Performance Evaluation #1
Caring for Cardiac Arrest
Basic Life Support — Adult
Student Name___________________________________________________ Class Date_________________________
Adult Scenario — You are a BLS provider responding to a bystander report of someone who has collapsed.
As you approach the location you can see that bystanders are available, but no bystander CPR is being per-
formed. Other BLS providers are en route to your location. You have disposable gloves and a CPR mask, and an
AED is located nearby.
Student Action Check
Procedure Instructor Prompt
(Performance Criteria) Off
Scene Assessment • Pauses and assesses scene Scene is safe!
for safety. £
Standard Precautions • Uses disposable gloves (can be
verbalized) £
Response Assessment • Taps or squeezes shoulder. There is no response!
• Asks loudly, “Are you all right?” £
Breathing and Pulse Assessment • Checks face and chest for signs of There is no breathing, or only
breathing. gasping, and no palpable pulse!
• At same time, feels for a carotid
pulse. £
• Takes no longer than 10 seconds to
check.
Emergency Protocol Activation • Asks another person to activate
emergency protocol and get an AED. £
30 Chest Compressions • Positions two hands on lower
breastbone.
• Uses upper body weight to
compress.
• Compresses at least 2 inches. £
• Compresses at a rate of 100–120
times per minute.
• Allows chest to fully recoil at top of
compressions.
2 Rescue Breaths • Establishes an open airway.
• Uses CPR mask.
• Creates visible rise of chest, but no
more.
• Ensures each breath is 1 second in £
length.
• Gives both breaths in less than 10
seconds.
Continued CPR • Repeats 30:2 CPR cycles. (Student needs to complete at
least 1 cycle of 30:2 CPR cycles
before indicating the arrival of an
AED.)
£
AED arrives!
Continued on next page ➠
© 2017 American Safety & Health Institute PRN3128 (1/17)
Student Action Check
Procedure Instructor Prompt
(Performance Criteria) Off
AED Attachment • Stops CPR and turns AED on.
• Bares chest.
• Applies pads as indicated by pictures
£
on them.
AED Analysis • Makes sure no one is touching (AED) Analyzing!
person being analyzed. £
Shock Delivery • Checks to make sure no one is in (AED) Shock advised!
contact with person being shocked.
£
• Presses shock button. (AED) Shock delivered!
Resumption of CPR • Immediately resumes CPR, starting
with compressions. £
End Evaluation
Overall Performance (check only one)
£ Checked Off: Met minimal competency as defined by the performance criteria
£ Not Checked Off: Did not meet minimal competency as defined by the performance criteria
Signature of Instructor_____________________________________________________________________________________________
© 2017 American Safety & Health Institute
Performance Evaluation #1
Caring for Cardiac Arrest
Basic Life Support — Infant
Student Name___________________________________________________ Class Date_________________________
Infant Scenario — A woman is running towards you with a limp infant in her arms, shouting, “Please help…
he’s not breathing!” As a BLS provider, you have disposable gloves, a pediatric CPR mask, and a radio to con-
tact other BLS providers.
Student Action Check
Procedure Instructor Prompt
(Performance Criteria) Off
Scene Assessment • Pauses and assesses scene Scene is safe!
for safety. £
Standard Precautions • Uses disposable gloves (can be
verbalized) £
Response Assessment • Taps foot. There is no response!
• Shouts loudly. £
Breathing and Pulse Assessment • Checks face and chest for signs of There is no breathing, or only
breathing. gasping, and no palpable pulse!
• At same time, feels for a brachial
pulse. £
• Takes no longer than 10 seconds to
check.
Emergency Protocol Activation • Uses radio to activate emergency
protocol. £
30 Chest Compressions • Positions two fingers on breastbone,
just below nipple line.
• Compresses at least 1/3 depth of
chest or about 1½ inches.
• Compresses at a rate of 100–120 £
times per minute.
• Allows chest to fully recoil at top of
compressions.
2 Rescue Breaths • Establishes an open airway.
• Uses CPR mask.
• Creates visible rise of chest, but no
more.
• Ensures each breath is 1 second in
£
length.
• Gives both breaths in less than 10
seconds.
Continued CPR • Repeats 30:2 CPR cycles. (Students need to complete at
least two 30:2 CPR cycles before
indicating the arrival a second
provider.) £
Second BLS provider with
pediatric bag-mask arrives!
Continued on next page ➠
© 2017 American Safety & Health Institute PRN3128 (1/17)
Student Action Check
Procedure Instructor Prompt
(Performance Criteria) Off
Change to Two-Provider CPR • Initial provider quickly adjusts to (Students need to complete at
perform compressions with thumb least one 15:2 CPR cycle after
tips and hands encircling chest. switching places.)
• Second provider opens airway and
prepares to give rescue breaths using £
bag mask.
• Changes to a 15:2 compression to
rescue breath CPR ratio.
Switch Roles • Communicates switch ahead of time. (Students need to complete at
• Switch is initiated while rescue least one 15:2 CPR cycle after
breaths are being given. switching places.) £
• Resumes 15:2 CPR cycles
End Evaluation
Overall Performance (check only one)
£ Checked Off: Met minimal competency as defined by the performance criteria
£ Not Checked Off: Did not meet minimal competency as defined by the performance criteria
Signature of Instructor_____________________________________________________________________________________________
© 2017 American Safety & Health Institute
