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Skills Evaluation Form Cardiopulmonary Resuscitation

1. The document is a skills evaluation form for performing cardiopulmonary resuscitation (CPR) on an adult. It lists the key steps of CPR and scores the performer on proper technique. 2. The evaluation covers assessing the scene, checking responsiveness, calling for emergency help, performing chest compressions and rescue breathing in the proper form and timing. 3. The performer is scored on their ability to complete each step correctly, with an emphasis on compression rate, depth, recoil and minimizing interruptions to compressions.

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0% found this document useful (0 votes)
1K views1 page

Skills Evaluation Form Cardiopulmonary Resuscitation

1. The document is a skills evaluation form for performing cardiopulmonary resuscitation (CPR) on an adult. It lists the key steps of CPR and scores the performer on proper technique. 2. The evaluation covers assessing the scene, checking responsiveness, calling for emergency help, performing chest compressions and rescue breathing in the proper form and timing. 3. The performer is scored on their ability to complete each step correctly, with an emphasis on compression rate, depth, recoil and minimizing interruptions to compressions.

Uploaded by

EMS Region2
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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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: _________________________

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