johngsdg

7/30/2019 Johngsdg

1/12

Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar

COLLEGE OF NURSING

(055)251-8360

Accredited Agency of Chartered Colleges and

Universities in the Philippines, Inc.,. Level 2

March 16, 2013 to March 15, 2017

ACTUAL DELIVERY in: Northern Samar Provincial Hospital, Catarman, N. Samar

Prepared by: Hospital, Municipality/City/Province

Printed Name with signature of Student: JOHN O. GOYENA

Date Performed

and

Time Started

Patients INITIAL PROCEDURE PERFORMED Nurse On Duty

(Name and Signature)

SUPERVISED BY

Name and Signature of Clinical

Instructor

Case Number

01-08-2011

5:37 P.M

M.R.

120267

Handled Delivery Zyra Rose B. Arban, RN Mary Day E. Florano, RN, MAN

03-30-2011

9:25 A.M

T.A

128152

Handled Delivery Janith Torres RN Mary Day E. Florano, RN, MAN

03-29-2011

2:50 P.M

S.J

128975

Handled Delivery Zyra Rose B. Arban, RN Mary Day E. Florano, RN, MAN

No

D.R. FORM

ACTUAL DELIVERY

FORM

Approved by:

MARIA LINDA S. AGUS, RN, MANDean

Date Signed_____________________

Degree : BSN, RN, MAN

PRC No. : 0147802

Valid until : March 8, 2014

PNA No. : 2013-600226

Valid Until : December 31, 2013

ADPCN No. : 1551

Valid Until : 2013-2014

Noted by:

RONA L. ALCERA, RN, MANClinical CoordinatorDate Signed_____________________


PRC No. : 0178033

Valid until : May 11, 2015

PNA No. : 2013-000227


7/30/2019 Johngsdg

2/12




COLLEGE OF NURSING

(055)251-8360


Universities in the Philippines, Inc., Accreditation level 2

March 16, 2013 to March 15, 2017

IMMEDIATE NEWBORN CORD CARE in: Northern Samar Provincial Hospital, Catarman, N. Samar

Hospital, Municipality/City/Province

Prepared by:

Printed Name with Signature of Student: JOHN O. GOYENA

Date Performed

and

Time Started

Patients INITIALS Immediate Newborn Cord Care PERFORMED Nurse On Duty


SUPERVISED BY


Instructor

Case Number

03-31-2011

8:25 A.M

Baby I.

128167

Immediate Newborn Cord Care Janith Torres, RN Mary Day E. Florano, RN, MAN

04-26-2011

2:50 P.M

Baby S.

118975

Immediate Newborn Cord Care Cresilda C. Maximo, RN Mary Day E. Florano, RN, MAN

09-02-2010

8:48 A.M

Baby B.

119430

Immediate Newborn Cord Care Cresilda C. Maximo, RN Mary Day E. Florano, RN, MAN

IMMEDIATE CARE OF THE

NEWBORN FORM

Approved by:


Date Signed_____________________


PRC No. : 0147802


PNA No. : 2013-600226


ADPCN No. : 1551


Noted by:



PRC No. : 0178033

Valid until: May 11, 2015

PNA No. : 2013-000227

Valid Until: December 31, 2013

7/30/2019 Johngsdg

3/12




COLLEGE OF NURSING

(055)251-8360


Universities in the Philippines, Inc., Level 2

March 16, 2013 to March 15, 2017

SURGICAL MAJOR SCRUB in: G.B Tan Memorial Hospital Laoang Northern Samar

Hospital, Municipality/City/Province

Prepared by:


Date Performed

and

Time Started

Patients INITIALS PROCEDURE PERFORMED O.R. Nurse On Duty


SUPERVISED BY


Instructor

Case Number

02-09-2012

08:52 A.M

I.E.

12-7

Total Thyroidectomy , RN Maryflor L. Cagro RN, MAN

02-09-2012

10:45 A.M

M.B.

12-24

Right Thyroid Lobectomy , RN Maryflor L. Cagro RN, MAN

02-10-2012

01:40 A.M

T.P

12-104

Left Hydrocelectomy , RN Maryflor L. Cagro RN, MAN

O.R. Form 1B

O.R. CIRCULATING

FORM

Approved by:


Date Signed_____________________


PRC No. : 0147802


PNA No. : 2013-600226


ADPCN No.: 1551


Noted by:



PRC No. : 0178033

Valid until : May 11, 2015

PNA No. : 2013-000227


7/30/2019 Johngsdg

4/12



COLLEGE OF NURSING

(055)251-8360


Universities in the Philippines, Inc., Accreditation level 2

March 16, 2013 to March 15, 2017

SURGICAL MAJOR SCRUB in:G.B Tan Memorial Hospital Laoang Northern SamarHospital, Municipality/City/Province

Prepared by:


Date Performed

and

Time Started

Patients INITIALS

PROCEDURE PERFORMED O.R. Nurse On Duty

(name and Signature)

SUPERVISED BY


InstructorCase Number

02-10-2012

8:46 A.M

F.H.

12-106Total Thyroidectomy , RN Maryflor L. Cagro RN, MAN

02-09-2012

05:02 P.M

B.J.

12-112Excision Scalp Limpoma , RN Maryflor L. Cagro RN, MAN

02-10-2012

9:45 A.M

M.E.

12-61Right Lampectomy , RN Maryflor L. Cagro RN, MAN

O.R. Form 1A

O.R. SCRUB FORM

MAJOR

Approved by:


Date Signed_____________________


PRC No. : 0147802

Valid until: March 8, 2014

PNA No. : 2013-600226


ADPCN No. : 1551

Valid Until: 2013-2014

Noted by:



PRC No. : 0178033

Valid until: May 11, 2015

PNA No. : 2013-000227


7/30/2019 Johngsdg

5/12



COLLEGE OF NURSING

(055)251-8360

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: CELINA APRIL S. DE ANDRES

INTRAPARTAL COMPETENCIES DESIRED

RATING

ACTUAL

RATING

I. SAFE AND QUALITY NURSING CARE (SQC)

1. Obtains obstetrical history including parity, gravid score,LMP,

EDC, AOG,BOW onset of true labor.

4 4

2. Checks vital signs. 1 1

3. Conducts physical assessment. 2 2

4. Performs Leopolds maneuver. 2 2

5. Checks Fetal Heart Rate and Fundic height. 2 2

6. Monitor progress of labor/uterine contractions as to:

Frequency Duration

Intensity Interval

1

1

1

1

1

1

1

1

7. Observes for the timely rupture membrane. 1 1

. Coaches mother on process of labor. 2 1

PERFORMS FUNCTIONS DURING ACTUAL LABOR

1. Transports clients safely while providing privacy. 1 1

2. Places mother in lithotomy position. 1 1

3. Performs Perineal care using sterile technique correctly. 1 1

4. Performs proper hand scrub. 1 1

5. Wears gown and gloves according to hospital policy. 1 1

6. Perform Ritgens maneuver safely. 2 27. Coaches mother on breathing and pushing techniques. 1 1

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 characteristics/completeness of the

placenta.

1

1

1

1

1

1

1

1

9. Assesses amount of blood loss (Normal:

7/30/2019 Johngsdg

6/12

INTRAPARTAL COMPETENCIES

14. Performs perineal care and applies pad correctly. 1 1

15. Provides emotional support to the mother throughout

labor

and delivery.

1 1

16. Evaluates patients condition and records pertinent data

accordingly.

2 1

17. Prepares patient for transfer to recovery room/ward. 1 1

II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE)

1. Prepares room, instruments and equipment needed.

Sterile drape Sterile instruments and equipment [Forceps, scissors,

bulb syringe, gauze, suture, needle holder, catheter

(optional)]

Kelly pad Disinfectant

1 1

2. Performs sterilization procedure. 1 1

3. Maintains adequacy of supplies as the delivery progresses. 1 1

4. Maintains orderliness of the sterile table. 1 1

5. Observes precautionary measures related to use of

electrical

equipment.

1 1

6. Ensures a quiet environment. 1 1

7. Uses supplies diligently. 1 1

8. Performs after care of the materials and equipment used. 1 1

9. Ensures proper disposal of hospital waste including bloodand

other fluids.

1 1

III. HEALTH EDUCATION (HE)

1. Teaches client on basic preparation during labor and

deliver

(can be done in the labor room)

1 .5

2. Coaches client on breathing down technique. 2 .5

3. Demonstrate proper latch-on breast feeding technique

(Done postpartum period).

1 1

4. Gives instructions to parents regarding infant care before

Discharge (done post-partum period).

1 1

5. Provides discharge instructions as feeding, bathing,

administration of ordered medications, appointment dates

for

post natal and well-baby check-up (done post-partum period).

1 1

6. Responds to questions of clients and relatives regarding

expectations.

1 1

IV. LEGAL RESPONSIBILITIES (LR)

1. Secures informed consent in all procedures related to labor

and delivery.

1 1

2. Reports accurately and honestly the gender, time of

delivery

of the baby and placenta.

2 1

3. Ensures proper identification of the mother and newborn. 2 1

4. Documents all pertinent data correctly and completely. 1 1

V. ETHICO-MORAL RESPONSIBILITIES (EMR)

1. Respects the religious, cultural and ethnic practices of the

family of the woman in labor and delivery.

1 1

7/30/2019 Johngsdg

7/12

2. Promotes emotional security by supporting needs. 1 1

3. Ensures privacy and confidentiality. 1 1

VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)

1. Updates oneself with the latest trends and development in

labor and delivery.

1 1

2. Projects a professional image of a delivery room nurse. 1 13. Accepts criticism and recommendations. 1 1

4. Performs functions according to standards. 1 1

VII. QUALITY IMPROVEMENT (QI) (preferably done during post conferences)

1. Identifies deviation of practice from the standards. 1 1

2. Participates in audit practices in the delivery room/lying in. 1 1

3. Recommends corrective and preventive measures for the

identified deviations.

1 1

VIII. RESEARCH (R)(preferably done during post conferences)

1. Documents accurately relevant data about client. 2 1

2. Utilize findings of research studies in intra-partal care. 2 1

IX. RECORD MANAGEMENT (RM)

1. Documents accurately relevant data about client. 1 1

2. Maintains an organized system of filing and keeping records

of the client

1 1

X. COMMUNICATION (Comm)

1. Utilizes appropriately all forms of communication; verbal,

non-verbal, electronic.

1 1

2. Inform clients significant others of the progress of labor

and delivery.

1 1

3. Listens attentively to clients and families queries and

requests.

1 1

XI. COLLABORATION AND TEAMWORK (CTW)

1. Functions effectively as a team player in the delivery

room/lying in.

1 1

2. Communicates the progress of labor/delivery to significant

others.

1 1

3. Establishes collaborative relationship with members of the

health team and family members.

1 1

TOTAL SCORE 90 80= 90%

Certified True and Correct:

MARY DAY E. FLORANO RN, MAN RONA L. ALCERA, RN, MAN

Clinical Instructor Coordinator

License Number: 0312835 License Number: 0178033

PRC Card-Validity Date: September 1, 2016 PRC Card-Validity Date: May 11, 2015

PERLIN ZELLAINE T. LICAS, RN, MAEd

Clinical InstructorLicense Number: 0258480

PRC Card-Validity Date: January 25, 2015

MARIA LINDA S. AGUS, RN, MAN

DEAN

License Number: 0178033 School Year 2012-2013

PRC Card-Validity Date: March 8, 2014 Academic Year Graduated

7/30/2019 Johngsdg

8/12



COLLEGE OF NURSING

(055)251-8360


IMMEDIATE CARE OF THE NEWBORN COMPETENCY

In Accordance with PRC Board of Nursing Memorandum No. 01 Series 2009

Signature over Printed Name of Student: MONTES, MARGOT FYNNE B.

INTRAPARTAL COMPETENCIES DESIRED

RATING

ACTUAL RATING

7/30/2019 Johngsdg

9/12


1. Establishes and maintains patent airway. 3 3

2. Puts the newborn in Trendelenburg position. 1 1

3. Suctions mouth and nose of the newborn gently. 2 1

4. Dries newborn and wraps warmly.

Places under droplight as needed. 1 15. Performs and interprets APGAR scoring correctly.

Immediately after delivery After 5 minutes 22 22

6. Ensures proper identification of newborn (name tag: name of

mother, date and time of delivery, gender and name of

attending physician).

2 2

7. Performs physical assessment including anthropometric

measurements including weight, height, head, chest

abdominal circumference.

4 3

8. Takes vital signs (temperature per rectum to check patency) 1 1

9. Give oil/water and soap bath according to institutional policy. 1 1

10. Latches newborn to mothers breast immediately after birth. 1 1

11. Applies CREDEs prophylaxis on the eyes. 1 1

12. Performs cord dressing aseptically. Disinfects area properly according to hospital policy. Clamps and cuts cord 1 inch from the abdomen Checks for the presence of 2 arteries and 1 vein Dresses cord aseptically according to hospital policy

1

1

1

1

1

1

1

1

13. Administers Vitamin K (1mg/IM) into the lateral anterior

thigh or vastuslateralis.

1 1

14. Keeps baby wrapped warmly under floor lamp or bedside. 1 1

15. Records pertinent observations and nursing care done. 1 1

16. Reports any signs of deviation/abnormality to the

paediatrician.

1 1

II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE)

1. Prepares instrument and equipment needed

Suction bulb, cord clamp, gauze, cotton balls, disinfectant,

blanket, droplight, Vitamin K, antimicrobial ophthalmic

ointment.

4 3

2. Ensures use of sterile equipment during immediate care of the

newborn.

1 1

3. Maintain adequacy of supplies as newborn care is rendered. 1 1

4. Maintains orderliness of the working area. 1 1

5. Observes precautionary measures related to use of electrical

equipment.

1 1

6. Ensures a warm and quiet environment. 1 1

7. Uses supplies diligently. 1 1

8. Ensures proper disposal of hospital waste. 1 1

III. HEALTH EDUCATION (HE)1. Provides instructions to the mother on daily cord care and

prevention of cord infection.

2 1

2. Provides discharge instructions to the mother on when to

expect cord to fall off or to report signs of cord infection.

1 1

3. Provides information regarding newborn screening,

immunization, feeding etc.

2 1

4. Responds to questions of mother and relatives regarding

expectations.

1 1


1. Identifies newborn by comparing ID band with data in the

chart.

2 1

2. Documents all pertinent data correctly and completely. 1 1

3. Reports accurately and deviations/abnormal findings and

nursing interventions rendered.

1 1

4. Ensures that birth certificate and other civil registration forms

are accomplished/filled out according to institutional policy.

2 1

5. Performs foot printing according to hospital policy. 1 1

V. ETHICO-MORAL RESPINSIBILITY (EMR)

1. Respects the religious, cultural and ethnic practices of the

family of the newborn.

1 1

2. Maintains privacy and confidentiality of findings of 1 1

7/30/2019 Johngsdg

10/12

assessments.

VI. PERSONAL AND PROFESSIONA DEVELOPMENT (PPD)

1. Updates oneself with the latest trends and developments in

newborn care.

1 1

2. Projects a professional image of the pediatric nurse. 1 1

3. Accepts criticisms and recommendations. 1 1

4. Performs functions according to standards. 1 1

VII. QUALITY IMPROVEMENT (QI)

1. Identifies deviation of practice from the standards. 1 1

2. Participates (whenever possible) in audit practices in the

nursery.

1 1

3. Recommends corrective and preventive measures for the

identified deviations.

1 1

VIII. RESEARCH (R)

1. Identifies researchable problems related to immediate care of

newborn.

2 1

2. Utilizes findings of research studies in the immediate care of

thenewborn.

2 2

IX. RECORDS MANAGEMENT (RM)

1. Documents accurately relevant data about the newborn. 1 1

2. Maintains an organized system of filing and record keeping. 1 1

X. COMMUNICATION (Comm)

1. Utilizes appropriately all forms of communication; verbal non-

verbal, electronic.

1 1

2. Maintains an open line of communication with the mother

and other family members.

1 1

3. Informs mother of relevant information about the newborn. 1 1

4. Listens attentively to queries and requests of mothers and

family members.

1 1

XI. COLLABORATION AND TEAMWORK (CTM)

1. Functions effectively as a team player in the nursery. 1 1

2. Communicates findings of assessment to all concerned. 1 1

3. Establishes a collaborative relationship with members of the

health team and family of the newborn.

1 1

TOTAL 75 68=90%


PERLIN ZELLAINE T. LICAS, RN, MAEd RONA L. ALCERA, RN, MAN

Clinical Instructor Clinical Coordinator

License Number:0258480 License Number: 0178033

PRC Card-Validity Date:January 25, 2015 PRC Card-Validity Date: May 11, 2015

MARY DAY E. FLORANO RN, MAN

Clinical Instructor

License Number: 0312835

PRC Card-Validity Date: September 1, 2013


DEAN



7/30/2019 Johngsdg

11/12



COLLEGE OF NURSING

(055)251-8360


INTRA-OPERATIVE CARE COMPETENCY

In Accordance with PRC Board of Nursing Memorandum No. 01 Series 2009

Signature over Printed Name of Student:MONTES, MARGOT FYNNE B.

INTRA-OPERATIVE CARE COMPETENCIES DESIRED

RATING

1ST

RLE

2ND

RLE

3RD

RLE

AVERAGE

RATING


1. Utilizes the nursing process in the care of OR client.

a. Obtains comprehensive clients information.

4 3 3 4 3.33

b. Identifies priority needs of the client at the

Operating Room

4 3 3 3 3

c. Provides needed nursing interventions based on

identified needs.

4 3 3 3 3

d. Monitors clients responses to surgery. 2 2 2 2 2

2. Promotes safety and comfort of patients inside the OR. 2 2 2 2 2

3. Promotes the functions of the scrub nurse.

a. Performs surgical scrub correctly.

4 4 3 4 4

b. Wears sterile gowns and gloves aseptically. 2 2 2 2 2

c. Prepares surgical instruments, sponges, sutures

and othersupplies in functional arrangement.

2 2 2 2 2

d. Hands instruments, sponges, sutures and other

needed materials according to surgeons preference.

2 2 2 2 2

e. Performs surgical count accurately. 2 2 1 1 1.33

4. Performs the functions of the circulating nurse.

a. Anticipates the needs of the surgical team.

2 2 2 2 2

b. Sets up the OR room and needed equipment. 2 2 2 2 2

c. Receives client for surgery/endorses client post-

operatively.

2 2 2 2 2

d. Assists in skin preparation and draping of client. 2 2 2 2 2

5. Administers medications and other health therapeutics

safely.

2 2 2 2 2

II. MANAGEMENT OF RESOURCES AND ENVIRONMENT (MRE)

1. Organizes work load to facilitate timely patient care 4 3 3 4 3.33

2. Utilizes adequate and appropriate resources to support

the OR team.

2 2 1 2 1.66

3. Ensures functionality of OR resources. 2 2 2 2 2

4. Maintains a safe environment at the OR by observing

the principles of asepsis.

2 2 2 2 2

III. HEALTH EDUCATION (HE)

1. Implements appropriate health education activities to 2 2 2 2 2

7/30/2019 Johngsdg

12/12

client based on needs assessment.


1. Adheres to legal and institutional protocols regarding

informedconsent.

2 2 2 2 2

V. ETHICO-MORAL RESPONSIBILITIES (EMR)

1. Respects the rights of the OR clients 2 1 1 2 1.33

2. Accepts responsibility and accountability for owndecisions and actions as an OR nurse.

2 1 2 2 1.66

VI. PERSONAL AND PROFESIONAL DEVELOPMENT (PPD)

1. Performs OR functions according to professional

standards.

4 4 4 4 4

2. Possesses positive attitude towards learning surgical

and OR-related knowledge and skills.

2 2 2 2 2

VII. QUALITY IMPROVEMENT

1. Participates in quality improvement activities related to

infection control and successful OR operations.

2 2 2 2 2

2. Identifies and reports variances in sterility and other OR

activities.

2 2 2 2 2

VIII. RESEARCH 1. Disseminates results of OR-related research findings to

clinical group and other members of the OR team as

appropriate.

2 2 2 2 2

IX. RECORD MANAGEMENT

1. Maintain accurate and updated documentation of

patient care.

2 2 2 2 2

X. COMMUNICATION

1. Establishes rapport with patients, significant others

and members of the health team.

1 1 1 1 1

2. Uses Appropriate information mechanism to facilitate

communication inside the OR and with other

departments in the hospital.

2 2 2 2 2

XI. COLLABORATION AND TEAMWORK (CTM)

1. Collaborates plan of care with other members of the

health team.

2 2 2 2 2

TOTAL 75 69 68 68 68.31=91.08%


MARY DAY E. FLORANO RONA L. ALCERA, RN, MAN

Clinical Instructor Clinical Coordinator

License Number: 0312835 License Number: 0178033

PRC Card-Validity Date:September 1, 2013 PRC Card-Validity Date: May 11, 2015


DEAN

