DE LA SALLE LIPA
COLLEGE OF NURSING
Nursing Care Management 109
Procedural Checklist in BLS (Basic Life Support)
Name:
Year/Sec:
Rating:
General Objective:
Given simulated situations/conditions, the students will be able to demonstrate correct procedures in
performing Basic Life Support to an infant.
CRITERIA:
Item Weight
4
Descriptors
Excellent
3
Very Satisfactory
2
Satisfactory
1
Needs
Improvement
Verbal Interpretation
Performed the procedure with great ease and confidence, observing work
ethics (prudent, accepts criticisms and suggestions), able to rationalize
scientifically, and shows diligence in documenting observations at all times.
Performed the procedure with less confidence and requires close supervision
observing work ethics (prudent, accepts criticisms and suggestions), able to
rationalize scientifically, and shows minimal diligence in documenting
observations.
Performed the procedure but requires close supervision and shows potential
for improvement.
Failed to perform the procedure, unable to function well, and needs to be
repeated
specific/ detailed guidance or direction.
Values-Based
1. Survey the scene. Identify yourself as a trained first aider. Check for
responsiveness. Activate medical assistance and arrange transfer facilities.
Knowledge-Based
2. Check the airway.
3. Check for breathing for 10 secs. (LLF position)
4.0
3.0
2.0
1.0
4. Give 2 initial ventilatory maneuvers. Perform FBAO mgt. Then give 2 IVM
again.
5. Check for breathing and circulation. LLF position (signs of breathing? signs of
circulation?)
6. Ask someone to reactivate medical assistance and transfer facilities and report
back while you do CPR. (if no signs of breathing and circulation) or RB/AR (if no
signs of breathing but with signs of circulation)
7. CPR (30 compressions: 2 ventilations) 2 cycles.
8. CPR (30 compressions: 2 ventilations) 2 cycles
9. CPR (30 compressions: 2 ventilations) 2 cycles
10. Rescue Breathing (2 counts, 20 repetitions) 2 cycles
11. Rescue Breathing (2 counts, 20 repetitions) 2 cycles
12. Rescue Breathing (2 counts, 20 repetitions) 2 cycles
13. Do the Head-to-Toe Examination.
III. Outcome Oriented
14. Position into the recovery position.
• Care for shock.
• Transfer to the nearest hospital.
• During the transfer, do the Head-to-Toe Examination every 5 minutes.
• All assessments should be properly endorsed to the medical personnel of
the hospital.
IV. Leadership and Governance
15. Reports with proper grooming and displays correct decorum.
Manifests great confidence in his/her work, and shows diligence in documenting
observations.
Comments / Strengths & Weaknesses:
Conforme:
Student’s Signature
Date:
Evaluated by:
Clinical Instructor’s Signature
Date:
Remarks