Summary Performance Evaluation Achieving

Republic of the Philippines
COLLEGE OF NURSING
Bicol University
Legazpi City
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 ACTUAL

RATING RATING
I. SAFE AND QUALITY NURSING CARE (SQC)
1. Obtains obstetrical history including parity, gravida score, LMP, EDC, AOG, BOW onset of 4
true labor.
2. Checks vital signs. 1
3. Conducts physical examination. 2
4. Performs Leopold’s maneuver. 2
5. Checks Fetal Heart Rate and Fundic height. 2
6. Monitor progress of labor/ uterine contractions as to: 1
• Frequency 1
• Duration 1
• Intensity 1
• Interval
7. Observes for the timely rupture of membrane. 1
8. Coaches mother on process of labor. 2
PERFORMS FUNCTIONS DURING ACTUAL LABOR
1. Transports clients safely while providing privacy. 1
2. Places mother in lithotomy position. 1
3. Performs perineal care using sterile technique correctly. 1
4. Performs proper hand scrub. 1
5. Wears gown and gloves according to hospital policy. 1
6. Performs Ritgen’s maneuver safely. 2
7. Coaches mother on breathing and pushing techniques. 1
8. Delivers baby and placenta carefully. 1
• Checks and manages cord recoil correctly 1
• Clamps and cuts the cord correctly 1
• Identify signs of placental separation 1
• Checks the characteristic/ completeness of the placenta
9. Assesses amount of blood loss (Normal: <500 cc) 2
10. Employs interventions to achieve and maintain a well contracted uterus to prevent/control 1
hemorrhage. 1
• Uterine massage 1
• Correct administration of oxytocin
• Cold compress
11. Assesses presence and degree of laceration. 1
12. Assists in episiorrhaphy. 1
13. Checks size, consistency and location of uterus. 1
14. Performs perineal care and applies pad correctly. 1
15. Provides emotional support to the mother throughout labor and delivery. 1
16. Evaluates patient’s condition and records pertinent data accordingly. 2
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.
• Sterile drape 1
• Sterile instruments and equipment [Forceps, scissors, bulb syringe, gauze, suture, needle 1
holder, catheter (optional)]
• Kelly pad 1
• Disinfectant 1
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 equipment. 1
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 fluids. 1
III. HEALTH EDUCATION (HE)
1. Teaches client on basic preparation during labor and deliver (can be done in the labor room) 1
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 (done post-partum 1
period.)
5. Provides discharge instructions as to feeding, bathing, administration of ordered medications, 1
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 delivery. 1
2. Reports accurately and honestly the gender, time of delivery of the baby and placenta. 2
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 the woman in labor and 1
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 delivery. 1
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 deviations. 1
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. 1
2. Maintains an organized system of filing and keeping records of the client. 1
X. COMMUNICATION (Comm)
1. Utilizes appropriately all forms of communication; verbal, non-verbal, electronic. 1
2. Inform client’s significant others of the progress of labor and delivery. 1
3. Listens attentively to clients and families queries and requests. 1
XI. COLLABORATION AND TEAMWORK (CTW)
1. Functions effectively as a team player in the delivery room/lying in. 1
2. Communicates the progress of labor/delivery to significant others. 1
3. Establishes collaborative relationship with members of the health team and family members. 1
TOTAL SCORE: 90
Certified True and Correct:

(Signature over Printed Names)
________________________________________ ___________________________________
Clinical Instructor Clinical Coordinator
License Number: _________________________ License Number: ____________________
PRC Card - Validity Date: _________________ PRC Card – Validity Date: ____________
________________________________________
DEAN __________________________________
License Number: _________________________ Academic Year Graduated
PRC Card - Validity Date: _________________
COLLEGE OF NURSING
Bicol University
Legazpi City

IMMEDIATE CARE OF THE NEWBORN COMPETENCY
NEWBORN COMPETENCIES DESIRED ACTUAL

RATING RATING
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
Immediately after delivery 2
After 5 minutes
6. Ensures proper identification of newborn (name tag: name of mother, date and time 2
of delivery, gender and name of attending physician).
7. Performs physical assessment including anthropometric measurements including 4
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 mother’s breast immediately after birth. 1
11. Applies CREDE’s prophylaxis on the eyes. 1
12. Performs cord dressing aseptically. 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 1
• Dresses cord aseptically according hospital policy
13. Administers Vitamin K (1 mg/M) into the lateral anterior thigh or vastus lateralis. 1
14. Keeps baby wrapped warmly under floor lamp or beside mother according to 1
institutional policy until discharge.
15. Records pertinent observations and nursing care done. 1
16. Reports any signs of deviation/abnormality to the pediatrician. 1
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 newborn. 1
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 equipment. 1
6. Ensures a warm and quiet environment. 1
7. Uses supplies diligently. 1
8. Ensures proper disposal of hospital waste. 1
1. Provides instructions to the mother on daily cord care and prevention of cord 2
infection.
2. Provides discharge instructions to the mother on when to expect cord to fall off or 1
to report signs of cord infection.
3. Provides information regarding newborn screening, immunization, feeding, etc. 2
4. Responds to questions of mother and relatives regarding expectations. 1

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 interventions 1
rendered.
4. Ensures that birth certificate and other civil registration forms are accomplished/ 2
filled out according to institutional policy.
5. Performs foot printing according to hospital policy. 1
1. Respects the religious, cultural and ethnic practices of the family of the newborn. 1
2. Maintains privacy and confidentiality of findings of assessments. 1
1. Updates oneself with the latest trends and developments in newborn care. 1
2. Projects a professional image of the pediatric nurse. 1
3. Accepts criticisms and recommendations. 1
4. Performs functions according to standards. 1
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 deviations. 1
1. Identifies researchable problems related to immediate care of newborn. 2
2. Utilizes findings of research studies in the immediate care of the newborn. 2
1. Documents accurately relevant data about the newborn. 1
2. Maintains an organized system of filing and record keeping. 1
1. Utilizes appropriately all forms of communication; verbal, non-verbal, electronic. 1
2. Maintains an open line of communication with the mother and other family 1
members.
3. Informs mother of relevant information about the newborn. 1
4. Listens attentively to queries and requests of mothers and family members. 1
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 team and 1
family of the newborn.
TOTAL SCORE: 75

________________________________________ ___________________________________
________________________________________
DEAN ___________________________________
COLLEGE OF NURSING
Bicol University
Legazpi City

INTRA-OPERATIVE CARE COMPETENCY
INTRA-OPERATIVE CARE COMPETENCIES DESIRED 1st 2nd 3rd AVERAGE

RATING RLE RLE RLE RATING
1. Utilizes the nursing process in the care of OR client 4
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 4
Room
c. Provides needed nursing interventions based on identified 4
needs
d. Monitors client’s responses to surgery 2
2. Promotes safety and comfort of patients inside the OR 2
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, sutures and other 2
supplies in functional arrangement
d. Hands instruments, sponges, sutures and other needed 2
materials according to surgeon’s preference
e. Performs surgical count accurately 2
4. Performs the functions of the circulating nurse 2
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 post – 2
operatively
d. Assists in skin preparation and draping of client 2
5. Administers medications and other health therapeutics 2
safely
1. Organizes work load to facilitate timely patient Care 4
2. Utilizes adequate and appropriate resources to support the 2
OR team
3. Ensures functionality of OR resources 2
4. Maintains a safe environment at the OR by observing the 2
principles of asepsis
1. Implements appropriate health education activities to client 2
based on needs assessment
1. Adheres to legal and institutional protocols regarding 2
informed consent
1. Respects the rights of the OR client 2
2. Accepts responsibility and accountability for own 2
decisions and actions as an OR nurse

1. Performs OR functions according to professional standards 4
2. Possesses positive attitude towards learning surgical and 2
OR-related knowledge and skills
1. Participates in quality improvement activities related to 2
infection control and successful OR operations
2. Identifies and reports variances in sterility and other OR 2
activities
1. Disseminates results of OR-related research findings to 2
clinical group and other members of the OR team as
appropriate
1. Maintain accurate and updated documentation of patient 2
care
1. Establishes rapport with patients, significant others and 1
members of the health team
2. Uses appropriate information mechanisms to facilitate 2
communication inside the OR and with other departments in
the hospital
1. Collaborates plan of care with other members of the health 2
team
TOTAL SCORE: 75

________________________________________ ___________________________________
________________________________________
DEAN ___________________________________

Summary Performance Evaluation Achieving

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Republic of the Philippines

SUMMARY PERFORMANCE EVALUATION ACHIEVING

Signature over Printed Name of Student: ___________________________________________

INTRAPARTAL COMPETENCIES DESIRED ACTUAL

Certified True and Correct:

SUMMARY PERFORMANCE EVALUATION ACHIEVING

Signature over Printed Name of Student: ___________________________________________

NEWBORN COMPETENCIES DESIRED ACTUAL

IV. LEGAL RESPONSIBILITIES (LR)

Certified True and Correct:

SUMMARY PERFORMANCE EVALUATION ACHIEVING

Signature over Printed Name of Student: ___________________________________________

INTRA-OPERATIVE CARE COMPETENCIES DESIRED 1st 2nd 3rd AVERAGE

VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)

Certified True and Correct:

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