Skills Evaluation Form

CARDIOPULMONARY RESUSCITATION
(Adult)

Name ________________________________________ Date _____________________ Group ______

POINT REMARK
√/x
S S
1. Proper use of PPE. 4
2. Survey the scene, introduce and ask permission. 4
3. Checking of responsiveness.
a. Tapping of shoulders (2x). 3
b. Calling of name 3
4. Direct someone to call EMS. 2
5. Check Circulation, Airway, Breathing (5 seconds) 2
6. Perform chest compression at least 100 – 120 per minute.
a. Proper location of compression area (Center of the chest lower half of 4
the breast bone)
b. Proper depth of compression (2 to 2.4 inches or 5- 6 centimeters) 4
c. Allow the chest to return to its normal position. 4
d. Position shoulder over hands with elbows locked and arms straight. 4
e. Keep fingers in contact with the chest at all times. 4

7. Open the airway (Head-tilt-chin-lift-maneuver)

a. Proper head tilt (Neutral or slightly extended position) 4
b. Hand position (Forehead) 4
c. Finger on chin (Proper position) 4
8. Give 2 (one second) breath after 30 chest compression 5
9. While giving ventilation:
a. Nose maintained pinched 4
b. Full slow breaths (1 sec) x 2 4
c. Mouth seal 4
10. Repeat cycles of chest compressions and 2 ventilations for 5
5
cycles(approximately 2 minutes)
11. Check the carotid pulse for 5 seconds for every 2 minutes (Equivalent
5
to 5 cycles of CPR.
12. If pulse is positive and breathing is negative, give artificial
respiration. Give 1 breath every 5 seconds for 24 cycles (Blow, 1..2..3.. 1 5
up to 24 cycles)
13. While giving ventilation: 4
a. Nose maintained pinched 4
b. Mouth seal 4
14. Recheck the carotid pulse and breathing for 5 seconds. 5
15. Place the patient in recovery position if pulse and breathing is
5
present.
100

Minimum passing score: 80 points Score: _________________

Instructor’s Name: ______________________

Instructor’s Signature: ___________________

COMMENTS: _________________________