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: JUDY ANN C. RUIZ

INTRAPARTAL COMPETENCIES DESIRED 1st 2nd 3rd AVERAGE

RATING RLE RLE RLE RATING
I. SAFE AND QUALITY NURSING CARE (SQC)
1. Obtains obstetrical history including parity, gravid score, 4
LMP, EDC, AOG, BOW onset of 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. Monitors progress of labor/uterine contractions as to:
 Frequency 1
 Duration 1
 Intensity 1
 Interval 1
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.
 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
1
placenta
9. Assess amount of blood loss (Normal: <500cc) 2
10. Employs interventions to achieve and maintain a well
contracted uterus to prevent/control hemorrhage by
 Uterine massage 1
 Correct administration of oxytocin 1
 Cold compress application 1
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 1
labor and delivery.
16. Evaluated patient’s condition and records pertinent data 2
accordingly.
17. Prepares patient for transfer to recovery room/ward. 1
II. MANAMGEMENT OF RESOURCES, ENVIRONMNET AND EQUIPMENT (MRE)
1. Prepares room. Instrumental and equipment needed.
 Sterile drape 1
 Sterile instruments and equipment [Forceps, 1
scissors, bulb, syringe, gauze, needle holder,
catheter (optional)
 Kelly pad 1
 Disinfectant
1
2. Performs sterilization procedure. 1
3. Maintains adequacy of supplies as the delivery 1
progresses
4. Maintains orderliness of the sterile table. 1
5. Observes precautionary measures related to use of 1
electrical equipment.
6. Ensures a quite environment. 1
7. Ensures supply diligently. 1
8. Performs after care of the materials and equipment 1
used.
9. Ensures p[roper disposal of hospital waste and including 1
blood and other fluids.
III. HEALTH EDUCATION
1. Teaches client on basic preparation during labor and 1
deliver.
2. Coaches client on breathing/bearing down technique. 2
3. Demonstrates proper “latch-on” breast feeding 1
technique.
4. Gives instructions to parents regarding infant care before 1
discharge.
5. Provides instructions as to feeding, bathing, 1
administration of ordered medications, appointment
dates for post natal and baby check-up.
6. Responds to questions of clients and relatives regarding 1
expectations.
IV. LEGAL RESPONSIBILITIES (LR)
1. Ensures informed consent on all procedures related to 1
labor and delivery.
2. Reports accurately and honestly the gender, time of 2
delivery of the baby and placenta
3. Ensures proper identification of the mother and 2
newborn
4. Documents all pertinent data correctly and completely. 1
V. ETHICO-MORAL RESPONSIBILITIES (EMR)
1. Respects the religious, cultural and ethnic practices of 1
the family of 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 1
in labor and 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)
1. Identifies deviation of practice from the standards 1
 2. Participates in audit practices in the delivery room/lying 1
in
3. Recommends corrective and preventive measures for 1
the identified deviations.
VIII.RESEARCH (R)(preferably done during post conference
1. Identifies researchable problems related to labor and 1
delivery
2. Utilize findings of research studies in intra-partal care 1
IX.RECORDS MANAGEMENT (RM)
1. Documents accurately relevant data about client 1
2. Maintains an organized system of filing and keeping 1
records of client
X.COMMUNITCATION (comm.)
1. Utilizes appropriately all forms of communication: 1
verbal, non-verbal, electronic
2. Informs client’s significant others of the progress of labor 1
and delivery
3. Listens attentively to clients and families queries and 1
requests
XI.COLLABORATION AND TEAMWORK (CTW)
1. Functions effectively as a team player in the delivery 1
room/lying in
2. Communicates the progress of labor/delivery to 1
significant others.
3. Establishes collaborative relationship with members of 1
the health team and family members.
TOTAL SCORE : 88

When Graded RLE’s were performed (Specify Academic Year and Semester):

First Graded RLE : Academic Year 1st Sem. 2nd Sem. Summer
Clinical Instructor : Name Signature
License Number: Validity :
First Graded RLE : Academic Year 1st Sem. 2nd Sem. Summer
Clinical Instructor : Name Signature
License Number: Validity :
Third Graded RLE : Academic Year 1st Sem. 2nd Sem. Summer
Clinical Instructor : Name Signature
License Number: Validity :

Verified True and Correct: License Number:

(Signature over Printed Name) Clinical Coordinator
 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: JUDY ANN C. RUIZ

NEWBORN COMPETENCIES DESIRED 1st 2nd 3rd AVERAGE

RATING RLE RLE RLE RATING
I. SAFE AND QUALITY NURSING CARE (SQC)
1. Establishes and maintains patent airway. 3
2. Performs and interprets APGAR scoring correctly.
Immediately after delivery 2
After 5 minutes 2
3. Establishes skin to skin contact between mother and 1
newborn
4. Performs properly timed cord clamping and cutting 1
5. Latches newborn to the mother’s breast immediately 1
after birth.
6. Dries newborn and wraps warmly.
Places under droplight. 1
7. Ensures proper identification of newborn (name tag:
name of mother, date and time of delivery, gender and 2
name of attending physician).
8. Performs physical assessment including anthropometric
measurements including weight, height, head, chest, 4
abdominal circumference.
9. Takes vital signs (temperature per rectum to check 1
patency).
10. Applies CREDE’s prophylaxis on the eyes. 1
11. Administers Vitamin K (1mg/IM) into the lateral anterior 1
thigh or vastuslateralis.
12. Keeps baby wrapped warmly under floor lamp or beside 1
mother according to institutional policy until discharge.
13. Records pertinent observations and nursing care done. 1
14. Report any signs of deviation/abnormality to the 1
pediatrician.
II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE)
1. Prepares instruments and equipment as 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 1
of the newborn
3. Maintains adequacy of supplies as newborn care is 1
rendered.
4. Maintains orderliness of the working area. 1
5. Observes precautionary measures related to use of 1
electrical 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 prevention of cord infection. 2
2. Provides discharge instruction to the mother on when to 1
expect cord to fall off or to report signs of cord infection.
IV. LEGAL RESPONSIBILITIES (LR)
1. Identifies newborn by comparing ID band with data in 2
the chart.
2. Documents all pertinent data correctly and completely. 1
3. Reports accurately any deviations/abnormal findings 1
and nursing interventions rendered.
V. ETHICO-MORAL RESPONSIBILITIES (EMR)
1. Respects the religious, cultural and ethnic practices of 1
the family of the newborn.
2. Maintains privacy and confidentiality of findings of 1
assessments.
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
1. Updates oneself with the latest trends and development 1
in newborn care.
2. Projects a professional image of a pediatric nurse. 1
3. Accepts criticisms and recommendations. 1
4. Performs functions according to standards. 1
VII. QUALITY IMPROVEMENT (QI)
1. *Identifies researchable problems related to immediate 1
care of newborn.
2. *Participates in audit practices in the nursery 1
3. *Recommends corrective and preventive measures for 1
the identified deviations.
VIII.RESEARCH (R)
1. *Identifies researchable problems related immediate 1
care of newborn.
2. *Utilize findings of research studies in immediate care of 1
the newborn.
IX.RECORDS MANAGEMENT (RM)
1. Documents accurately relevant data about newborn. 1
2. Maintains an organized system of filing and record 1
keeping
X.COMMUNICATION (comm.)
1. Utilizes appropriately all forms of communication: 1
verbal, non-verbal, electronic
2. Maintains and open line of communication with the 1
mother and other family members.
3. Informs mother of relevant information about the 1
newborn.
4. Listens attentively to queries and requests of mother and 1
family 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 collaborative relationship with members of 1
the health team and family of the newborn.
TOTAL SCORE :
When Graded RLE’s were performed (Specify Academic Year and Semester):

First Graded RLE : Academic Year 1st Sem. 2nd Sem. Summer
Clinical Instructor : Name Signature
License Number: Validity :
Second Graded RLE : Academic Year 1st Sem. 2nd Sem. Summer
Clinical Instructor : Name Signature
License Number: Validity :
Third Graded RLE : Academic Year 1st Sem. 2nd Sem. Summer
Clinical Instructor : Name Signature
License Number: Validity :

Verified True and Correct: License Number:

(Signature over Printed Name) Clinical Coordinator

Note: Opportunity of student to perform items with asterisk (*) is limited since clinical exposure is governed
by hospitals’ policies. In the event that student is given the chance to perform these tasks, a grade is given,
otherwise these items are not included in the determination of grades.

SUMMARY PERFORMANCE EVALUATION ACHIEVING

 ACHIEVING INTRA-OPERATIVE CARE COMPETENCY
In Accordance with PRC Board of Nursing Memorandum No. 01 Series 2009

Signature over Printed Name of Student: JUDY ANN C. RUIZ

INTRAPARTAL 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 OR client
a. Obtains comprehensive client’s information by 4
checking complete accomplishment of the
preoperative checklist/client’s chart
b. Identifies priority needs of the client at the
4
Operating Room.
c. Provides needed nursing interventions based on
identified needs 4
d. Monitoring client’s response to surgery.
2
2. Promotes safety and comfort of patients inside the OR. 2
3. Performs the functions of the scrub nurse
a. Performs surgical scrub correctly 2
b. Wears sterile gowns and gloves aseptically 2
c. Prepares surgical instruments, sponges, sutures and 2
other supplies in functional arrangement
d. Hands instruments, sponges, sutures and other
2
needed materials according to surgeon’s preference.
e. Perform surgical count accurately.
2
4. Performs the functions of the circulating nurse.
a. Anticipates the needs of the circulating nurse 2
b. Sets up the OR 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.
II. MANAGEMENT OF RESOURSES, ENVIRONMENT AND EQUIPMENT (MRE)
1. *Organizes work load to facilitate timely patient care. 4
2. Utilizes adequate and appropriate resources to support 2
the OR team.
3. Ensures functionality of OR sources. 2
4. Maintains a safe environment at the OR by observing the 2
principles of asepsis.
III. HEALTH EDUCATION (HE)
1. *Implements appropriate health education activities to 2
client based on needs assessment.
IV. LEGAL RESPONSIBILITIES (LR)
1. Adheres to legal and institutional protocols regarding 2
informed consent.
V. ETHICO-MORAL RESPONSIBILITIES (EMR)
1. Respects the rights of the OR client 2
2. *Accepts responsibility and accountability for own 2
decisions and actions as an OR nurse.
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
 1. Performs OR functions according to professional 4
standards.
2. Possesses positive attitude towards learning surgical and 2
OR-related knowledge and skills.
VII. QUALITY IMPROVEMENT (QI)
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.
VIII. RESEARCH (R)
1. *Disseminates results of OR-related research findings to 2
clinical group and other members of the OR team as
appropriate.
IX.RECORDS MANAGEMENT (RM)
1. Maintains accurate and updated documentation of 2
patient care.
X.COMMUNITCATION (comm.)
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.
XI.COLLABORATION AND TEAMWORK (CTW)
1. Collaborates plan of care with other members of the 2
health team.
TOTAL SCORE : 75

When Graded RLE’s were performed (Specify Academic Year and Semester):

First Graded RLE : Academic Year 1st Sem. 2nd Sem. Summer
Clinical Instructor : Name Signature
License Number: Validity :
First Graded RLE : Academic Year 1st Sem. 2nd Sem. Summer
Clinical Instructor : Name Signature
License Number: Validity :
Third Graded RLE : Academic Year 1st Sem. 2nd Sem. Summer
Clinical Instructor : Name Signature
License Number: Validity :

Verified True and Correct: License Number:

(Signature over Printed Name) Clinical Coordinator

Note: Opportunity of student to perform items with asterisk (8) is limited since clinical exposure is governed
by hospitals’ policies. In the event that student is given the chance to perform these tasks, a grade is given,
otherwise these items are not included in the determination of grades.