Rescuer Skills Testing Sheet Template
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1
2A p p e n d i x
BLS Skills Testing
1- and 2-Rescuer Child BLS With AED
Skills Testing Sheet
See 1- and 2-Rescuer Child BLS With AED Skills Testing Criteria and Descriptors on next page
Student Name: ________________________________________________________________________ Test Date: ________________________
1-Rescuer BLS and CPR Skills (circle one):
Pass
Needs Remediation
2-Rescuer CPR Skills
Bag-Mask (circle one):
Pass
Needs Remediation
AED Skills (circle one):
Pass
Needs Remediation
Skill
if done
✓
Critical Performance Criteria
Step
correctly
1-Rescuer Child BLS Skills Evaluation
During this first phase, evaluate the first rescuer’s ability to initiate BLS and deliver high-quality CPR for 5 cycles.
1
ASSESSES: Checks for response and for no breathing or only gasping (at least 5 seconds but no
more than 10 seconds)
2
Sends someone to ACTIVATE emergency response system
3
Checks for PULSE (no more than 10 seconds)
4
GIVES HIGH-QUALITY CPR:
Cycle 1:
•
C orrect compression HAND PLACEMENT
•
A DEQUATE RATE: At least 100/min (ie, delivers each set of 30 chest compressions in
Cycle 2:
Time:
18 seconds or less), using 1 or 2 hands
•
A DEQUATE DEPTH: Delivers compressions at least one third the depth of the chest
Cycle 3:
(approximately 2 inches [5 cm]) (at least 23 out of 30)
Cycle 4:
•
A LLOWS COMPLETE CHEST RECOIL (at least 23 out of 30)
Cycle 5:
•
M INIMIZES INTERRUPTIONS: Gives 2 breaths with pocket mask in less than 10 seconds
Second Rescuer AED Skills Evaluation and SWITCH
During this next phase, evaluate the second rescuer’s ability to use the AED and both rescuers’ abilities to switch roles.
5
DURING FIFTH SET OF COMPRESSIONS: Second rescuer arrives with AED and bag-mask device,
turns on AED, and applies pads
6
First rescuer continues compressions while second rescuer turns on AED and applies pads
7
Second rescuer clears victim, allowing AED to analyze—RESCUERS SWITCH
8
If AED indicates a shockable rhythm, second rescuer clears victim again and delivers shock
First Rescuer Bag-Mask Ventilation
During this next phase, evaluate the first rescuer’s ability to give breaths with a bag-mask device.
9
Both rescuers RESUME HIGH-QUALITY CPR immediately after shock delivery:
Cycle 1
Cycle 2
•
S ECOND RESCUER gives 15 compressions (in 9 seconds or less) immediately after shock
Time:
delivery (for 2 cycles)
•
F IRST RESCUER successfully delivers 2 breaths with bag-mask device (for 2 cycles)
AFTER 2 CYCLES, STOP THE EVALUATION
•
I f the student completes all steps successfully (a ✓ in each box to the right of Critical Performance Criteria), the student passed this
scenario.
•
I f the student does not complete all steps successfully (as indicated by a blank box to the right of any of the Critical Performance
Criteria), give the form to the student for review as part of the student’s remediation.
•
A fter reviewing the form, the student will give the form to the instructor who is reevaluating the student. The student will
reperform the entire scenario, and the instructor will notate the reevaluation on this same form.
•
I f the reevaluation is to be done at a different time, the instructor should collect this sheet before the student leaves the classroom.
Remediation (if needed):
Instructor Signature: ____________________________________
Instructor Signature: _________________________________________
Print Instructor Name: ___________________________________
Print Instructor Name: ________________________________________
Date: _ ________________________________
Date: _________________________________
234
90-1052_PALS_PrvdrMnl_Appendix.indd 234
7/5/11 3:44 PM
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