Republic of the Philippines

PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

INTENSIVE CARE NURSING – SKILLS CHECKLIST

MEGACODE/ADVANCED CARDIAC LIFE SUPPORT

NAME:

SECTI BSN 4-9 DATE: November 20, 2023

ON

Scenario
In cardiopulmonary arrest, the client’s heart, circulation and respiration suddenly ceased.
Cardiopulmonary Resuscitation (CPR) is a technique of basic life support used for the
purpose of oxygenating the brain and the heart until Advanced Cardiac Life support team
has arrived to take over the CPR and restore the normal cardiac and respiratory function of
the patient.

Typically, a nurse from the coronary care unit, the emergency room physician, a
respiratory therapist, an intravenous nurse, and a pharmacist make up the core of the
resuscitation team. In the community, this team may include emergency medical
personnel in contact with the hospital emergency department.

EQUIPMENT:
● Direct current defibrillator with paddles

● Interface material (disposable conducive gel pads, electrode gels and pastes)

● Resuscitative Equipment including Emergency Drugs

● ECG Machine/Cardiac Monitor

STEPS/PROCEDURE ACLS RATIONAL

1. Assess clinical manifestations of
cardiopulmonary arrest:
● Abrupt and complete
unconsciousness (no response
to tap or gentle shaking while
asking “Are you OK?”
● Apnea or gasping (agonal)
E
● Recognizing signs of
cardiopulmonary arrest is vital for
prompt intervention:
● A sudden loss of consciousness is a
hallmark sign, indicating oxygen
deprivation in the brain. Lack of
response to stimulation confirms
this scenario (Schlesinger, S. A.,
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

respirations. 2023).
● Cardiopulmonary arrest involves
● Absence of heart beat (no the cessation of effective
carotid, femoral, or radial breathing. Apnea, the absence of
pulsations) and blood pressure. spontaneous breathing, and
● ECG reveals asystole or gasping, known as agonal
respirations, are critical indicators
ventricular fibrillation of respiratory failure and
● Development of pallor or impending cardiac arrest (AHA
cyanosis Journals, n.d.).
● The absence of palpable pulses
(e.g., carotid, femoral, or radial)
indicates the cessation of the
heart's pumping action, leading to
systemic organ failure due to
inadequate blood circulation (Lee,
A.R., n.d.).
● Electrocardiogram (ECG) findings
play a crucial role in diagnosing
the underlying cardiac rhythm
during cardiopulmonary arrest.
Asystole (absence of any cardiac
activity) or ventricular fibrillation
(chaotic, uncoordinated
contractions of the heart muscle)
are often observed (Science.gov.,
n.d.).
● Reduced blood flow and oxygen
delivery to tissues result in
changes in skin color. Pallor (pale
skin) indicates inadequate blood
perfusion, while cyanosis (bluish
discoloration of the skin and
mucous membranes) signals a lack
of oxygen in the blood. These
changes are visible signs of the
systemic effects of
cardiopulmonary arrest (Balingit,
A. 2023; Pahal & Goyal, 2022).
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

2. The resuscitation team addresses Identifying why a cardiac arrest occurred,

the following questions:
● What is the underlying cause of
the cardiac arrest, and can it be
corrected?
● What type of arrest has
occurred (cardiac,
respiratory or both) ?
● What is the underlying heart
rhythm?
● What intervention
should be instituted?
3. The resuscitation team makes
every effort to limit the number
of times CPR must be
interrupted to perform
emergency procedures. Two
team members must continue to
administer CPR.
4. While some of the
resuscitation team members
do the following:
a. Apply a cardiac monitor
to the client and
identify the rhythm.
b. Record electrocardiac events
that occur during
resuscitation.
c. Immediately administer
defibrillation in the event of
the type of arrest, the heart rhythm
involved, and choosing the right
interventions are key factors in guiding
the resuscitation process and making
well-informed decisions (Kurkciyan I.,
1998).
Consistent chest compressions are crucial
to keep blood flowing to vital organs.
Limiting pauses increases the chances of a
successful resuscitation (Meaney P. A., et
al., 2013).
Regularly monitoring the cardiac rhythm
enables quick detection of shockable
rhythms like ventricular fibrillation or
ventricular tachycardia. The goal of
defibrillation is to restore a normal heart
rhythm (LMS Resus., n.d.).
Recording electro cardiac events is crucial
for various reasons. It creates a
documented record of a patient's
response to interventions, aids in
assessing treatment effectiveness, and
facilitates post-event analysis and
debriefing. This documentation is
valuable for quality improvement
initiatives and research focused on
improving resuscitation outcomes (The
Royal Children’s Hospital Melbourne,
n.d.).
Ventricular fibrillation (VF) and
ventricular tachycardia (VT) are severe
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

ventricular fibrillation or heart rhythm disturbances that can lead

ventricular tachycardia.
5. Quickly attend to the client’s
ABCD
● Airway
● Breathing
● Circulation
● Differential diagnosis
6. Insert an oral (artificial)
airway to maintain the
tongue in a forward
position.
7. Administer 100% oxygen.
to cardiac arrest. Defibrillation is the
conclusive treatment for these shockable
rhythms. By delivering an electric shock,
defibrillation aims to depolarize the
myocardium, intending to restore a
regular cardiac rhythm. The prompt
administration of defibrillation enhances
the likelihood of successfully restoring a
perfusing rhythm and improving survival
outcomes (ACLS.com, n.d.).
When managing a patient in cardiac
arrest, fundamental steps include
addressing airway, breathing, and
circulation, along with conducting a
differential diagnosis. This approach
ensures a systematic and comprehensive
method for resuscitation (Cooksley, T. et
al., 2018).
In a cardiac arrest, the loss of
consciousness and muscle tone can lead
to the tongue falling backward, potentially
obstructing the airway. To prevent this,
an oral airway, also called an
Oropharyngeal Airway (OPA), is inserted
to keep the tongue from blocking the
upper airway. By ensuring an open
airway, this facilitates the passage of air,
enabling effective ventilation with rescue
breaths, especially in situations where
bag-mask ventilation is employed (Castro
& Freeman, 2023).
Sufficient oxygenation is crucial for
maintaining vital organ function during a
cardiac arrest. Providing 100% oxygen
ensures a higher concentration in the
bloodstream, supporting organs and
tissues, including the heart and brain.
This is typically achieved through a bag-
mask ventilation system or advanced
airway devices. Elevated oxygen levels
are essential for cellular respiration,
helping to mitigate potential hypoxia-
related damage to vital organs (Henlin, et
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

al., 2014).

8. Insert an endotracheal tube as Endotracheal intubation entails inserting

soon as possible to achieve
maximal airway clearance and
oxygenation.
a tube through the trachea to establish a
secure airway, offering a more definitive
approach compared to other methods.
This procedure provides enhanced
control over ventilation and oxygenation.
Additionally, it safeguards the airway
from gastric content aspiration and
facilitates direct medication delivery into
the lungs. The objective is to achieve
optimal airway clearance and enhance
oxygenation, supporting overall
resuscitation efforts (Avva, et al., 2023).
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

9. Suction the client as Suctioning plays a crucial role in preserving an

necessary to maintain a open airway, preventing blockages, and
patent airway. facilitating effective ventilation. Nasogastric
Nasogastric suction can suction specifically addresses gastric distension,
also facilitate gastric thereby reducing the risk of regurgitation
decompression if the (Pasrija, D., 2023).
stomach fills with air
during artificial
ventilation.
10. Start an intravenous line Establishing intravenous (IV) access is vital for
for administration of promptly administering medications to support
resuscitation cardiac function, correct arrhythmias, and
medications. Large-bore address metabolic imbalances (American Heart
catheters are preferable. Association, 2020).
11. Administer medications to: ● Epinephrine serves as the primary drug
administered during cardiopulmonary
● Stimulate
resuscitation (CPR) to reverse cardiac
myocardi arrest. Its alpha-1-adrenoceptor agonist
al effects increase arterial blood pressure
contractio and coronary perfusion during CPR
n (Callaway, 2013).
● Suppress ● In Advanced Cardiovascular Life Support
(ACLS), amiodarone is employed for its
ventricular antiarrhythmic properties, proving
ectopy effective in treating supraventricular and
● Accelerate ventricular arrhythmias (ACLS
cardiac rate Algorithms, n.d.).
● Within the cardiac arrest algorithm,
● Correct epinephrine takes precedence due to its
metabolic potent vasoconstrictive effects and its
acidosis. capacity to increase cardiac output by
elevating heart rate, heart muscle
contractility, and conductivity through
the AV node (ACLS Algorithms, n.d.).
● Sodium bicarbonate plays a role in
correcting metabolic acidosis during
cardiac arrest. This condition arises
post-cardiac arrest due to the
accumulation of acidic waste materials in
the body (Nurses Learning, n.d.).
12. Prepare for transthoracic Immediate transthoracic pacing demonstrated
or transverse pacing in the temporary effectiveness in restoring myocardial
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

event of asystole, severe electrical and mechanical activity in a

bradycardia, or complete
heart block.
13. Document the
resuscitation. The nurse
must keep an accurate,
ongoing record,
documenting all
procedures and
medications given during
the resuscitative effort.
14. Provide information. The
client’s record and the
primary caregiver, who
either knows the client or
has witnessed the
precipitating event,
should remain close by to
provide information to
the resuscitating team.
15. Reduce environmental
overcrowding. If
appropriate, ask people to
leave the room.
16. Notify significant others of
the critical nature of events
if they are not present at
the time of emergency.
17. The client’s spiritual
adviser may also be
notified to render
spiritual support.
18. Follow-up intervention.
significant number of asystolic patients (White,
J. & Brown, C., 1985).
The primary and most essential reason for
documenting the code is that the CPR record
serves as the medical record documenting all
interventions that take place during a
resuscitation (Resuscitation Central, 2022).
Trained support staff designated to accompany
family members must be available and present
at all times during the resuscitation, and must
be available to continue to provide support and
answer questions after the event. The patient’s
caregivers must have absolute veto power on
family presence (Brasel, K et. al., 2017).
Emergency Department (ED) overcrowding is
linked to higher rates of medical errors, lower
patient satisfaction scores, increased physician
burnout rates, elevated adverse events in older
patients, and heightened mortality rates
(Helman, A., 2019).
Recent evidence indicates that Family Presence
During Resuscitation provides psychological
benefits for family members present during
arrests, both in out-of-hospital and in-hospital
settings, irrespective of the treatment outcome
(Goldberger, Z et al., 2015).
Addressing the spiritual care needs of patients
can contribute to physical healing, pain
reduction, and personal growth. Nurses who
provide spiritual care tend to experience lower
stress levels and reduced burnout (Connerton,
C. & Moe, C., 2018).
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

a. Assess patient for ● The clinician should assess vital

possible post signs and monitor for recurrent
resuscitation disorders cardiac arrhythmias. Continuous
like: electrocardiographic (ECG)
monitoring should persist after
● Recurrent return of spontaneous circulation
dysrhythmias (ROSC), during transport, and
● Coma throughout ICU care until stability
has been achieved (Peberdy, M. et
● Other neurologic al., 2010).
disorders ● Post-cardiac arrest brain injury
(PCABI) results from initial
● Renal failure ischemia and subsequent
reperfusion of the brain following
resuscitation. In those admitted to
the intensive care unit after
cardiac arrest, PCABI presents as
coma and stands as the primary
cause of mortality and long-term
disability (Sandroni, C. et al.,
2021).
● Hypoxic-ischemic brain injury, the
most common neurological
consequence of cardiac arrest,
occurs when the heart is restarted.
This injury arises from the
interaction of oxygen,
reintroduced to the brain post-
cardiac arrest, with highly reactive
metabolites produced during the
arrest. The outcome is neuronal
damage and death (NYU Langone
Health, n.d.).
● Acute kidney injury (AKI) is
prevalent among cardiac arrest
survivors. It is associated with an
increased risk of mortality and
poor neurological outcomes
(Dutta, A. et al., 2020).
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

19. Diagnostic tests are often made
during and after resuscitation.
● Chest radiograph
● ECG
● Hemodynamic
monitoring
● Laboratory studies
(ABG, electrolytes,
BUN, creatinine,
blood glucose, and
cardiac enzyme).
● Chest X-Ray (CXR): A portable CXR
can identify pulmonary causes or
complications such as pulmonary
edema, pneumothorax, and
pneumonia. It also verifies the
correct positioning of an
endotracheal tube in intubated
patients (Mangla, A. et al., 2014).
● Bedside echocardiography can be
conducted if there is suspicion of
underlying cardiac ischemia, and
the initial ECG is inconclusive. In
patients unable to undergo CT for
suspected pulmonary embolism
(PE), echocardiographic evidence
of right ventricular dysfunction or,
in some cases, direct visualization
of clot can confirm the diagnosis.
Bedside echocardiography also
swiftly identifies conditions like
pericardial tamponade and
structural heart diseases such as
hypertrophic cardiomyopathy
(Mangla, A. et al., 2014).
● After cardiac arrest, maintaining
perfusion to vital organs is crucial
to prevent further clinical
deterioration (Mangla, A. et al.,
2014). Post–cardiac arrest care
holds significant potential for
reducing early mortality due to
hemodynamic instability and later
morbidity and mortality from
multiorgan failure and brain
injury (Peberdy, M. et al., 2010).
● Urine output and Serum
Creatinine are assessed to detect
acute kidney injury, maintain
euvolemia, and determine the
need for renal replacement
therapy if indicated. Serum
glucose levels are monitored to
identify and address
hyperglycemia or hypoglycemia
(Peberdy, M. et al., 2010).
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

20. Clients who survive
cardiopulmonary arrest are
admitted to critical care unit.
The study aims to assess the clinical and
evolving characteristics of patients
admitted to an intensive care unit
following cardiopulmonary resuscitation,
with a focus on identifying prognostic
factors influencing survival (Moreira, D.
et al., 2002).

SCORE

References:

American Heart Association (2020). 2020 Interim Training Materials: ACLS EP Changes.
https://cpr.heart.org/-/media/CPR2-Files/News-and-Events/Science-and-Guidelines/
2020_Guidelines_Interim_Materials/
2020_Interim_Training_Materials_ACLSEP_Changes_ONLY_ucm_506837.pdf

Avva, et al. (2023). Airway Management. https://www.ncbi.nlm.nih.gov/books/NBK470403/

Balingit, A. (2023) . What Causes Paleness and How To Treat It.

https://www.healthline.com/health/paleness

Lee, A. R. (2023). What Is Cardiac Arrest? https://www.health.com/cardiac-arrest-overview-

7484277

Castro & Freeman. (2023). Oropharyngeal Airway.

https://www.ncbi.nlm.nih.gov/books/NBK470198/

Cooksley, T. et al., (2018). A systematic approach to the unconscious patient.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6330912/

Henlin, et al. (2014). Oxygenation, Ventilation, and Airway Management in Out-of-Hospital Cardiac
Arrest: A Review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3958787/

Kurkciyan I., (1998). Accuracy and Impact of Presumed Cause in Patients With Cardiac Arrest.
https://www.ahajournals.org/doi/10.1161/01.CIR.98.8.766#:~:text=The%20knowledge%20of%20the
%20origin,an%20extremely%20high%20mortality%20rate.

LMS Resus. (n.d.). Cardiac Monitoring, Electrocardiography, and Rhythm Recognition.

https://lms.resus.org.uk/modules/m20-v2-monitoring-rhythm/11118/resources/chapter_8.pdf

Meaney P. A., et al. (2013). Cardiopulmonary Resuscitation Quality: Improving Cardiac

Resuscitation Outcomes Both Inside and Outside the Hospital.
https://www.ahajournals.org/doi/10.1161/CIR.0b013e31829d8654
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

Pasrija, D. (2023). Airway Suctioning. https://www.ncbi.nlm.nih.gov/books/NBK557386/

Pahal & Goyal, (2022). Central and Peripheral Cyanosis.

https://www.ncbi.nlm.nih.gov/books/NBK559167/

Schlesinger, S. A., (2023). Cardiac Arrest and CPR. https://www.msdmanuals.com/home/heart-

and-blood-vessel-disorders/cardiac-arrest-and-cpr/cardiac-arrest-and-cpr

Science.gov., (n.d.). Sample records for out-of-hospital ventricular fibrillation.

https://www.science.gov/topicpages/o/out-of-hospital+ventricular+fibrillation

ACLS.com. Shockable Rhythms: Ventricular Tachycardia, Ventricular Fibrillation, Supraventricular

Tachycardia. https://acls.com/articles/shockable-rhythms/

The Royal Children’s Hospital Melbourne. (n.d.) Nursing Documentation Principles.

Callaway CW. Epinephrine for cardiac arrest. Curr Opin Cardiol. 2013 Jan;28(1):36-42. doi:
10.1097/HCO.0b013e32835b0979. PMID: 23196774

Prepared by: Prof. Jennifer T. Lagundino

GRADING:
2 POINTS Complete Performance and
Rationale 1 POINT Incomplete Performance
and Rationale 0 POINT Incorrect
Performance and Rationale
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

Megacode Testing
Checklist
✓ if
Critical Performance
done
Steps correc
tly
Team Leader
1. Ensures high-quality CPR at all times
2. Assigns team member roles
3. Ensures that team members perform well
Bradycardia Management
1. Starts oxygen if needed, places monitor, starts IV
2. Places monitor leads in proper position
3. Recognizes symptomatic bradycardia
4. Administers correct dose of atropine
5. Prepares for second-line treatment
Pulseless VT and Ventricular Fibrillation Management
1. Recognizes pVT or V fib
2. Clears before analyze and shock
3. Immediately resumes CPR after shocks
4. Appropriate airway management
5. Appropriate cycles of drug–rhythm check/shock–CPR
6. Administers appropriate drug(s) and doses
Asystole and PEA Management
1. Recognizes Aystole or PEA
2. Verbalizes potential reversible causes of PEA (H’s and T’s)
3. Administers appropriate drug(s) and doses
4. Immediately resumes CPR after rhythm checks
Post–Cardiac Arrest Care
1. Identifies ROSC
2. Ensures BP and 12-lead ECG are performed, O2 saturation is monitored,
verbalizes need for endotracheal intubation and waveform capnography, and
carry out orders of laboratory tests
3. Considers targeted temperature management
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

Republic of the Philippines

 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)
General Luna Street corner Muralla
Street
Intramuros, Manila

COLLEGE OF
NURSING
INTENSIVE CARE
NURSING

MEGACODE / ADVANCED CARDIAC LIFESUPPORT

CARDIO-PULMONARY ARREST RECORD / CODE
FORM

PATIENT:
AGE/SEX: DATE:
TIME CODE STARTED: INITIATED BY:
DOCUMENTATION OF INTERVENTION
TIME ASSESSMENT MEDICATION GIVEN INTERVENTION REMARKS

RESUSCITATION OUTCOME
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

( ) REVIVED DATE: TIME:

BP: HR: RR: RHYTHM:
( ) EXPIRED DATE: TIME:
POST CARDIAC ARREST INTERVENTIONS:
 Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)

Intensive Care Nursing Skills Laboratory

STUDENT NURSES IN CHARGE:

RLE GROUP AND BLOCK:

Comments:

Student’s Name:
Date:

Clinical Instructor:
Signature