OUR LADY OF FATIMA UNIVERSITY
College of Nursing – Pampanga
PROGRAM Bachelor of Science in Nursing Student Name
Year and Section
COURSE NCM 104 Instructor
Date
PROCEDURE : CARDIO PULMONARY RESUSCITATION (CPR) ADULT
EXPECTED OUTCOME : The student should be able to perform CPR
ASESSMENT TASK : Return demonstration
Exceptional Good Average Poor
Assessment Dimension SCORE
(3) (2) (1) (0)
1. DANGER
A. Wear PPE (gloves, Performed Performed Performed the Failed to
apron, mask), look out for assessment with assessment with assessment perform the
blood spills, sharps, ease without little errors with some assessment.
electric wires, supervision. errors.
Unsteady beds, trolley
2 RESPONSE
A. Shoulder Tap The procedure The procedure The procedure Failed to
B. Shout & Speak performed performed but performed with perform the
accurately with needs minimal slight difficulty, procedure.
evident ease supervision. needs
without supervision supervision
most of the
time.
3. SHOUT FOR HELP
A. Shout ‘Emergency! The procedure The procedure The procedure Failed to
Emergency! Bring the performed performed but performed with perform the
resuscitation trolley and accurately with needs minimal slight difficulty, procedure
defibrillator!’ evident ease supervision. needs
without supervision supervision
most of the
time.
4. AIRWAY
A. Head Tilt Chin Lift The procedure The procedure The procedure Failed to
B. Jaw Thrust performed performed but performed with perform the
accurately with needs minimal slight difficulty, procedure
evident ease supervision. needs
without supervision supervision
most of the
time.
5. BREATHING
Absent / abnormal breathing The procedure The procedure The procedure Failed to
A. Determined performed performed but performed with perform the
simultaneously while opening accurately with needs minimal slight difficulty, procedure
the airway by looking at the evident ease supervision. needs
chest, neck and face for not without supervision supervision
more than 10s. most of the
time.
B. Chest compression shall
begin with absence of normal
breathing.
Normal breathing Performed the Performed the Performed the Failed to
Recovery position procedures with procedure with procedures with perform the
ease little errors some errors. procedure
6 CIRCULATION (CPR)
A. Location (Middle of chest, Performed the Performed the Performed the Failed to
lower half of sternum) procedures with procedure with procedures with perform the
B. Rate (100-120/min) ease little errors some errors. procedure
C. Depth (5-6 cm)
D. Full recoil after each
compression
E. Minimize Interruption
F. 30 compressions: 2
ventilations
G. Each ventilation in 1
second
7. PULSE CHECK ( After 5 Performed the Performed the Performed the Failed to
cycles/ 2 minutes) procedures with procedure with procedures with perform the
ease little errors some errors. procedure
A. Pulse Present, Abnormal or Performed the Performed the Performed the Failed to
No Breathing (not more than procedures with procedure with procedures with perform the
10 sec) --> ventilation 1 in 5-6 ease little errors some errors procedure
seconds
B. Pulse & Breathing Present - Performed the Performed the Performed the Failed to
---> procedures with procedure with procedures with perform the
Recovery Position ease little errors some errors. procedure
OVERALL SCORE: ________________
Target raw score is 23 out of 30. If raw score is less than 23, repeat the return demonstration.
___________________________________
FACULTY SIGNATURE OVER PRINTED NAME
OUR LADY OF FATIMA UNIVERSITY
College of Nursing – Pampanga
PROGRAM Bachelor of Science in Nursing Student Name
Year and Section
COURSE NCM 104 Instructor
Date
PROCEDURE : CARDIO PULMONARY RESUSCITATION (CPR) INFANT
EXPECTED OUTCOME : The student should be able to perform CPR
ASESSMENT TASK : Return demonstration
Exceptional Good Average Poor
Assessment Dimension SCORE
(3) (2) (1) (0)
1. DANGER
A. Wear PPE (gloves, Performed Performed Performed the Failed to
apron, mask), look out for assessment with assessment with assessment perform the
blood spills, sharps, ease without little errors with some assessment.
electric wires, supervision. errors.
Unsteady beds, trolley
2 RESPONSE
A. Shoulder Tap The procedure The procedure The procedure Failed to
B. Shout & Speak performed performed but performed with perform the
accurately with needs minimal slight difficulty, procedure.
evident ease supervision. needs
without supervision supervision
most of the
time.
3. SHOUT FOR HELP
A. Shout ‘Emergency! The procedure The procedure The procedure Failed to
Emergency! Bring the performed performed but performed with perform the
resuscitation trolley and accurately with needs minimal slight difficulty, procedure
defibrillator!’ evident ease supervision. needs
without supervision supervision
most of the
time.
4. AIRWAY
A. Head Tilt Chin Lift The procedure The procedure The procedure Failed to
performed performed but performed with perform the
accurately with needs minimal slight difficulty, procedure
evident ease supervision. needs
without supervision supervision
most of the
time.
5. BREATHING
A. Determined Performed the Performed the Performed the Failed to
simultaneously looking at the procedures with procedure with procedures with perform the
chest, neck and face for not ease little errors some errors. procedure
more than 10s.
B. Absent or abnormal
breathing
Give 5 initial rescue breaths
(Duration of delivering a
breath is about 1
second sufficient to produce
a visible chest rise)
Normal breathing Performed the Performed the Performed the Failed to
A.Recovery position procedures with procedure with procedures with perform the
Turn him on his side into the ease little errors some errors. procedure
recovery position.
B. Send or go for help.
C. Check for continuous
normal breathing
6 CIRCULATION (CPR)
A. Brachial Pulse Felt (not Performed the Performed the Performed the Failed to
more than 10 sec) procedures with procedure with procedures with perform the
B. Start chest compression ease little errors some errors. procedure
Technique:
a. For one rescuer CPR in an
infant, the rescuer
compresses with the tips of 2
fingers.
b. For two rescuers CPR in an
infant, the two-thumb chest
compression technique is
used.
Site of Compression Performed the Performed the Performed the Failed to
Lower half of the sternum procedures with procedure with procedures with perform the
Depth of Compression: ease little errors some errors procedure
At least 1/3 the depth of the
chest or 4 cm
Rate of Compression:
Push at the rate of at least
100-120/mm
Ratio of Compressions to
Breaths:
One Rescuer CPR - 15:2
Two Rescuers CPR - 15:2
7. a. Pulse Present/ pulse ≥ Performed the Performed the Performed the Failed to
60b/min (No procedures with procedure with procedures with perform the
Breathing/inadequate ease little errors some errors. procedure
breathing)
Give breathing 12-20
breaths/min for 2 min
b. Pulse present / pulse ≥ 60
b /min and normal
breathing- Recovery position
OVERALL SCORE: ________________
Target raw score is 23 out of 30. If raw score is less than 23, repeat the return demonstration.
___________________________________
FACULTY SIGNATURE OVER PRINTED NAME
