NURSING EDUCATION ADMINISTRATION

COMPETENCY ASSESSMENT TOOL

TITLE: Nursing role in cardiac/respiratory arrest.
Staff name: Job number: Job title: Unit:
Qualification: Diploma: ( ) BSN: ( ) Post-graduate: ( ) Contract date:

Self-assessment key: Evaluation: Validation:

0 – No experience/not competent M – Met V – Verbal
1 – Satisfactory/requires further NM – Not met DO – Direct observation
development R – Refer to improvement plan SP- Simulation Practice
Please tick (√) the appropriate box depending on the self-assessment key indicated above.
Self- EVALUATION
PERFORMANCE CRITERIA
assessment (ASSESSOR)
Date &
0 1 2 KNOWLEDGE Validation M NM R
Initial
1. Defines the meaning of Code Blue.
2. Identifies the members of the team for code blue.
3. Enumerate the role of each member (Team
leader, primary nurse, ICU nurse, charge
nurse nursing supervisor, Anesthesiologist,
Respiratory therapist.
4. Mentions how to activate the code blue.
SKILLS
Any Nurse who discovers the victim:
1. Assess/determine patient's responsiveness.
2. Call for help.
3. Position victim and open the airway .
4. Determine pulselessness not more than 10 seconds.
5. Position cardiac board under the patient.
6. Initiate Chest Compression.
7. Attach patient to monitor or defibrillator.
8. Insert intravenous cannula.
9. Check vital signs .
10. Start initial intravenous fluid.
11. Collect Blood sampling as ordered.
12. Administer emergency drugs as ordered by physician.
ICU Nurse Role:
1- Receives report from the available persons from the
treating team.
1. Directs code when Code Blue team Leader or a doctor
is not available.
2. Assist during endotracheal intubation (if Respiratory
Therapist is not available)
3. Assist patient's ventilation (Manual Resuscitation bag
and mask with O2 source).
4. Defibrillates/Cardioversion.
5. Vascular access if not yet established.
Charge Nurse Role :
1. Monitor Code Process.
2. Scene Control (Non participating Observers).
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3. Arrange for necessary equipment's.

4. Assist Code Team as needed.
Nurse Supervisor Role :
1. Documentation on the CPR data sheet .
2. Review with the team leader Cardiopulmonary
Resuscitation Sheet and for any problems that have
been identified.
3. Ensure that original CPR data sheet are fixed in patient
file, ensure to take the copy for CPR data sheet to be
submitted to respective CPR sub-committee.
4. Sending a request to the pharmacy as soon as possible
to get stock replacement.
Documentation:
1. The primary team nurse who is present during the
entire code must document on the CPR sheet prior the
arrival of the nurse supervisor who is going to
complete the documentation process. Documentation
on the CPR record includes:
1.1 Patient ID
1.2 Code Team Leader and rest of the members
1.3 Date, time and location
1.4 Intubation details and ventilation
1.5 Clinical data, eg. Pulse, blood pressure, breathing,
defibrillation, etc
1.6 Medications, infusions, outcome
ATTITUDE
1. Provide privacy & confidentiality.
2. Respect patient rights & responsibilities.
3. Displays confidence during the procedure.
Total
Total Evaluation Score in percentage % =
Total number of met
Total number of steps in each procedure x 100%

Comments:
_______________________________________________________________________________________________
Improvement plan:
_______________________________________________________________________________________________
Recommendation:
_______________________________________________________________________________________________
Evaluator’s Signature over printed name: Date: ________________________
Staff printed signature over printed name: Date: ________________________

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