University of Nueva Caceres

College of Nursing
Naga City
PERFORMANCE CHECKLIST

Capillary Blood Glucose Monitoring

Name _____________________________________________ Year & Section _______ Rating ____

Instruction: Check the following criteria after the student has practiced the skills. Check appropriate
scale.
Legend: 3 – Satisfactory 1- Poor/ Needs improvement
4 – Very Satisfactory 2 – Fair

Performance points 1 2 3 4 CI’s Remarks

Knowledge 30 %

Skills 35%

1. Verify doctor’s order on the frequency of

monitoring.
2. Gather the necessary equipment. Includes
glucometer, cotton balls with alcohol, dry cotton
balls, test strip, needle/lancet, clean gloves.
3. Prepare the equipment.
a. Check the expiration date of the test strips
b. Check the sterility and integrity of the test
strips, lancet and glucometer.
c. Calibrate and run the blood glucose meter with
a quality – control test following
manufacturer’s instructions as needed.
4. Perform hand hygiene and put on gloves.

5. Introduce yourself. Confirm the patient’s identity

6. Ensure the privacy of the patient

7. Explain the procedure to the patient.

8. Determine the time of the last meal of the patient.

9. Select the puncture site. If necessary, apply warm

moist compresses to the area for about 10
minutes.

10. Clean the intended puncture site with an alcohol

pad. Let it dry to air completely.

11. Insert the test strip into the blood glucose meter,
according to the manufacturer’s instructions.
12. Puncture the skin with a quick, continuous and
deliberate stroke using a single – use, auto
disabling lancet on the side of the patient’s
fingertip perpendicular to the lines of the
fingerprints.
13. Wipe away the first drop of blood using a gauze
pad or dry cotton balls.
14. Touch a drop of blood to the test area of the test
strip, make sure the entire test area is covered.
*** Don’t squeeze the patient’s finger too tightly because
doing so may dilute the specimen with plasma.
 15. After collecting the blood sample, apply firm
pressure to the puncture site using dry cotton to
stop the bleeding.
16. Read the digital display on the blood glucose meter
when the alarm sounds.
17. Provide after care to your equipment used.
Dispose used needle and strips properly
18. Remove gloves and wash hands.

19. Report any critical test results to the physician.

Administer medication corresponding to blood
glucose level as prescribed.
20. Document the procedure, result and management
given if any.
Attitude 35%

1. Performs procedure systematically

2. Performs procedure with ease and confidence.

3. Willingly accepts correction to improve

performance.
4. Demonstrates willingness to improve performance.

5. Observes proper decorum.

6. Wears appropriate uniform.

_________________ ______________ ___________________________

Student’s Signature Date CI’s Signature Over Printed Name
 University of Nueva Caceres
College of Nursing
Naga City
PERFORMANCE CHECKLIST

CATHETERIZATION

Name _____________________________________________ Year & Section _______ Rating _______

Instruction: Check the following criteria after the student has practiced the skills. Check appropriate
scale.

Legend: 3 – Satisfactory 1 – Poor / Needs Improvement

4 – Very Satisfactory 2 – Fair

Performance points 1 2 3 4 CI’s Remarks

Knowledge ( 30% )

Skills ( 35 % )

1. Check the doctor’s order.

2. Washes hands.

3. Gathers or assembles the equipment needed.

4. Prepares patient psychologically.

5. Provides the privacy and explains the procedure to the

patient.
6. Assist the patient to a supine position with legs slightly
spread.
7. Drapes the patient abdomen and thighs if needed.

8. Ensure adequate lighting of the penis and perineal area.

9. Applies the sterile gloves.

10. Opens the catheterization kit, using aseptic technique. Uses

the wrapper to establish a sterile field.
11. If inserting a retention catheter, attaches the syringe filled
with sterile water to the luer lock of the catheter. Inflates
and deflates the retention balloon. Detaches the water
filled syringe.
12. Attaches the catheter to the urine drainage bag.

13. Coats the distal portion of the catheter with water soluble,
sterile lubricant and places it nearby on the sterile field.
14. MALE
1. With non dominant hand, gently grasps the penis and
retracts the foreskin. With non dominant hand,
cleanses the glands penis with a povidone-iodine
solution.

2. Holds the penis perpendicular to the body and pulls up

gently.

3. Holding the catheter in the dominant hand, steadily

 inserts the catheter 8inches until the urine is noted in
the drainage bag or tubing.

4. If the catheter will be remove as soon as the patient’s

bladder is empty, inserts the catheter another inc,
places the penis in a comfortable position and holds the
catheter in place as the bladder drains.

5. Continues inserting until the hub of the catheter is met.

15. FEMALE
1. Gently spreads the labia minora with the fingers of non
dominant hands and visualizes the urinary meatus.
2. Holding apart with nondominant hand, uses the forceps
to pick up a cotton ball soaked in povidone iodine
solution and cleanses the periurethral mucosa.

3. Uses the downward stroke for each cotton ball and

disposes.

4. Keeps the labia separated with nondominant hand until

you inserts the catheter.

5. Steadily inserts the catheter into the meatus until urine

is noted in the drainage bag or tubing.
16. Reattached the water filled syringe to the inflation port.

17. Inflates the retention balloon with sterile water.

18. Once the balloon has been inflated, gently pulls the catheter
until the retention balloon is resting snug against the
bladder neck.
19. Secure the catheter either on the patient thigh or abdomen
is generally acceptable.
20. Places the drainage bag below the level of the bladder. Do
not let it rest on the floor. Secures the drainage tubing to
prevent pulling on the tubing and the catheter.
21. Removes gloves, disposes equipment.

22. Washes hands.

23. Assesses or documents the amount, color, odor, and quality

of urine.
Attitude ( 35% )

1. Performs procedure systematically

2. Performs procedure with ease and confidence.

3. Willingly accepts correction to improve performance.

4. Demonstrates willingness to improve performance.

5. Observes proper decorum.

6. Wears appropriate uniform.

_________________ ______________ ___________________________

Student’s Signature Date CI’s Signature Over Printed Name
 University of Nueva Caceres
College of Nursing
Naga City
PERFORMANCE CHECKLIST

SETTING UP

Name _____________________________________________ Year & Section _______ Rating _______

Instruction: Check the following criteria after the student has practiced the skills. Check appropriate
scale.

Legend: 5 – Excellent 3 – Satisfactory 1 – Poor / Needs Improvement

4 – Very Satisfactory 2 – Fair 0 – Not Done

Performance points 1 2 3 4 CI’s Remarks

Knowledge ( 30 % )

Skills ( 35 % )

1. Verifies written prescription and make IV label.

2. Observe 10 R’s when preparing and administering

medications.
3. Explains procedure (medication and action) to reassure
patient and significant others; secure consent if necessary.
4. Verifies for skin test of drug for IV incorporation (if skin
testing is necessary).
5. Does hand hygiene before and after the procedure.

6. Prepares necessary materials needed for the procedure such

as: IV tray with IV solution, administration set, IV cannula,
forceps soaked in antiseptic solution, alcohol swabs or
cotton balls soaked in alcohol with cover, plaster,
tourniquet, gloves, splint, and IV pole, sterile 2X2 gauze or
transparent dressing.
7. Checks the sterility and integrity of the IV solution, IV set
and other devices.
8. Places IV label on IVF bottle duly signed by RN who prepared
it (patient’s name, room no., solution, drug incorporation,
bottle sequence and duration, time and date.
9. Opens the seal of the IV infusion aseptically and disinfects
rubber port with cotton ball with alcohol.
10. Opens IV administration set aseptically and close the roller
clamp and spike the infusate container aseptically.
11. Fills drip chamber to at least half and prime it with IV fluid
aseptically
12. Expels air bubbles if any and put back the cover to the distal
end of the IV set.
Attitude ( 35% )

1. Performs procedure systematically

2. Performs procedure with ease and confidence.

3. Willingly accepts correction to improve performance.

4. Demonstrates willingness to improve performance.

 5. Observes proper decorum.

6. Wears appropriate uniform.

_________________ ______________ ___________________________

Student’s Signature Date CI’s Signature Over Printed Name
 University of Nueva Caceres
College of Nursing
Naga City
PERFORMANCE CHECKLIST

CHANGING AN IV SOLUTION

Name _____________________________________________ Year & Section _______ Rating _______

Instruction: Check the following criteria after the student has practiced the skills. Check appropriate
scale.

Legend: 5 – Excellent 3 – Satisfactory 1 – Poor / Needs Improvement

4 – Very Satisfactory 2 – Fair 0 – Not Done

Performance points 1 2 3 4 CI’s Remarks

Knowledge ( 35 % )

Skills ( 35 % )

1. Verifies doctor’s prescription in doctors order sheet,

countercheck IV label, IV card, infusate sequence, type,
amount, additives (if any), and duration of infusion.
2. Observe 10 R’s

3. Explains procedure to reassure patient and significant

others and assess IV site for redness, swelling, pain and etc.
4. Changes IV tubings and cannula if 48 – 72 hrs. has lapsed
after IV insertion.
5. Washes hands before and after the procedure.

6. Prepares necessary materials; place on an IV tray.

7. Checks the sterility and integrity of IV solution.

8. Places IV label on IV bottle.

9. Calibrates new IV bottle according to duration of infusion as

per prescription.
10. Opens and disinfect rubber port of IV solution to follow.

11. Closes the roller clamp and spike the container aseptically.

12. Regulates the flow rate based on the prescribed infusion

rate of infusion. Expels air bubbles (if any).
13. Reiterates assurance to patient and significant others.

14. Discards all waste materials according to Health Care Waste

Management (DOH/DENR).
15. Documents and endorse accordingly.

Attitude ( 35% )

1. Performs procedure systematically

2. Performs procedure with ease and confidence.

3. Willingly accepts correction to improve performance.

4. Demonstrates willingness to improve performance.

 5. Observes proper decorum.

6. Wears appropriate uniform.

________________ ______________ ___________________________

Student’s Signature Date CI’s Signature Over Printed Name
 University of Nueva Caceres
College of Nursing
Naga City
PERFORMANCE CHECKLIST

DISCONTINUING AN IV SOLUTION

Name _____________________________________________ Year & Section _______ Rating _______

Instruction: Check the following criteria after the student has practiced the skills. Check appropriate
scale.

Legend: 3 – Satisfactory 1 – Poor / Needs Improvement

4 – Very Satisfactory 2 – Fair

Performance points 1 2 3 4 CI’s Remarks

Knowledge ( 30 % )

Skills ( 35 % )

1. Verifies written doctor’s order to discontinue IV including IV

medicines.
2. Observe 10 R’s

3. Assesses and inform the patient of the discontinuation of IV

infusion and of any medicine.
4. Prepares the necessary materials; IV tray or injection tray
with sterile cotton balls with alcohol, plaster, pick-up forceps
in antiseptic solution, kidney basin, band-aid.
5. Washes hands before and after the procedure.

6. Closes the roller clamp of the IV administration set.

7. Moistens adhesive tapes around the IV catheter with cotton

ball with alcohol; remove plaster gently.
8. Uses pick-up forceps to get cotton ball with alcohol and
without applying pressure, remove needle or IV catheter
then immediately apply pressure over the venipuncture site.
9. Inspect IV catheter for completeness.

10. Places dressing over the venipuncture site.

11. Discards all waste materials including the IV cannula

according to Health Care Waste Management (DOH/DENR).
12. Reassures patient.

13. Documents time of discontinuance, status of insertion site

and integrity of IV catheter and endorse accordingly.
Attitude ( 35% )

1. Performs procedure systematically

2. Performs procedure with ease and confidence.

3. Willingly accepts correction to improve performance.

4. Demonstrates willingness to improve performance.

 5. Observes proper decorum.

6. Wears appropriate uniform.

_________________ ______________ ___________________________

Student’s Signature Date CI’s Signature Over Printed Name
 University of Nueva Caceres
College of Nursing
Naga City
PERFORMANCE CHECKLIST

BLOOD TRANSFUSION

Name _____________________________________________ Year & Section _______ Rating _______

Instruction: Check the following criteria after the student has practiced the skills. Check appropriate
scale.

Legend: 3 – Satisfactory 1 – Poor / Needs Improvement

4 – Very Satisfactory 2 – Fair

Performance points 1 2 3 4 CI’s Remarks

Knowledge ( 30 % )

Skills ( 35 % )

1. Verifies doctor’s written prescription and make a treatment

card according to hospital policy.
2. Observe 10 R’s when preparing and administering blood or
blood components.
3. Explains the procedure/rationale for giving blood
transfusion to reassure patient and significant others and
secure consent. Gets patient’s history regarding previous
administration.
4. Explains the importance or the benefits on Voluntary Blood
Donation (RA 7719 – National Blood Service Act of 1994).
5. Request prescribed blood/blood components from blood
bank to include blood typing and X-matching and blood
result of transmissible disease.
6. Using a clean lined tray, gets compatible blood from hospital
blood bank.
7. Wraps blood bag with clean towel and keep it at room
temperature.
8. Have a doctor and a nurse assess patient’s condition.
Countercheck compatible blood to be transfused against X-
matching sheet noting ABO grouping and Rh, serial no. of
each blood unit, and expiry date with the blood bag label
and other lab. Blood exam as required before transfusion
(Hgb. And Hct.).
9. Gets the baseline vital signs – BP, R, temperature before
transfusion. Refer to M.D. accordingly.
10. Gives pre-med 30 minutes before transfusion as prescribed.

11. Does hand hygiene before and after the procedure.

12. Prepares equipment needed for BT (IV injection tray,

compatible BT set, IV catheter/needle G18/19, plaster,
tourniquet, blood component to be transfused, Plain NSS
500cc, IV set, G18 needle (only if needed), IV hook, gloves,
sterile 2X2 gauze or transparent dressing, etc.
13. If main IVF is with dextrose 5% initiates an IV line with
appropriate IV catheter with Plain NSS on another site,
anchor catheter properly and regulates IV drops.
14. Opens compatible blood set aseptically and close roller
 clamp. Spike blood bag carefully; fill the drip chamber at
least half full; prime tubing and remove air bubbles (if any).
Use needle G18/19 for side drip (for adults) or G22 for pedia
(if blood is given through the Y injection port, the gauge of
needle is disregarded).
15. Disinfects the Y-injection port of IV tubing (Plain NSS) and
insert the needle from BT administration set and secure with
adhesive tape.
16. Closes roller clamp of IV fluid of Plain NSS and regulate t
KVO while transfusion is going on.
17. Transfuses the blood via the injection port and regulate at
10-15gtts. Initially for 15 minutes and then at prescribed
rate. (usually based on the patient’s condition)
18. Observes patient for 10-15 minutes for any immediate
reaction.
19. Observes patient on an on-going basis for any untoward
signs and symptoms such as flushed skin, chills, elevated
temperature, itchiness, urticaria, and dyspnea. If any of
these symptoms occur stop the transfusion, open the roller
clamp of the IV line with Plain NSS, and report to doctor
immediately.
20. Swirls the bag hourly to mix the solid with plasma. N.B. one
B.T. set should be used for 1-2 units of blood.
21. When blood is consumed, closes the roller clamp of BT, and
disconnect from IV lines then regulate the IVF of plain NSS
as prescribed.
22. Continues to observe and monitor patient post transfusion,
for delayed reaction could still occur.
23. Re-checks Hgb and Hct, bleeding time, serial platelet count
within specified hours as prescribed and/or per institution’s
policy.
24. Discards blood bag and BT set and sharps according to the
Health Care Waste Management (DOH/DENR).
25. Documents the procedure, pertinent observations and
nursing intervention and endorse accordingly.
26. Reminds the doctor about the administration of Calcium
Gluconate if patient had several nits of blood transfusion (3-
6 or more units of blood).
Attitude ( 35% )

1. Performs procedure systematically

2. Performs procedure with ease and confidence.

3. Willingly accepts correction to improve performance.

4. Demonstrates willingness to improve performance.

5. Observes proper decorum.

6. Wears appropriate uniform.

_________________ ______________ ___________________________

Student’s Signature Date CI’s Signature Over Printed Name
 University of Nueva Caceres
College of Nursing
Naga City

PERFORMANCE CHECKLIST
ADMINISTRATION OF OXYGEN

Name _____________________________Year & Section _______________ Rating _______

Instruction: Check the following criteria after the student has practiced the skills. Check appropriate
scale.

Legend: 4 – Excellent 3 – Satisfactory 2 – Fair 1 – Poor/Needs Improvement

Performance points 4 3 2 1 CI’s Remarks

Knowledge ( 30 % )

Skills ( 35 % )
1. Verifies doctor’s order regarding oxygen therapy.
2. Prepares the necessary equipment.
3. Identifies the patient.
4. Introduces self.
5. Explains the procedure to the patient.
6. Positions the patient in semi-fowler’s position.
7. Plugs the flow meter into a wall outlet or tank. It should be
in the off position.
8. Attaches the humidifier bottle to the base of the flow
meter.
9. Attaches the prescribed oxygen at the prescribed rate and
ensures proper functioning.
10. Turns on the oxygen at the prescribed rate and ensures
proper functioning.
11. Tests the oxygen flow prior to catheter insertion.
12. Puts the nasal cannula over the patient’s face, with the
outlet prongs fitting into the nares or guide the mask
toward the client’s face and apply it from the nose
downward.
13. Secures the elastic band around the head or chin for the
nasal catheter and around the head for the mask.
14. Pads the tubing and band over the ears and cheekbones as
needed.
15. Provides the tubing and band over the ears and
cheekbones as needed.
16. Washes hands.
17. Documents oxygen use, flow rate and client’s response.

Attitude ( 35% )
1. Performs procedure systematically
2. Performs procedure with ease and confidence.
3. Willingly accepts correction to improve performance.
4. Demonstrates willingness to improve performance.
5. Observes proper decorum.
6. Wears appropriate uniform.

_________________ ______________ __________

Student’s Signature Date CI’s Signature Over Printed Name
 University of Nueva Caceres
College of Nursing
Naga City

PERFORMANCE CHECKLIST
NASOPHARYGNEAL AND OROPHARYNGEAL SUCTIONING

Name _____________________________________________ Year & Section ________Rating _______

Instruction: Check the following criteria after the student has practiced the skills. Check appropriate
scale.
Legend: 4 – Excellent 3 – Satisfactory 2 – Fair 1 – Poor / Needs Improvement

Performance points 4 3 2 1 CI’s Remarks

Knowledge ( 30 % )

Skills ( 35 % )
1. Determine the need for suctioning for postoperative clients,
and administer pain medication before suctioning.
2. Explain the procedure to client.
3. Assemble equipment needed.
4. Perform hand hygiene.
5. Adjust bed to a comfortable position. Lower slide rail to
closer to you.
 If clients are conscious, place his/her in a semi-
Fowler’s positions.
 If patients are unconscious, place his/her in the
lateral position, facing you.
6. Place a towel or waterproof pad across the client’s chest.
7. Turn suction to appropriate pressure.
8. Open sterile suction package. Set up sterile container,
touching only the outside surface, and pour sterile saline
into it.
9. Don’t sterile gloves. The dominant hand that will handle the
catheter must remain sterile, while the non-dominant hand
is considered clean rather than sterile.
10. With sterile gloved hand, pick up sterile catheter and
connect to suction tubing that is held with unsterile hand.
11. Moisten catheter by dipping it into the container of sterile
saline.
12. Estimate the distance from the ear lobe to the nostril and
place thumb and forefinger of gloved hand at the point on
the catheter.
13. Gently insert the catheter with the suction off by leaving
vent on Y connector open.
14. Apply suction intermittently occluding the suctioning port
with your thumb, and gently rotate the catheter as it is
being withdrawn. Do not suction more than 10 to 15 second
at a time.
15. Flush catheter with saline and repeat suctioning as needed
and according to the client’s tolerance.
16. Allow at least 20-30 second interval if suctioning is needed.
Alternate the nares if repeated suctioning is required. Do
not force catheter through the nares. Encourage patient to
cough and deep breathe between suctioning in proper.
Suction the oropharynx.
17. When suctioning is completed, remove gloves inside out and
dispose gloves, catheter, and container with solution in
proper receptacle.
18. Perform hand hygiene.
19. Use auscultation to listen to chest and breathing sounds to
 assess effectiveness of suctioning.
20. Offer oral hygiene after suctioning.
21. Document the time of suctioning and the characteristics and
the time of secretions. Also note the character of the client’s
respiration before and after suctioning.
Attitude (35%)
1. Performs procedure systematically
2. Performs procedure with ease and confidence.
3. Willingly accepts correction to improve performance.
4. Demonstrates willingness to improve performance.
5. Observes proper decorum.
6. Wears appropriate uniform.

__________________ ______________ ____________________________

Student’s Signature Date CI’s Signature over Printed Name
 University of Nueva Caceres
College of Nursing
Naga City

PERFORMANCE CHECKLIST
ASSISSTING PATIENT UNDERGOING NEBULIZATION

Name ___________________________ Year & Section ________________ Rating _______

Instruction: Check the following criteria after the student has practiced the skills. Check appropriate
scale.

Performance points 4 3 2 1 CI’s Remarks

Knowledge ( 30 % )
Skills ( 35 % )
1. Verifies doctor’s order regarding nebulization therapy.
2. Prepares the necessary equipment.
3. Identifies the patient.
4. Introduces self.
5. Explains the procedure to the patient.
6. Washes hands.
7. Places the patient in sitting or semi-fowler’s position.
8. Attaches the tubing to an outlet connector of the nebulizer.
9. Fills the nebulizer cup with the required medication.
10. Plugs the power cord into the wall outlet.
11. Presses “ON” the power switch.
12. Instructs patient on to inhale slowly, deeply from the
mouthpiece, hold breath and exhale until all medication is
nebulized.
13. Perform chest clapping.
14. Encourages the patient to periodically cough and expectorate
loosened secretions during the treatment.
15. Encourages proper disposal of secretion.
16. Performs aftercare of the equipment.
17. Washes hands.
18. Documents medication used, respiratory rate, effort and
description of secretions
Attitude ( 35% )
1. Performs procedure systematically
2. Performs procedure with ease and confidence.
3. Willingly accepts correction to improve performance.
4. Demonstrates willingness to improve performance.
5. Observes proper decorum.
6. Wears appropriate uniform.
Legend: 4 – Excellent 3 – Satisfactory 2 – Fair 1 – Poor/ Needs Improvement

_________________ ______________ ________________

Student’s Signature Date CI’s Signature Over Printed Name
 University of Nueva Caceres
College of Nursing
Naga City

PERFORMANCE CHECKLIST
INFANT NASO GASTRIC TUBE FEEDING

Name ____________________________Year & Section __________Rating ____________

Instruction: Check the following criteria after the student has practiced the skills. Check appropriate
scale.
Legend:
4 – Excellent 3 – Satisfactory 2 – Fair 1 – Poor / Needs Improvement
 Performance points 4 3 2 1 CI’s
Remarks
Knowledge (30 % )
Skills (35%)
1.Verifies doctor’s order.
2.Prepares the needed equipment and supplies.
3.Identifies the patient.
4.Introduces self to the significant other.
5.Explains to the significant others what you are going to do,
why is it necessary and how they can cooperate.

6.Washes hands.
7.Loosely swaddle the infant.
8.Using a French 8-10 inches feeding tube measure from the
infant’s nose to the earlobe to a point halfway between the
umbilicus and the xyphoid process.
9.Mark the tube at measured point and lubricate the tip with
sterile water.
10.Pass catheter gently into the nose through the mouth with
gentle pressure until the marked point is reached.
11.Check the catheter position by checking placement into the
stomach.
a. Attach a 10cc syringe into the tube and check
placement by aspirating stomach contents.
b. Places your stethoscope on the abdomen over the
stomach and introduce 5 ml of air into the tube and listen
for gurgling sound.
FEEDING
12.Assess stomach contents.
13.Attach syringe or feeding funnel into the tube.
14.Elevates infant’s head and chest.
15.Slowly introduce feeding/ milk into the syringe or funnel by
means of gravity.
16.After desired feeding, flush with 1 to 5 ml of water and
recap the tube.
17.Unswaddle the baby, bubble and place the baby on her
right side with the head slightly elevated.
18.Evaluates cry sounds, use a stethoscope to check air entry
into the lung by auscultation

19.Washes hands.

20.Document infant’s response to feeding

Attitude ( 35% )
Performs procedure systematically
Performs procedure with ease and confidence.
Willingly accepts correction to improve performance.
Demonstrates willingness to improve performance.
Observes proper decorum.
Wears appropriate uniform.

_______________ __________________ _____________________________

Student’s Signature Date CI’s Signature Over Printed Name
 University of Nueva Caceres
College of Nursing
Naga City

CHILD CPR

Name ______________________________Year & Section ____________Rating __________

Instruction: Check the following criteria after the student has practiced the skills. Check the appropriate
scale.

Legend:
4 – Excellent 3 – Satisfactory 2 – Fair 1 – Poor / Needs Improvement

Performance points 4 3 2 1 CI’s Remarks

Knowledge ( 35 % )

Skills ( 35 % )

1. Defines Cardiopulmonary Resuscitation

2. Differentiates cardiac arrest from respiratory arrest

3. Enumerates ratio of compression and ventilation to a

child
4. Enumerates the causes of cardiac and pulmonary arrest

Skills

1. Survey the scene

2. If the scene is safe, tap the shoulder: “Hey, hey are you
okay?
3. Patient is unresponsive, call for help

4. open the airway using the head/tilt chin lift method:

Place one hand on victims forehead and the fingers of
the other hand under the bony part of the lower jaw
near chin, the tilt head and lift jaw-avoid closing victims
mouth; or the jaw thrust method if suspected with neck
injury.

5. Do finger sweep to remove the object

6. Check for breathlessness

a. Maintain open airway

b. Place your ear over victims mouth

c. Look at the chest, listen and feel (LLF) for breathing for
10 seconds:” thousand-one, 1002…. 1010”

7. IF the victims is not breathing , give 2 full breaths

a. Maintain open airway

b. Pinch nose using index and thumb

c. Open your mouth wide, take a deep breath, and make a

tight seal around outside of victims mouth

d. Give 2 slow breaths (1 ½ to 2 seconds per breath)

e. Observe chest rise and fall; listen and feel for escaping
air
f. Allow for chest recoil

8. Check again for breathing and pulse

a. Maintain head tilt one-hand and forehead

b. Locate adams apple with middle and index fingers

offhand then slide fingers down into the groove of neck
on side closest to you
c. Look, listen and feel (LLF) for breathing and check
carotid pulse for 10 seconds
9. If not breathing and pulse same
 a. Give one breath every 3 seconds (40 cycles)

b. breathe , 1, 1001(2nd breath) 1, 1002 ( 3rd breath).....n

1, 1003) (40th breath)
10. Check Breathing And pulse ( same as #8)

11. If with (-) breathing , (-) pulse:

a. Kneel facing victims chest at the level of victims

shoulder
b. With middle and index finger of hand nearest victims
legs, locate lower edge of victims rib cage on side
closest to you
c. Follow rib cage to “notch” at lower end of breastbone

d/ place middle finger ion “notch” and index finger next to

it on the lower end of breastbone

e. place heel of hand nearest victim's head on breastbone

next ro index finger if hand used to find “:notch”

F. keep finger off victim's chest

G. position shoulder over hand with elbow locked and arms

straight

H. compress the breastbone 1 to 1 ½ inches of 100

compressions per minute( 30 compressions should take
60 to 120 seconds)

I. count aloy (30:2)

“1, 2, 3, 4, 5, 6, 7, ,8 ,9 10, 11, 12, 13, 14, 15, 16, 17, 18, 19,
20, 1, 2, 3, 4, 5, 6, 7, ,8 9, and 1 and the give 2 breaths
“1, 2, 3, 4, 5, 6, 7, ,8 ,9 10… 20, 1, 2, 3, and 5m then give
1 breath

J. compress down and release pressure smoothly, keeping

han in contact with chest all the times

K. Check Breathing And pulse (LLF)

12. If with (+) breathing (+) pulse, place patient in recovery

position

Attitude ( 30% )

1. Performs procedure systematically

2. Performs procedure with ease and confidence.

3. Willingly accepts correction to improve performance.

4. Demonstrates willingness to improve performance.

5. Observes proper decorum.

6. Wear appropriate uniforms.

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Student’s Signature Date CI’s Signature Over Printed Name