St. Joseph College of Cavite, INC.

Institute of Health Sciences

Cavite City

Name: _____________________________________ Date: _________________

Inclusive Date of Experience: _____________________________ Grade:________________

CLINICAL PERFORMANCE EVALUATION CHECKLIST

(Immediate Care of the New born)

Instructions: Check the appropriate column. Check column “YES” if the behaviour/competency has
been observed . Check the column “NO” of identifies behaviour/skill is not demonstrated. Specific
remarks may be written in the column provided, especially for answers that are neither in the YES or NO
columns.

BEHAVIOR/SKILL YES NO SCORE REMARKS

1. Checks identification (name of mother, baby’s sex and bed number) 1
upon receiving from the DR nurse.
2. Takes the Vital Signs (TPR) properly. 5
3. Takes anthropometric measurements correctly. 10
4. Performs physical assessment correctly and thoroughly. 20
5. Identifies immediate needs in order to establish an appropriate plan of 20
care.
6. Keeps baby warm by wrapping up with blanker or exposure to droplight. 10
7. Gently suctions mouth and ns according to hospital/ health center 5
procedure.
8. Dresses/ clamps/ ligates cord aseptically and correctly according to 10
hospital/ health center procedure.
9. Administers Crede’s prophylaxis according to hospital/health center 1
policy.
10. Administers Vit. K correctly, as ordered. 1
11. Reports immediately any signs of abnormality to paediatrician on duty 1
(e.g Patency of anus, congenital defects)
12. Gives the baby a thorough, quick and proper “admission bath”. 5
13. Puts baby in designed cribs/ bassinets. 1
14. Lifts and holds baby correctly and gently. 3
15. Cuddles baby as needed. 1
16. Performs proper positioning of the baby. (position/s that drain our 1
secretions or promote adequate lung expansion, or promote gastric
emptying time, whichever is appropriate.)
17. Feeds baby properly and periodically, depending on hospital/ health 5
center policy.
18. Observes asepsis at all times. 5
19. Helps ensure a quiet environment for adequate rest and sleep of the 1
baby.
20. Gives Instructions to parents before discharge.
20.1 Starts by asking what the patients knows regarding infant care. 1
20.2 Praises and encourages parents regarding the right infant care 1
methods the know.
20.3 Suggests alternative course of action for incorrect infant care 5
methods employed by parents in the past.
20.4 Gives explanations at the level of parents’ understanding 5
20.5 Patiently repeats instructions to parents whenever necessary. 1
20.6 Discharge instruction consist of:
20.6.1 Feeding (5 points)
 Kind of formula, if not breastfed 1
 Amount to be given per feeding 1
  Dilution/ ratio/ proportion of formula 1
 Proper sterilization techniques, if not breastfed 1
 Burping after every feeding 1
 Frequency of feeding 1
20.6.2 Bathing (4 points)
 Advisable time 1
 Method, if cord is intact 1
 Method, after cord has fallen off 1
 Prevention of drafts and unnecessary exposure 1
20.6.3 Exposure to Sunlight (2 points)
 Proper time 1
 duration 1
20.6.4 Administration of ordered medications (points)
 Frequency 1
 Amount 1
20.6.5 Appointment date for well-baby check-up 1
20.6.6 Assists nursing personnel in feeding, bathing, ect,. 1
whenever necessary
21. Records all pertinent data correctly and completely 1
22. Referes to other health personnel whenever necessary 1
TOTAL 130

Students Signature Teachers Signature