Name: ______________________________________ Date: _______________________________

Year / Section / Group: ____________________________ Semester: ____________ SY: ____________

Return Demonstration: PERFORMING CARDIOPULMONARY RESUSCITATION

Objective: To administer cardio-pulmonary resuscitation correctly and competently following the principles and set of rules in
performing the procedure in order to restore and maintain breathing and circulation and to provide oxygen and blood flow to the
heart, brain, and other vital organs to support and maintain breathing and circulation for an infant, child, or adolescent who has
breathing (respiratory arrest) and/or whose heart has ceases (cardiac arrest).
Instruction: Check on the column of your choice as to what level is the performance of the student in the following procedure.
Be guided in the scoring with the legend below.
4 – Very Satisfactory (Performed all the procedures correctly)
3 – Satisfactory (Needs Minimal assistance in performing the procedure)
2 – Good (Needs more practice in performing the procedure)
1 – Fair (Inappropriate in the performance of the procedure)

Score
Step Criteria 4 3 2 1

1 Assesses the patient’s responsiveness

 Calls for help if the patient is unresponsive
2 Positions the patient on his back on a firm flat surface with arms alongside the
body
 If the patient is in bed, places a cardiac board or any rigid surface
under the patient
3 Uses the head tilt chin lift maneuver to open the airway
 Places one hand on the victim’s forehead and applies a firm backward
pressure with the palm to tilt the head back
 Places the finger of the other hand under the bony part of the lower
jaw near the chin and lifts the jaw upward to bring the chin forward
4 Looks, listens, and feels for the air exchange
5 If the patient resumes breathing, or adequate respirations and signs of
circulation are noted are noted, places the patient in recovery position
6 Notes for spontaneous breathing.
 Assess oral airway for any foreign material lodged in
 If foreign material is present, uses either suction, finger sweep, or
chest thrust to remove foreign object
7 Reassesses for spontaneous breathing
8 If spontaneous breathing does not resume, seals the patient’s mouth and nose
with a face shield and instills 2 rescue breaths each lasting for 1 second
9 Checks the carotid pulse, simultaneously evaluates breathing, coughing, or
movement
10 If patient has a pulse but remains without spontaneous breathing, continues
rescue breathing at a rate of 1 breath per 5-6 seconds/ 10-12 breaths per minute

11 If patient exhibits no signs of circulation, positions the heel of one hand in the
center of the chest between the nipples, directly over the lower half of the
sternum
 Places the other hand directly over the first hand and interlaces
finers.
12 Performs 30 chest compressions (counting “one, two, three, and four…”)
 Keeps elbows locked, arms straight, and shoulders positioned directly
over the hands
 Depresses the sternum 1/3 the depth of the chest, and allows full chest
recoil after each compression
13 Gives 2 rescue breaths after each set of 30 compressions
 Does 5 cycles of compressions and ventilations
14 Reassess breathing and circulation after each set of 5 compression-breathing
cycles
15 Continues CPR until patient resumes spontaneous breathing and circulation
SUBTOTAL
TOTAL SCORE
PERFECT SCORE 60 PTS.

Date Performed: _______________________________________

_________________________ ______________________________
Name & Signature of Student Name & Signature of RD Instructor

Remarks
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