Start Time: _______________Stop Time: _______________ Date: ______________________
Candidate’s Name: _______________________________________
Evaluator’s Name: ________________________________________
Possible Points | Awarded Points | |
Takes, or verbalizes, body substance isolation precautions | 1 |
|
Establishes unresponsiveness—attempts to stimulate | 1 |
|
Prevents heat loss—keeps newborn as warm as possible | 1 |
|
Opens the airway (head tilt – chin lift or jaw thrust maneuver to a neutral position) | 1 |
|
Assesses breathing (look, listen, and feel) to identify absent or inadequate breathing—taking no more than 10 seconds | 1 |
|
If victim is not breathing, gives 2 slow breaths (mouth-to-mouth-and-nose with enough volume to make the chest rise, taking 1/2 to 1 second per breath) | 1 |
|
Assesses for signs of circulation by feeling for a brachial pulse—taking no more than 10 seconds | 1 |
|
If heart rate is 60 to 80 bpm and not rising, ventilation should be the priority in resuscitation. If there are no signs of circulation or if heart rate is <60 bpm, begins chest compressions by locating proper hand position. | 1 |
|
Performs 3 chest compressions at a rate of approximately 120 per minute at a depth of 1/2 to 1 inch, using the 2 finger technique for 1 rescuer and 2 thumb technique for 2 rescuers [unless local protocols require a 5:1 ratio] | 1 |
|
Opens the airway and delivers 1 slow rescue breath (1/2 second, using a bag-mask ventilation for 2 rescuers, if readily available) | 1 |
|
Finds the proper hand position and continues with a series of 3 compressions and 1 breath at a rate of 120 per minute (unless local protocols require a 5:1 ratio) | 1 |
|
After approximately 1 minute, reassesses for signs of circulation— taking no more than 10 seconds | 1 |
|
If there are still no signs of circulation, resumes CPR, beginning with chest compressions, checking for signs of circulation and spontaneous breathing every few minutes | 1 |
|
If signs of circulation are present, checks for breathing | 1 |
|
If breathing is present, places the victim in a recovery position and monitors breathing and circulation | 1 |
|
If breathing is absent but signs of adequate circulation are present or if heart rate continues at a rate <100 bpm, provides rescue breathing at 40 to 60 per minute using a neonatal BVM and monitors for signs of circulation every few minutes | 1 |
|
16 |
|
Critical Criteria
_____ Did not take, or verbalize, body substance isolation precautions
_____ Did not take steps to prevent heat loss
_____ Did not open the victim’s airway
_____ Did not establish that the victim was not breathing or that breathing was inadequate
_____ Took longer than 10 seconds to establish the patient was not breathing
_____ Did not assess for a pulse
_____ Took longer than 10 seconds to establish the patient had no pulse
_____ Did not begin assisted ventilations with heart rate of 100 bpm or less
_____ Did not begin chest compressions with heart rate of 60 bpm or less
_____ Did not deliver adequate rescue breaths
_____ Did not deliver compressions at an appropriate depth, location, or rate
_____ Did not reassess the patient’s circulatory or respiratory status
_____ Did not assess breathing status after the return of a pulse
_____ Did not provide appropriate rescue breaths as necessary after the return of a pulse