COLLEGE OF NURSING SUMMARY PERFORMANCE EVALUATION ACHIEVING INTRA-OPERATIVE CARE COMPETENCY In Accordance with PRC Board of Nursing Memorandum

No. 01 Series 2009

SIGNATURE OVER PRINTED NAME: JUAN DELA CRUZ INTRA-OPERATIVE CARE COMPETENCIES 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 checking complete accomplishment of the perioperative checklist/client's chart. b. Identifies priority needs of the client at the Operating Room. c. Provides needed nursing interventions based on identified needs. d. Monitors client's responses to surgery. 2. Promotes safety and comfort of patients inside the OR. 3. Performs the functions of the scrub nurse a. Performs surgical scrub correctly. b. Wears sterile gowns and gloves aseptically. c. Prepares surgical instruments, sponges, sutures and other d. Hands instruments, sponges, sutures and other needed materials according to surgeon's preference. e. Performs surgical count accurately. 4. Performs the functions of the circulating nurse a. Anticipates the needs of the surgical team. b. Sets up the OR room and needed equipment. c. Receives client for surgery/endorses client post-operatively 5. Administers medications and other health therapeutics safely. II. MANAGEMENT OR RESOURCES AND ENVIRONMENT (MRE) 1. Organizes work load to facilitate timely patient care. 2. Utilizes adequate and appropriate resources to support the OR team. 3. Ensures functionality of OR resources. 4. Maintains a safe environment at the OR by observing the principles of asepsis. III. HEALTH EDUCATION (HE) 1. Implements appropriate health education activities to client based on needs assessment. IV. LEGAL RESPONSIBILITIES (LR) 1. Adheres to legal and institutional protocols regarding informed consent. V. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Respects the rights of the OR client. 2. Accepts responsibility and accountability for own decisions and actions as an OR nurse. VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PDD) 1. Performs OR functions according to professional DESIRED RATING 1ST RLE 2ND RLE 3RD RLE AVERAGE RATING

4 4 2 2 4 2 2 2 2 2 2 2 2

4 2 2 2

2 2

standards. 2. Possesses positive attitude towards learning surgical and OR-related knowledge and skills. VII. QUALITY IMPROVEMENT (QI) 1. Participates in quality improvement and activities related to infection control and successful OR operations. 2. Identifies and reports variances in sterile and other OR activities. VIII. RESEARCH 1. Disseminates results of OR-related research findings to clinical group and other members of the OR team as appropriate. IX. RECORDS MANAGEMENT (RM) 1. Maintain accurate and updated documentation of patient care. X. COMMUNICATION (Comm) 1. Establishes rapport with patients, significant others and members of the health team. 2. Uses appropriate information mechanisms to facilitate 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 health team. TOTAL
Certified True and Correct:

2 2

1 2

2 75

Academic Year Graduated

NENITA B. PANALIGAN, RN, MAN Clinical Instructor PRC I.D No.: 0201832 Valid Until: March 1, 2014 PNA No.:2012- 023203 Valid Until: October 31, 2012 Date Signed: ________________

EVELYN M. DEL MUNDO, RN, MAN Clinical Instructor PRC No.: 0130620 Valid until: June 12, 2012 PNA: 2012-023204 Valid until: October 31, 2012 Date signed:________________________

LETICIA M. DEL ROSARIO, RN, MAN Clinical Instructor PRC No.:0110878 Valid until: March 8, 2014 PNA No.:18655 Valid until: Lifetime Date Signed: _______ Noted by: NENITA B. PANALIGAN, RN, MAN Clinical Coordinator PRC I.D No.: 0201832 Valid Until: March 1, 2014 PNA No.:2012- 023203 Valid Until: October 31, 2012 Date document is signed:_________ Time: _______ Highest Nursing Degree Earned: Master of Arts in Nursing

Approved by: LENILA A. DE VERA, RN, MPH, MAN Dean PRC I.D No.:0083977 Valid Until: March 8, 2015 PNA No.:2012-023201 Valid Until: October 31, 2012 ADPCN No.:11-175 Valid Until: December 31, 2012 Date document is signed:____________ Time: _______ Highest Nursing Degree Earned: Master of Arts in Nursing