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Name:______________________________________ Year: _______________________

Date of Assignment:_________________________ Final Rating:_________________

I: Knowledge and Understanding ----------------------------------------------------------------------- 35%

At the end of 4 weeks, the student is expected to:
1. Explain the important scientific principles in the nursing care plan
Pre-operative and post operative patients in O.R. --------------------------------------- 5%
2. Explain intelligently the Pathophysiology of the disease
condition of the patients ----------------------------------------------------------------------- 10%
3. Identify correctly signs and symptoms of impending complications
referable to the disease condition of the pre-operative patients ----------------- 5%
4. State the action, contraindications, usual dosage, and side effects if
Anesthetic agents and other drugs are used by the patient ------------------------------ 5%
5. State the correct surgical aseptic techniques in the performance
of nursing procedure in the O.R. ------------------------------------------------------------ 10%

II: Skills and Activities --------------------------------------------------------------------------------- 40%

1. Implements planned nursing care inside the O.R. by
a. preparing the patient physical and emotional -------------------------------------- 5%
b. preparing the necessary instruments and articles needed for
the operation ---------------------------------------------------------------------- 5%
2. Perform effectively the duties and responsibilities
of the scrub nurse ------------------------------------------------------------------------------- 5%
3. Perform effectively the duties and responsibilities of the circulating
nurse ------------------------------------------------------------------------------------------ 5%
4. Carries out physician’s order accurately ----------------------------------------------- 5%
5. Writes accurate, concise and legible recording ------------------------------------ 5%
6. Communicates effectively with the operative team regarding
Patients condition in the O.R. ---------------------------------------------------------- 5%
7. Anticipates the needs of the operative team before, during
and after course of the operation ---------------------------------------------------------- 5%

III: Professional and personal Assets ------------------------------------------------ 25%

1. Attitudes, appreciation’s and interest
a. Accept nursing service responsibilities with interest
and eagerness to work and to use learning opportunities ---------------------- 5%
b. Accept constructive criticism and profit form it --------------------------- 5%
c. Establishes good relationship with the patient,
Family and other health team members --------------------------------------- 5%
d. Finishes work load and submits report on time ---------------------------- 5%

2. Personal Habits
a. Neat clean in appearance, and mindful of personal hygiene -------------------- 2%
b. Honest courteous and respectful --------------------------------------------------- 3%

Total 100%

Instructor. Head nurse remark

Student Signature

Instructor/Head nurse’s signature

Issue: 05 April 2006 Revision Code: 003