2 2 2 2 4 2 2 2 2

1 2

2 75

Summer _____

Summer _____

Summer _____

Verified True and Correct: Mr. Janus S. Fuertes, RN, MAN RLE Coordinator License No: 0346339 Validity: November 1, 2012 Academic Year Graduated: _____________

Dr. Aurora Q. Pestao Dean Licence No: 0186407 Validity: April 23, 2014