Name: __________________________ Section: ______ Over-all Score: ________

Adventist University of the Philippines

COLLEGE OF NURSING
ABC-MEGACODE CY2020-21

ACLS Code Blue Checklist Form

SKILL PC PI REMARKS
1 Emergency Interventions (based on initial assessment)
Tasks to be performed :
a. Initial Quick Assessment for Carotid or Apical Pulse
b. Hyperoxygenate with Bag-Valve-Mask
c. Apply cardiac board and perform CPR x 2 minutes to a
pulseless client (can ONLY be interrupted by defibrillation
when desired energy level is available)
d. Connect to Defibrillator (Defibrillation/Synchronized
Cadioversion is administered if needed)
e. IV Insertion ASAP (Administer emergency drugs)
f. Intubation set standby (hook to Ambu bag once intubated)
g. Suction Machine standby
h. Use of the Code Blue Documentation
i. Re-check pulse and LOC every 5 cycles of CPR
(approximately 2 minutes)
2 Emergency Interventions (based on dysrhythmias)
A. Asystole
a. Correct identification of dysrhythmia
b. CPR (5 cycles)
c. Epinephrine 1 mg every 3-5minutes as needed
d. Check rhythm after 2 minutes or 5 cycles of CPR/check
pulse
B. V-Fib/Pulseless V-Tach
a. Correct identification of dysrhythmia
b. CPR (5 cycles)
c. Administer 360 joules for monophasic (repeat if needed)
d. Resume CPR
e. Administer 2nd 360 joules for monophasic
f. Epinephrine 1 mg every 3-5minutes as needed
g. Check rhythm after 2 minutes or 5 cycles of CPR/check
pulse

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 C. PSVT/V-Tach with PULSE
a. Correct identification of dysrhythmia
b. Stop CPR (if asystole, VF, PVT is converted to SVT or VT w/
Pulse) then announce “REVIVED!”
c. Perform Vagal Maneuvers (Carotid Sinus Massage)
d. Give adenosine 6 mg rapid IV push. If patient does not
convert in one minute, give adenosine 12 mg rapid IV push.
May repeat 12 mg dose of adenosine once. If ineffective…
e. Perform Synchronize Cardioversion at 120-200 joules
f. Check rhythm
D. Bradycardia with sign of poor perfusion (symptomatic, e.g. hypotension)
a. Correct identification of dysrhythmia and assess for
symptomatic badycardia
b. Stop CPR (if arrest rhythm is converted to bradycardia) then
announce “REVIVED!”
c. Atropine 0.5mg IV every 3-5 minutes for symptomatic
bradycardia
d. May start dopamine infusion for hypotension
e. Check rhythm/VS
E. Normal Sinus Rhythm
a. Correct identification of rhythm
b. Stop CPR / (if arrest rhythm is converted to bradycardia)
then announce “REVIVED!”
c. Check carotid or apical pulse
d. Continue manual oxygenation using Ambu bag (at the
rhythm of every 5 counts), hook to ventilator once available
e. Check BP/GCS
f. Start Inotropic (Dopamine drip) for hypotension
g. Place patient on semi-fowler’s position (if BP is stable)
h. Stat 12-Lead ECG and Chest X-ray
i. Code Blue after care and check ABG after 30minutes
j. Sign “Code Blue Record Form”
Perfect Score: 82 pts. SUMMARY TL SCORE= P. Score: 62 pts.

(P.S.: 232 pts.) TOTAL ACLS SIMULATION SCORE= P.Score: 175 pts.
LEGEND: 2 PTS - PERFORMED CORRECTLY WITHOUT SUPERVISION (P.C.) RMF
1 PT. - PERFORMED I NCORRECTLY AND/ OR NEED SUPERVISION (P.I.)
0 PT. - NOT PERFORMED (N.P.)
D ATE / T IME

S ECTION / G ROUP #

S TUDENT’S N AME AND S IGNATURE

C LINICAL INSTRUCTOR’S NAME AND S IGNATURE

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Student’s Name:________________ Evaluator:____________________
Section/Group#:________________ Date:________________________

ACLS-CPR Checklist
PERFORMANCE CRITERIA PC (2 pts.) PI (1 PT) NP (0) REMARKS

Immediate Recognition/Assessment
1. Check for unresponsiveness
2. Check pulse and breathing for
10 seconds
Activation of Emergency Response System (EMS)
3. Shout for “Code Blue”
Execution of CPR
4. Apply cardiac board once
available
5. Place dominant hand 2
fingerbreadths above the
xyphoid process and interlock
with the non-dominant hand
6. Lock elbows and maintain on
vertical line
7. Deliver 1st cycle of CPR
At least 100-120 chest
compression per minute x 2
minutes
8. Vertical angle of arms during
compression
9. Compress chest at the depth
of 2 inches per compression
(adult)
10. Allows full recoil of chest per
compression
11. Check pulse and breathing
after 5 cycles (approximately
2 minutes) for 10 seconds
12. Resume 2nd cycle of CPR if
needed
13. Discontinue CPR if with pulse
P.S. - 26 pts. TOTAL SCORE=
LEGEND: 2 PTS. - PERFORMED CORRECTLY WITHOUT SUPERVISION (P.C.) RMF
1 PT. - PERFORMED INCORRECTLY AND / OR NEED SUPERVISION (P.I.)
0 PT. - NOT PERFORMED (N.P.)

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Student’s Name: ________________ Evaluator: ____________________
Section/Group#:________________ Date: ________________________

DEFIBRILLATION/SYNCHRONIZED CARDIOVERSION
Checklist
PERFORMANCE CRITERIA PC (2 PTS) PI (1 PT) NP (0) Remarks
FOR DEFIBRILLATION:
1. Press ON
2. Bares patient chest
3. Attaches ECG cable to the patient
4. Select appropriate energy level
5. Announce to team members:
“Charging defibrillator-stand clear”
6. Announce “360 joules available” (120-200
joules for synchronized cardioversion)
7. Apply gel to paddle pads
8. Position paddle on patient (sternum-apex)
9. State in a forceful voice the following
chant before each shock:
 I’m going to give shock on five.
One, I’m clear.
 Two, your clear.
 Three, everybody’s clear
 Four, O2 out.
 Five, still on…(rhythm)
 Clear?!
Code team’s response: CLEAR!!!
10. Apply 25 lbs. pressure on paddles
11. Press the ‘discharge’ buttons
simultaneously
12. Announce ‘Shock delivered’ ( Announce
“shock on R wave” for synchronized
cardioversion)
13. Check/Document the rhythm post
administration of shock
FOR SYNCHRONIZED CARDIOVERSION:
14. Engage the synchronization mode by
pressing the ‘SYNC’ control button
15. Look for markers on R waves indicating
sync mode (synchronized cardioversion)
(Repeat #4-14)
P.S. - 30 pts. TOTAL SCORE =
LEGEND: 2 PTS. - PERFORMED CORRECTLY WITHOUT SUPERVISION (P.C.) RMF
1 PT. - PERFORMED I NCORRECTLY AND / OR NEED SUPERVISION (P.I.)
0 PT. - NOT PERFORMED (N.P.)

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Student’s Name: ________________ Evaluator: ____________________
Section/Group#:________________ Date: ________________________

ET-TUBE INSERTION CHECKLIST

PC PI NP
PERFORMANCE CRITERIA Remarks
(2 pts.) (1pt) (0)
1. Hyperoxygenate using Bag-Valve-Mask
 Connect to O2 source
 Turn oxygen ON at 10L/min
2. Explain procedure to the client and his family and obtain
informed consent (verbalize “procedure explained and
consent signed”).
3. Wear gloves/protective goggles
4. Prepare Intubation Set
 Assemble laryngoscope
 Check laryngoscope light
5. Obtain the correct size for an oral ET tube. (Verbalize ET size)
6. Check ET balloon/inflate with 10cc syringe
7. Insert guide wire in ET tube
8. Hyperoxygenate using bag-valve-mask
9. Hyper -extend patient’s head
10. Perform tracheal intubation / proper handling of
laryngoscope and ET tube
11. Remove laryngoscope
12. Pull out guide wire

13. Inflate ET cuff using 10cc syringe

14. Auscultate breath sounds and watch for chest movement to
ensure correct placement and full lung ventilation.
15. Secure the tube firmly with tape (verbalized “ET tube
secured”)
P.S. – 30 pts. TOTAL SCORE =
LEGEND: 2 PTS. - PERFORMED CORRECTLY WITHOUT SUPERVISION (P.C.) RMF
1 PT. - PERFORMED INCORRECTLY AND/ OR NEED SUPERVISION (P.I.)
0 PT. - NOT PERFORMED (N.P.)

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Student’s Name: ________________________ Evaluator: _____________________
Section/Group#:________________________ Date: _________________________

IV INSERTION SKILL CHECKLIST

PERFORMANCE CRITERIA PC (2 pts.) PI (1 pt.) NP (0) REMARKS

1. Prepare materials needed

2. Prime IV fluid

3. Apply tourniquet

4. Clean site with alcohol pad

5. Insert IV cannula (demonstrate the
right technique)
6. Secure IV cannula with tape

7. Hook IV tubing to cannula

8. Regulate IV PNSS to fast drip
during code blue
9. Verbalize “IV access available”
10. Verbalize given emergency
medicine via IV push / IV infusion
(e.g. 1st Epi given or Dopamine
drip started)
11. Recorded time of administration

12. Regulated IV rate as ordered

P.S. – 24 pts. TOTAL SCORE =

LEGEND: 2 PTS. - PERFORMED CORRECTLY W ITHOUT SUPERVISION (PC) RMF

1 PT. – PERFORMED I NCORRECTLY AND/ OR NEED SUPERVISION (RIS)
0 PT. - NOT P ERFORMED (N.P.)

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Student’s Name: ________________ Evaluator: ____________________

Section/Group#:________________ Date: ________________________

SUCTIONING SKILL CHECKLIST

PERFORMANCE CRITERIA PC (2 pts.) PI (1 pt.) NP (0) REMARKS

1. Hyperoxygenate using resuscitator

mask and bag
TO BE DONE ONCE INTUBATED:
2. Prepare suction machine and
suction catheters
3. Wear gloves

4. Turn on suction machine and

checks for function
5. Attaches top of catheter to suction
tubing
6. Hyperventilate using the
resuscitator bag (request other
member to perform the task)
7. Inserts and advances catheter into
endotracheal (ET) tube without
suction
8. Applies suction intermittently on
suction catheter adapter while
withdrawing the catheter
9. Coil catheter between fingers as it
is pulled out of ET tube, staying in
no more than 10 seconds
10. Hook back to resuscitator bag after
catheter has been removed from
ET tube
11. Rinse and flush suction catheter
12. Repeat suctioning in above order
(5-10) until secretions are removed
13. Suctions oral route

14. Completes suctioning, disconnects

catheter from suction tubing, wraps
catheter around gloved hand and
pulls glove off inside out
15. Turn off suction machine

P.S. – 30 pts. TOTAL SCORE=

LEGEND: 2 PTS - PERFORMED CORRECTLY W ITHOUT SUPERVISION (P.C.) RMF
1 PT - PERFORMED INCORRECTLY AND/ OR NEED SUPERVISION (P.I.)
0 PT - NOT PERFORMED (N.P.)

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