Escolar Documentos
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College of nursing
Magsaysay Ave. Baguio City 2600 Tel. nos.: (074) 445-2210, 445-2209 Fax: (074) 445-2208 www.pcc.edu.ph
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
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9. Assesses amount of blood loss (Normal: <500 cc) 10. Employs interventions to achieve and maintain a well contracted uterus to prevent/control hemorrhage. 11. Assesses presence and degree of laceration. 12. Assists in episiorrhaphy. 13. Checks size, consistency and location of uterus.
Uterine massage Correct administration of oxytocin Cold compress
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INTRAPARTAL COMPETENCIES 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. 17. Prepares patient for transfer to recovery room/ ward. 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
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Performs sterilization procedure. Maintains adequacy of supplies as the delivery progresses. Maintains orderliness of the sterile table. Observes precautionary measures related to use of electrical equipment. Ensures a quiet environment. Uses supplies diligently. Performs after care of the materials and equipments used. Ensures proper disposal of hospital waste including blood and other fluids.
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VII. QUALITY IMPROVEMENT (QI) 1. Identifies deviation of practice from the standards. 2. Participates in audit practices in the delivery room/lying in. 3. Recommends corrective and preventive measures for the
identified deviations.
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X. COMMUNICATION (Comm)
1. Utilizes appropriately all forms of communication; verbal, non-verbal, electronic. 2. Inform clients significant others of the progress of labor and delivery. 3. Listens attentively to clients and families queries and requests. 1 1 1
TOTAL SCORE:
90
When Graded RLEs were performed (Specify Academic Year and Semester): First Graded RLE
Clinical Instructor : Academic Year _____________ 1 Sem.__ 2 Sem.__ Summer__ : Name ________________________ Signature __________________ License Number: ______________ Validity: ___________________ : Academic Year ___________ 1st Sem.__ 2nd Sem.__ Summer__ : Name ________________________ Signature __________________ License Number: ______________ Validity: ___________________ : Academic Year ___________ 1st Sem.__ 2nd Sem.__ Summer__ : Name ________________________ Signature __________________ License Number: ______________ Validity: ___________________
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Verified True and Correct : LYNN B. LABAN (Signature over Printed Name) Clinical Coordinator
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X. COMMUNICATION (Comm)
1. Utilizes appropriately all forms of communication; verbal, non-verbal, electronic. 2. Maintains an open line of communication with the mother and other family members. 3. Informs mother of relevant information about the newborn. 4. Listens attentively to queries and requests of mothers and family members. 1 1 1 1
TOTAL SCORE:
75
When Graded RLEs were performed (Specify Academic Year and Semester): First Graded RLE
Clinical Instructor : Academic Year _____________ 1 Sem.__ 2 Sem.__ Summer__ : Name ________________________ Signature __________________ License Number: ______________ Validity: ___________________ : Academic Year ___________ 1st Sem.__ 2nd Sem.__ Summer__ : Name ________________________ Signature __________________ License Number: ______________ Validity: ___________________ : Academic Year ___________ 1st Sem.__ 2nd Sem.__ Summer__ : Name ________________________ Signature __________________ License Number: ______________ Validity: ___________________
st nd
Verified True and Correct : LYNN B. LABAN (Signature over Printed Name) Clinical Coordinator
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3 RLE
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AVERAGE RATING
I. SAFE AND QUALITY NURSING CARE (SQC) 1. Utilizes the nursing process in the care of OR client 4 a. Obtains comprehensive clients information by checking complete accomplishment of the preoperative checklist/clients chart 4 b. Identifies priority needs of the client at the Operating Room 4 c. Provides needed nursing interventions based on identified needs 2 d. Monitors clients responses to surgery 2 2. Promotes safety and comfort of patients inside the OR 3. Performs the functions of the scrub nurse 4 a. Performs surgical scrub correctly 2 b. Wears sterile gowns and gloves aseptically 2 c. Prepares surgical instruments, sponges, sutures and other supplies in functional arrangement 2 d. Hands instruments, sponges, sutures and other needed materials according to surgeons preference 2 e. Performs surgical count accurately 4. Performs the functions of the circulating nurse 2 a. Anticipates the needs of the surgical team 2 b. Sets up the OR room and needed equipment 2 c. Receives client for surgery / endorses client post operatively 2 d. Assists in skin preparation and draping of client 2 5. Administers medications and other health therapeutics safely II. MANAGEMENT OF RESOURCES AND ENVIRONMENT (MRE) 4 1. Organizes work load to facilitate timely patient Care 2 2. Utilizes adequate and appropriate resources to support the OR team 2 3. Ensures functionality of OR resources 4. Maintains a safe environment at the OR by observing the principles of asepsis 2
III. HEALTH EDUCATION (HE) 2 1. Implements appropriate health education activities to client based on needs assessment IV. LEGAL RESPONSIBILITIES (LR) 2 1. Adheres to legal and institutional protocols regarding informed consent V. ETHICO-MORAL RESPONSIBILITIES (EMR) 2 1. Respects the rights of the OR client 2 2. Accepts responsibility and accountability for own decisions and actions as an OR nurse VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 4 1. Performs OR functions according to professional standards 2 2. Possesses positive attitude towards learning surgical and OR-related knowledge and skills VII. QUALITY IMPROVEMENT (QI) 2 1. Participates in quality improvement activities related to infection control and successful OR operations 2 2. Identifies and reports variances in sterility and other OR activities VIII. RESEARCH (R) 2 1. Disseminates results of OR-related research findings to clinical group and other members of the OR team as appropriate IX. RECORDS MANAGEMENT (RM) 2 1. Maintain accurate and updated documentation of patient care X. COMMUNICATION (Comm) 1 1. Establishes rapport with patients, significant others and members of the health team 2 2. Uses appropriate information mechanisms to facilitate communication inside the OR and with other departments in the hospital XI. COLLABORATION AND TEAMWORK (CTM) 2 1. Collaborates plan of care with other members of the health team TOTAL SCORE 75
When Graded RLEs were performed (Specify Academic Year and Semester): First Graded RLE
Clinical Instructor : Academic Year _____________ 1 Sem.__ 2 Sem.__ Summer__ : Name ________________________ Signature __________________ License Number: ______________ Validity: ___________________ : Academic Year ___________ 1st Sem.__ 2nd Sem.__ Summer__ : Name ________________________ Signature __________________ License Number: ______________ Validity: ___________________ : Academic Year ___________ 1st Sem.__ 2nd Sem.__ Summer__ : Name ________________________ Signature __________________ License Number: ______________ Validity: ___________________
st nd
Verified True and Correct : LYNN B. LABAN (Signature over Printed Name) Clinical Coordinator