Colegio de Sta. Lourdes of Leyte Foundation, Inc.

COLLEGE OF NURSING Tabontabon, Leyte INTRA-OPERATIVE PERFORMANCE EVALUATION CHECKLIST Name of Student: ______________________________ Year/Clinical Group:______ School Year: ________Term:_______ First Semester _____ Second Semester _____ Summer _____ Inclusive Dates of Clinical Rotation: ___________________ Legend: 4 3 2 1 Competent (student performs consistently in an effective and efficient manner) Progress acceptable (performance is usually effective and efficient but not always) Needs improvement (progress in performance is too slow to judge satisfactorily; task performance is not done properly for majority of the time) Progress unacceptable (no progress in performance has been demonstrated, and/or performance is consistently ineffective and inefficient) Score Remarks

Core Competency A. Safe and Quality Nursing Care 1. Utilize the nursing process in the care of 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 OR c. Provides needed nursing interventions based on identified needs d. Monitors clients responses to surgery 2. Promotes safety and comfort of patients inside the OR a. Transport client safely from the unit to OR b. Transfer client safely from the stretcher, stretcher to RR bed (e.g. use of side rails) c. Places properly grounding pad under the patient for electro surgical equipment d. Monitor vital signs e. Provides physical comfort utilizing devices/techniques f. Provides needed blankets and sheets to prevent hypothermia and provide privacy g. Assist in proper and safe positioning of clients in preparation for surgery h. Observes the principles of strict surgical aseptic techniques i. Observes universal precautions in handling body fluids 3. Performs the functions of the scrub nurse a. Drapes the operative field correctly b. Performs surgical scrub correctly c. Don surgical gown and gloves correctly d. Serves gowns, gloves and drapes aseptically e. Prepares surgical instruments, sponges, sutures, and other supplies in functional arrangement f. Hand instruments, sponges, sutures and other needed materials according to surgeons preference g. Performs surgical count accurately h. Performs after care of the surgical instruments i. Checks the integrity and sterility of the OR packs j. Sets up the OR and needed equipment k. Receives client for surgery/endorses client post-op l. Assist in skin preparation and draping of client 4. Administers medications and other health therapeutics safely 5. Execute legal orders of the surgeon/anesthesiologist accurately and timely 6. Evaluates patients response to interventions 7. Monitor patients progress during surgery and immediate post op phase B. Management of Resources and Environment 1. Ensures availability, completeness and functionality of OR equipment 2. Observes protocols in an unrestricted, semi-restricted and restricted areas in the OR 3. Performs proper disinfection and sterilization protocols

4. Observes proper disposal of hazardous and non-hazardous wastes 5. Observes proper handling and up keeping of OR resources 6. Observes OR policies, procedures and protocols on infection control 7. Conducts inventory of OR resources 8. Awareness of the institutional evacuation and location plan both for fire, earthquake and other major emergencies C. Health Education 1. Implements appropriate health education activities to client based on needs assessment of the intra-operative client 2. Reinforces pre-operative health teachings to client D. Legal Responsibility 1. Adheres to legal and institutional protocols regarding informed consent and other legal documents E. Ethico-moral Responsibility 1. Respect the rights of an operative client 2. Accepts responsibility and accountability for own decisions and actions as an OR nurse 3. Maintains privacy and confidentiality of clients information 4. Adheres to the Code of Ethics for nurses F. Personal and Professional Development 1. Performs OR functions according to professional standards 2. Possesses positive attitude towards learning surgical and OR related knowledge and skills G. Quality Improvement 1. Reports significant actual or potential observations regarding the surgical client 2. Reports positive or negative variances at the OR 3. Identifies and reports variances in sterility and other OR activities H. Research 1. Disseminate results of OR related research findings to clinical group and other members of the OR team as appropriate I. Records Management 1. Maintains legible, accurate and updated documentation of patient care in the chart and OR forms 2. Submit timely, complete and accurate surgical slips and OR write ups for cases handled J. Communication 1. Utilizes therapeutic communication skills with patients, significant others and members of the health team 2. Establishes professional relationships with members of the surgical health team 3. Utilizes proper channel of communication 4. Observes complete and accurate endorsement procedures 5. Uses appropriate information mechanisms to facilitate communication inside the OR and with other departments in the hospital K. Collaboration and Teamwork 1. Collaborates plan of care with other members of the health team TOTAL SCORE

_____________________________________ Signature Over Printed Name Clinical Instructor

________________________________ Signature Over Printed Name Student

Colegio de Sta. Lourdes of Leyte Foundation, Inc. COLLEGE OF NURSING Tabontabon, Leyte INTRA-OPERATIVE PERFORMANCE EVALUATION CHECKLIST Name of Student: ______________________________ Year/Clinical Group:______ School Year: ________Term:_______ First Semester _____ Second Semester _____ Summer _____ Inclusive Dates of Clinical Rotation: ___________________ Legend: 4 3 2 1 Competent (student performs consistently in an effective and efficient manner) Progress acceptable (performance is usually effective and efficient but not always) Needs improvement (progress in performance is too slow to judge satisfactorily; task performance is not done properly for majority of the time) Progress unacceptable (no progress in performance has been demonstrated, and/or performance is consistently ineffective and inefficient) Score Remarks

Core Competency A. Safe and Quality Nursing Care 1. Utilize the nursing process in the care of 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 OR c. Provides needed nursing interventions based on identified needs d. Monitors clients responses to surgery 2. Promotes safety and comfort of patients inside the OR a. Transport client safely from the unit to OR b. Transfer client safely from the stretcher, stretcher to RR bed (e.g. use of side rails) c. Places properly grounding pad under the patient for electro surgical equipment d. Monitor vital signs e. Provides physical comfort utilizing devices/techniques f. Provides needed blankets and sheets to prevent hypothermia and provide privacy g. Assist in proper and safe positioning of clients in preparation for surgery h. Observes the principles of strict surgical aseptic techniques i. Observes universal precautions in handling body fluids 3. Performs the functions of the circulating nurse a. Prepares the surgical table and all needed equipment and supplies for surgery b. Assist the anesthesiologist in the induction of anesthesia c. Performs the surgical skin preparation of the client d. Checks with the scrub nurse the completeness of surgical sponges, needles and instruments e. Anticipates the needs of the surgical team f. Ensures intactness and functionality of all contraptions (e.g. IVF, BT, IFC, NGT) g. Helps in the after care of all equipment and the OR as a whole h. Hands additional instruments and supplies aseptically as needed i. Checks the integrity and sterility of the OR packs j. Sets up the OR and needed equipment k. Receives client for surgery/endorses client post-op l. Assist in skin preparation and draping of client 4. Administers medications and other health therapeutics safely 5. Execute legal orders of the surgeon/anesthesiologist accurately and timely 6. Evaluates patients response to interventions 7. Monitor patients progress during surgery and immediate post op phase B. Management of Resources and Environment 1. Ensures availability, completeness and functionality of OR equipment 2. Observes protocols in an unrestricted, semi-restricted and restricted areas in the OR 3. Performs proper disinfection and sterilization protocols 4. Observes proper disposal of hazardous and non-hazardous wastes

5. Observes proper handling and up keeping of OR resources 6. Observes OR policies, procedures and protocols on infection control 7. Conducts inventory of OR resources 8. Awareness of the institutional evacuation and location plan both for fire, earthquake and other major emergencies C. Health Education 1. Implements appropriate health education activities to client based on needs assessment of the intra-operative client 2. Reinforces pre-operative health teachings to client D. Legal Responsibility 1. Adheres to legal and institutional protocols regarding informed consent and other legal documents E. Ethico-moral Responsibility 1. Respect the rights of an operative client 2. Accepts responsibility and accountability for own decisions and actions as an OR nurse 3. Maintains privacy and confidentiality of clients information 4. Adheres to the Code of Ethics for nurses F. Personal and Professional Development 1. Performs OR functions according to professional standards 2. Possesses positive attitude towards learning surgical and OR related knowledge and skills G. Quality Improvement 1. Reports significant actual or potential observations regarding the surgical client 2. Reports positive or negative variances at the OR 3. Identifies and reports variances in sterility and other OR activities H. Research 1. Disseminate results of OR related research findings to clinical group and other members of the OR team as appropriate I. Records Management 1. Maintains legible, accurate and updated documentation of patient care in the chart and OR forms 2. Submit timely, complete and accurate surgical slips and OR write ups for cases handled J. Communication 1. Utilizes therapeutic communication skills with patients, significant others and members of the health team 2. Establishes professional relationships with members of the surgical health team 3. Utilizes proper channel of communication 4. Observes complete and accurate endorsement procedures 5. Uses appropriate information mechanisms to facilitate communication inside the OR and with other departments in the hospital K. Collaboration and Teamwork 1. Collaborates plan of care with other members of the health team TOTAL SCORE

_____________________________________ Signature Over Printed Name Clinical Instructor

________________________________ Signature Over Printed Name Student

COLEGIO DE STA. LOURDES OF LEYTE FOUNDATION, INC. COLLEGE OF NURSING

BRGY. 1, QUEZON, TABONTABON, LEYTE Tel.No. 332-7824 Fax No. (053)332-7826 E-mail Add.csllfi@yahoo.com

O.R. Form 1A O.R. SCRUB FORM Major

SURGICAL SCRUB in ______________________________________________________________ Hospital, Municipality/City/Province Prepared by: Printed Name with Signature of Student: _______________________________________________ Date Performed And Time Started Patients INITIALS Only Case Number SUPERVISED BY Clinical Instructor Name and Signature

SURGICAL PROCEDURE PERFORMED

O.R. Nurse on Duty (Name and Signature)

Noted by: MRS. MARIA MELANDA V. SOSING, RN, MAN

Clinical Coordinator, PRC I.D. No.:0169383 Valid Until: February 10, 2014 PNA No.:0169383 Valid Until: Life Member Highest Nursing Degree Earned: Master of Arts in Nursing, Major in Clinical Supervision

Approved by: MRS. LILIA C. TISTON-GALES, RN, MAN

Dean, PRC I.D. No.:0486030 Valid Until: January 3, 2014 ADPCN No.: 11-475 Valid Until: May 31, 2013 PNA No.:057981 Valid Until: December 31, 2012 Highest Nursing Degree Earned: Master of Arts in Nursing, Major in Clinical Supervision

COLEGIO DE STA. LOURDES OF LEYTE FOUNDATION, INC. COLLEGE OF NURSING

BRGY. 1, QUEZON, TABONTABON, LEYTE Tel.No. 332-7824 Fax No. (053)332-7826 E-mail Add.csllfi@yahoo.com

O.R. Form 1B O.R. CIRCULATING FORM Major

MAJOR CASES in ______________________________________________________________ Hospital, Municipality/City/Province Prepared by: Printed Name with Signature of Student: _______________________________________________ Date Performed And Time Started Patients INITIALS Only Case Number SUPERVISED BY Clinical Instructor Name and Signature

SURGICAL PROCEDURE PERFORMED

O.R. Nurse on Duty (Name and Signature)

Noted by: MRS. MARIA MELANDA V. SOSING, RN, MAN

Clinical Coordinator, PRC I.D. No.:0169383 Valid Until: February 10, 2014 PNA No.:0169383 Valid Until: Life Member Highest Nursing Degree Earned: Master of Arts in Nursing, Major in Clinical Supervision

Approved by: MRS. LILIA C. TISTON-GALES, RN, MAN

Dean, PRC I.D. No.:0486030 Valid Until: January 3, 2014 ADPCN No.: 11-475 Valid Until: May 31, 2013 PNA No.:057981 Valid Until: December 31, 2012 Highest Nursing Degree Earned: Master of Arts in Nursing, Major in Clinical Supervision