Far Eastern University

Institute of Health Sciences and Nursing

Department of Nursing

PERFORMANCE EVALUATION TOOL FOR

CPR: ADULT (ONE RESCUER)

NAME: SCORE:
SEC & GRP NO: CONCEPT:

DIRECTION: Rate the Learner based on the expected procedure/behavior listed below.

RATING DESCRIPTION
2 - Acceptable Demonstrates expected procedure / behaviors correctly.
1 - Moderately Acceptable Demonstrates expected procedure / behavior with minimal error.
0 - Unacceptable Missed procedure or procedure done but entirely incorrect.

Step Critical Performance Step Rating Remarks

Assessment & Activation

1 Survey the Scene: Shout “The scene is safe.” 0 1 2

2 Check for responsiveness: Taps and shouts, "Are

you alright, are you ok?"

3 Shout for help/Activates emergency response 0 1 2

system/Sends for AED. “Hey, you activate the EMS.
and grab an AED!”
4 Checks for no breathing or no normal breathing 0 1 2
(only gasping) by scanning from the head to the
chest for a minimum of 5 seconds and no more than
10 seconds.
5 Checks carotid pulse. Checks for a minimum of 5 0 1 2
seconds and no more than 10 seconds. Should be
done simultaneously with check for breathing.
Performs High Quality CPR

6 Bares patient's chest and locate CPR hand position. 0 1 2

Using 2 handed technique (second hand on top of
the first or grasping the wrist of the first hand)
place it at the lower half of sternum and start CPR.
7 Deliver compression rate at 100-120bpm. (30 0 1 2
compressions in 15 to 18 seconds)
8 Provides compression depth at least 2 in (5cm) – 2.4 0 1 2
in (6cm).
9 Allows full chest recoil. 0 1 2
10 Minimizes Interruptions during CPR 0 1 2
11 Opens airway by head-tilt-chin-lift or jaw thrust 0 1 2
maneuver
12 Provides 2 breath (using a barrier device or BVM) 0 1 2
over 1 second, each breath 6 seconds apart (Avoids
excessive ventilation).
13 Resumes chest compression. 0 1 2
AED Arrives (after 1 minute of CPR)

14. Powers on AED 0 1 2

 15. Attaches pads of AED correctly over the chest 0 1 2

16. Clears patient for analysis of cardiac rhythm. 0 1 2

Communicates clearly to all other rescuers to stop
touching victim.

17. Delivers shock (as prompted) 0 1 2

18. Resume High quality CPR for 2 minutes (Steps 5- 0 1 2

12)

Return Of Spontaneous Circulation

19. Reassess breathing and pulse for a minimum of 5 0 1 2

seconds and no more than 10 seconds.

20. If ROSC is noted, place patient on recovery 0 1 2

position.

Grade: Raw Score / 40 X 100 =

Signature of Student Name & Signature of Faculty