Performance Evaluation Checklist

PERFORMANCE EVALUATION CHECKLIST
INTRA-PARTAL COMPETENCY
Name of Student: _____________________________________________________________________

Year / Clinical Group: __________________________________________________________________
School Year: _________________________________________________________________________
Semester/ Term: ______ First Term ____ Second Semester__________ Summer_________________
Inclusive Dates of Clinical Rotation:_______ ________________________________________________
INTRAPARTAL COMPETENCIES WEIGHT SCORE REMARKS

I. SAFE AND QUALITY NURSING CARE 4
1. Obtains obstetrical history including parity, gravid
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. Monitor progress of labor/ uterine contractions as to:
. Frequency 1
. Duration 1
. Interval 1
7. Observes for the timely rupture of membrane. 1
8. Coaches mother on process of labor. 2
II.PERFORMS FUNCTIONS DURING ACTUAL LABOR
1. Transports clients safely while providing privacy. 1
2. Places mother in lithotomy position. 1
Performs perineal care using sterile technique 1
correctly.
3. Performs perineal care using sterile technique 1
correctly
4. Performs proper hand scrub. 1
5. Wears gown and gloves according to hospital policy 1
6. Performs Rigen’s maneuver safely 2
7. Coaches mother on breathing and pushing 1
techniques.
8. Delivers baby and placenta carefully.
. Checks and manages cord recoil correctly. 1
. Clamps and cuts the cord correctly 1
. Checks the characteristic completeness of the 1
placenta
9. Assessess amount of blood loss (Normal:<500cc) 2
10. Employs interventions to achieve and maintain a well
contracted uterus to prevent / control hemorrage.
. Uterine massage 1
. Correct administration of oxytocin. 1
. Cold Compress 1
11. Assesses presence and degree of laceration. 1
12. Assists in episiorrhapy. 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 1
throughout labor and delivery.
16. Evaluates patient’s condition and records pertinent 2
data accordingly.
17. Prepares patient for transfer to recovery room/ward 1
III.MANAGEMENT OF RESOURCES, ENVIRONMENT AND
EQUIPMENT
1. Prepares room, instruments and equipment needed. 1
. Sterile drape 1
. Sterile instruments and equipment 1
[ Forceps,scissors,bulb syringe,gauze, suture,needle 1
Holder,cathether (optiona)]
2. Performs sterilization procedure. 1
3. Maintains adequacy of supplies as the delivery
progresses.
4. Maintains orderliness of the sterile table. 1
5. Observes precautionary measures related to use of 1
electrical equipment.
6. Ensures a quiet environment. 1
7. Uses supplies diligently. 1
8. Performs after care of the materials and equipment 1
used.
9. Ensures proper disposal of hospital waste including 1
blood another fluids.
IV. 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 1
before discharge.
5. Provides discharge instructions as to feeding, bathing, 1
administration of ordered medications,appointment
dates for post natal and well baby check – up.
6. Responds to questions of clients and relatives regarding 1
expectations.
V. LEGAL RESPONSIBILITY
1. Secures informed consent in all procedures related 1
to labor
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 1
completely.
IV. ETHICO – MORAL RESPONSIBILITY
1. Respects the religious, cultural and ethnic practices 1
of the family of the woman in labor and delivery
2. Promotes emotional security by supporting needs. 1
3. Ensures privacy and confidentiality. 1
VII. PERSONALITY AND PROFESSIONAL DEVELOPMENT
1. Updates oneself with the latest trends and
development in labor and delivery.
2. Projects a professional image of a delivery room
nurse.
3. Accepts criticisms and recommendations.
4. Performs functions according to standards.
5.

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PERFORMANCE EVALUATION CHECKLIST

Name of Student: _____________________________________________________________________

INTRAPARTAL COMPETENCIES WEIGHT SCORE REMARKS

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