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Republic of the Philippines Samar State University COLLEGE OF NURSING Catbalogan City Telefax: (055)543-83-94/Tel. No.

(055)251-21-39 Website: www.ssu.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 I. SAFE AND QUALITY NURSING CARE (SQC) 1. Obtains obstetrical history including parity, gravida score, LMP, EDC, AOG, BOW onset of true labor. 2. Checks vital signs. 3. Conducts physical examination. 4. Performs Leopolds maneuver. 5. Checks Fetal Heart Rate and Fundic height. 6. Monitor progress of labor/ uterine contractions as to: Frequency Duration Intensity Interval 7. Observes for the timely rupture of membrane. 8. Coaches mother on process of labor. PERFORMS FUNCTIONS DURING ACTUAL LABOR 1. Transports 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 Ritgens maneuver safely. 7. Coaches mother on breathing and pushing techniques. 8. 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 9. Assesses amount of blood loss (Normal: <500 cc) 10. Employs interventions to achieve and maintain a well contracted uterus to prevent/control hemorrhage. Uterine massage Correct administration of oxytocin 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 patients condition and records pertinent data accordingly. DESIRED ACTUAL RATING RATING 4 1 2 2 2 1 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 2 1 1 1

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17. Prepares patient for transfer to recovery room/ ward. 1 II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE) 1. Prepares room, instruments and equipment needed. 1 Sterile drape 1 Sterile instruments and equipment [Forceps, scissors, bulb syringe, gauze, suture, needle holder, catheter (optional)] 1 Kelly pad 1 Disinfectant 2. Performs sterilization procedure. 1 3. Maintains adequacy of supplies as the delivery progresses. 1 4. Maintains orderliness of the sterile table. 1 5. Observes precautionary measures related to use of electrical 1 equipment. 6. Ensures a quiet environment. 1 7. Uses supplies diligently. 1 8. Performs after care of the materials and equipments used. 1 9. Ensures proper disposal of hospital waste including blood and other 1 fluids. III. HEALTH EDUCATION (HE) 1. Teaches client on basic preparation during labor and deliver (can be 1 done in the labor room) 2. Coaches client on breathing/ bearing down technique. 2 3. Demonstrates proper latch-on breast feeding technique 1 (done post-partum period). 4. Gives instructions to parents regarding infant care before discharge 1 (done post-partum period.) 5. Provides discharge instructions as to feeding, bathing, administration 1 of ordered medications, appointment dates for post natal and well baby check up (done post-partum period.) 6. Responds to questions of clients and relatives regarding expectations. 1 IV. LEGAL RESPONSIBILITIES (LR) 1. Secures informed consent in all procedures related to labor and 1 delivery. 2. Reports accurately and honestly the gender, time of delivery of the 2 baby and placenta. 3. Ensures proper identification of the mother and newborn. 2 4. Documents all pertinent data correctly and completely. 1 V. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Respects the religious, cultural and ethnic practices of the family of 1 the woman in labor and delivery. 2. Promotes emotional security by supporting needs. 1 3. Ensures privacy and confidentiality. 1 VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. Updates oneself with the latest trends and development in labor and 1 delivery. 2. Projects a professional image of a delivery room nurse. 1 3. Accepts criticisms and recommendations. 1 4. Performs functions according to standards. 1 VII. QUALITY IMPROVEMENT (QI) (preferably done during post conferences) 1. Identifies deviation of practice from the standards. 1 2. Participates in audit practices in the delivery room/lying in. 1 3. Recommends corrective and preventive measures for the identified 1 deviations. VIII. RESEARCH (R) (preferably done during post conferences) 1. Identifies researchable problems related to labor and delivery. 2 2. Utilize findings of research studies in intra-partal care. 2

IX. RECORDS MANAGEMENT (RM) 1. Documents accurately relevant data about client. 2. Maintains an organized system of filing and keeping records of the client. X. COMMUNICATION (Comm) 1. Utilizes appropriately all forms of communication; verbal, nonverbal, electronic. 2. Inform clients 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 labor/delivery to significant others. 3. Establishes collaborative relationship with members of the health team and family members. TOTAL SCORE: Certified True and Correct: (Signature over Printed Names)

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__________________________________ Clinical Instructor License Number: ___________________ PRC Card - Validity Date: ____________

____________________________________ Clinical Coordinator License Number: _____________________ PRC Card Validity Date: _____________

_________________________________ DEAN License Number: __________________ PRC Card - Validity Date: ___________

___________________________________ Academic Year Graduated

Republic of the Philippines Samar State University COLLEGE OF NURSING Catbalogan City Telefax: (055)543-83-94/Tel. No. (055)251-21-39 Website: www.ssu.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 DESIRED ACTUAL RATING RATING

I. SAFE AND QUALITY NURSING CARE (SQC) 1. Establishes and maintains patent airway. 3 2. Puts the newborn in Trendelenburg position. 1 3. Suctions mouth and nose of the newborn gently. 2 4. Dries newborn and wraps warmly. 1 Places under droplight as needed 5. Performs and interprets APGAR scoring correctly. 2 2 Immediately after delivery After 5 minutes 6. Ensures proper identification of newborn (name tag: name of 2 mother, date and time of delivery, gender and name of attending physician). 7. Performs physical assessment including anthropometric 4 measurements including weight, height, head, chest, abdominal circumference. 8. Takes vital signs (temperature per rectum to check patency) 1 9. Gives oil/ water and soap bath according to institutional policy. 1 10. Latches newborn to the mothers breast immediately after birth. 1 11. Applies CREDEs prophylaxis on the eyes. 1 12. Performs cord dressing aseptically. 1 1 Disinfects area properly according to hospital policy 1 Clamps and cuts cord 1 inch from the abdomen 1 Checks for the presence of 2 arteries and 1 vein Dresses cord aseptically according hospital policy 13. Administers Vitamin K (1 mg/M) into the lateral anterior thigh or 1 vastus lateralis. 14. Keeps baby wrapped warmly under floor lamp or beside mother 1 according to institutional policy until discharge. 15. Records pertinent observations and nursing care done. 1 16. Reports any signs of deviation/abnormality to the pediatrician. 1 II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE) 1. Prepares instrument and equipment needed 4 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 1 newborn. 3. Maintain adequacy of supplies as newborn care is rendered 1 4. Maintains orderliness of the working area. 1 5. Observes precautionary measures related to use of electrical 1 equipment. 6. Ensures a warm and quiet environment. 1

7. Uses supplies diligently. 1 8. Ensures proper disposal of hospital waste. 1 III. HEALTH EDUCATION (HE) 1. Provides instructions to the mother on daily cord care and 2 prevention of cord infection. 2. Provides discharge instructions to the mother on when to expect 1 cord to fall off or to report signs of cord infection. 3. Provides information regarding newborn screening, immunization, 2 feeding, etc. 4. Responds to questions of mother and relatives regarding 1 expectations. IV. LEGAL RESPONSIBILITIES (LR) 1. Identifies newborn by comparing ID band with data in the chart. 2 2. Documents all pertinent data correctly and completely. 1 3. Reports accurately any deviations/abnormal findings and nursing 1 interventions rendered. 4. Ensures that birth certificate and other civil registration forms are 2 accomplished/ filled out according to institutional policy. 5. Performs foot printing according to hospital policy. 1 V. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Respects the religious, cultural and ethnic practices of the family of 1 the newborn. 2. Maintains privacy and confidentiality of findings of assessments. 1 VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. Updates oneself with the latest trends and developments in newborn 1 care. 2. Projects a professional image of the pediatric nurse. 1 3. Accepts criticisms and recommendations. 1 4. Performs functions according to standards. 1 VII. QUALITY IMPROVEMENT (QI) (preferably done during post conferences) 1. Identifies deviation of practice from the standards. 1 2. Participates in audit practices in the delivery room/lying in. 1 3. Recommends corrective and preventive measures for the identified 1 deviations. VIII. RESEARCH (R) (preferably done during post conferences) 1. Identifies researchable problems related to immediate care of 2 newborn. 2. Utilizes findings of research studies in the immediate care of the 2 newborn. IX. RECORDS MANAGEMENT (RM) 1. Documents accurately relevant data about the newborn. 1 2. Maintains an organized system of filing and record keeping. 1 X. COMMUNICATION (Comm) 1. Utilizes appropriately all forms of communication; verbal, non1 verbal, electronic. 2. Maintains an open line of communication with the mother and other 1 family members. 3. Informs mother of relevant information about the newborn. 1 4. Listens attentively to queries and requests of mothers and family 1 members. XI. COLLABORATION AND TEAMWORK (CTW) 1. Functions effectively as a team player in the nursery. 1 2. Communicates findings of assessment to all concerned. 1 3. Establishes a collaborative relationship with members of the health 1 team and family of the newborn. TOTAL SCORE: 75

Certified True and Correct: (Signature over Printed Names)

__________________________________ Clinical Instructor License Number: ___________________ PRC Card - Validity Date: ____________

____________________________________ Clinical Coordinator License Number: _____________________ PRC Card Validity Date: _____________

_________________________________ DEAN License Number: __________________ PRC Card - Validity Date: ___________

___________________________________ Academic Year Graduated

Republic of the Philippines Samar State University COLLEGE OF NURSING Catbalogan City Telefax: (055)543-83-94/Tel. No. (055)251-21-39 Website: www.ssu.edu.ph 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: ___________________________________________ INTRA-OPERATIVE CARE COMPETENCIES DESIRED 1st 2nd 3rd AVERAGE RATING RLE RLE RLE RATING

I. SAFE AND QUALITY NURSING CARE (SQC) 1. Utilizes the nursing process in the care of 4 OR client a. Obtains comprehensive clients information by checking complete accomplishment of the preoperative checklist/clients chart b. Identifies priority needs of the client at the 4 Operating Room c. Provides needed nursing interventions based 4 on identified needs d. Monitors clients responses to surgery 2 2. Promotes safety and comfort of patients 2 inside the OR 3. Performs the functions of the scrub nurse 4 a. Performs surgical scrub correctly b. Wears sterile gowns and gloves aseptically 2 c. Prepares surgical instruments, sponges, 2 sutures and other supplies in functional arrangement d. Hands instruments, sponges, sutures and 2 other needed materials according to surgeons preference e. Performs surgical count accurately 2 4. Performs the functions of the circulating 2 nurse a. Anticipates the needs of the surgical team b. Sets up the OR room and needed equipment 2 c. Receives client for surgery / endorses client 2 post operatively d. Assists in skin preparation and draping of 2 client 5. Administers medications and other health 2 therapeutics safely II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE) 1. Organizes work load to facilitate timely 4 patient Care 2. Utilizes adequate and appropriate resources 2 to support the OR team 3. Ensures functionality of OR resources 2 4. Maintains a safe environment at the OR by 2 observing the principles of asepsis

III. HEALTH EDUCATION (HE) 1. Implements appropriate health education 2 activities to client based on needs assessment IV. LEGAL RESPONSIBILITIES (LR) 1. Adheres to legal and institutional protocols 2 regarding informed consent V. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Respects the rights of the OR client 2 2. Accepts responsibility and accountability 2 for own decisions and actions as an OR nurse VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. Performs OR functions according to 4 professional standards 2. Possesses positive attitude towards learning 2 surgical and OR-related knowledge and skills VII. QUALITY IMPROVEMENT (QI) (preferably done during post conferences) 1. Participates in quality improvement activities 2 related to infection control and successful OR operations 2. Identifies and reports variances in sterility 2 and other OR activities VIII. RESEARCH (R) (preferably done during post conferences) 1. Disseminates results of OR-related research 2 findings to clinical group and other members of the OR team as appropriate IX. RECORDS MANAGEMENT (RM) 1. Maintain accurate and updated 2 documentation of patient care X. COMMUNICATION (Comm) 1. Establishes rapport with patients, significant 1 others and members of the health team 2. Uses appropriate information mechanisms to 2 facilitate communication inside the OR and with other departments in the hospital XI. COLLABORATION AND TEAMWORK (CTW) 1. Collaborates plan of care with other 2 members of the health team TOTAL SCORE: 75

Certified True and Correct: (Signature over Printed Names)

__________________________________ Clinical Instructor License Number: ___________________ PRC Card - Validity Date: ____________

____________________________________ Clinical Coordinator License Number: _____________________ PRC Card Validity Date: _____________

_________________________________ DEAN License Number: __________________ PRC Card - Validity Date: ___________

___________________________________ Academic Year Graduated