Name: __________________________ Section: ______ Over-all Score: _____/ 270
Passing Score: 232
Adventist University of the Philippines
COLLEGE OF NURSING
ELIOENAI-MEGACODE AY2023-24
ACLS Checklist Form
Prepared by: Raymund M. Falculan RN MAN
TEAM LEADER C HECKLIST PC PI REMARKS
1 Initial Tasks and Command upon arrival on the Code Scenario
a. Introduce self clearly as the Team Leader of the Code
b. Initial Assessment / Check carotid pulse or auscultate the apical
heart sound to confirm cardiac arrest
c. Hyperoxygenate using Bag-Valve-Mask at 100% FIO2
d. Apply cardiac board and perform high-quality chest compression x
2 minutes (can ONLY be interrupted by defibrillation when desired
energy level is available)
e. Connect to Defibrillator (for ECG reading and shock delivery):
Defibrillation/ Synchronized Cardioversion is administered if needed
f. IV access ASAP (for administration of emergency drugs)
g. Intubation set on standby (hook to Ambu bag once intubated)
h. Suction Machine on standby (suction as needed)
i. Check rhythm, check pulse every 2 minutes of CPR
2 Emergency Interventions (based on dysrhythmias)
A. Asystole/Pulseless electrical activity (PEA)
a. Correct identification of pulseless dysrhythmia
b. Start/Resume CPR for 2 minutes
c. Administer Epinephrine 1 mg then every 3-5minutes as needed
d. Check rhythm, check pulse after 2 minutes of chest compression
e. If still on Asystole go back to letter “b”, If revived, record ECG
B. V-Fib/Pulseless V-Tach
a. Correct identification of pulseless dysrhythmia
b. Start/Resume CPR immediately for 2 minutes
c. Monophasic: Administer 360 joules once available
Manual biphasic: 120-200 joules
AED: Device specific
d. After shock delivered, resume CPR immediately for 2 minutes
e. Monophasic: Administer 2nd/another 360 joules for monophasic
after 2 minutes of compression if still on shockable rhythm
Manual biphasic: 120-200 J (same as first shock or higher dose)
1
AED: Device specific
f. Administer Epinephrine 1mg during CPR (administer only after 2
shocks delivered and can be repeated every 3-5minutes as
needed)
g. Check rhythm, check pulse after 2 minutes of compression
h. If still on shockable arrest rhythm, go back to letter “b.” If revived,
record ECG
C. PSVT/SVT (Narrow QRS Complex)
a. Correct identification of dysrhythmia
b. Check vital signs for any signs of shock
c. Record 12LECG and continue ECG Monitoring
For Stable Patient and Narrow QRS
d. Perform Vagal Maneuvers (Carotid Sinus Massage)
e. Give adenosine 6 mg rapid IV push (consider contraindications). If
rhythm does not convert within 1-2 minutes, give adenosine 12 mg
rapid IV push. May repeat 12 mg dose of adenosine once.
f. Perform Synchronize Cardioversion at 50-100 joules (biphasic).
120-200 joules (monophasic) if become UNSTABLE. Sedate
patient as needed prior to delivery of shock.
g. If converted to NSR, immediately record ECG, and check vital signs
For Unstable Patient: (Unstable Signs, e.g., altered mental status, ongoing chest
pain, hypotension, tachypnea and other signs of shock)
h. Immediately Perform Synchronize Cardioversion at 50-100 joules
(biphasic), 120-200 joules (monophasic)
i. If converted, immediately record ECG, and monitor vital signs
D. Bradycardia (heart rate typically <50 breaths per minute)
a. Correct identification of dysrhythmia, check vital signs, and assess
for symptomatic bradycardia.
b. Stop CPR (if from arrest rhythm and then converted to bradycardia
with pulse) then announce “REVIVED!”
For Stable Patient (asymptomatic bradycardia)
c. Monitored closely
For Unstable Patient: (Unstable Signs, e.g., altered mental status, ongoing chest
pain, hypotension and other signs of shock)
d. Atropine 1mg IV every 3-5 minutes for symptomatic bradycardia for
a maximum of 3 doses of 1mg only
e. May start inotropic (Dopamine 5-10 mcg/kg/min) IV infusion (titrate
to patient response; taper slowly) or apply Transcutaneous pacing.
f. Monitor closely the cardiac rhythm/blood pressure, oximetry until
stable
E. Normal Sinus Rhythm
a. Correct identification of rhythm, check pulse
b. Stop CPR / (if from arrest rhythm then converted to NSR with
pulse) then announce “REVIVED!”
c. Check vital signs (cardiac rhythm, pulse, blood pressure,
temperature, oxygen saturation, Glasgow coma scale, pupillary
light response)
2
F. Post-Cardiac Arrest Care/Return of Spontaneous Circulation
(ROSC) – ABC
a. Continue manual oxygenation using Ambu bag to maintain O2 sat
>94% (at the rate of 10 breaths/minute or bag every 6 seconds).
b. Intubate if patient cannot be adequately ventilated, hook to
mechanical ventilator once available at 100% FIO2
c. Obtain chest x-ray, and arterial blood gas (ABG)
d. Start Inotropic (e.g., Dopamine drip) for persistent hypotension
(SBP <90) or titrate ongoing drip to maintain SBP >90 mm Hg
e. Stat 12-Lead ECG for possible STEMI
f. Activate cardiac catheterization lab for STEMI as ordered;
coordinate with CCU/ICU for admission
g. Assess GCS. If patient is not following commands, start Targeted
Temperature Management (TTM) as soon as possible. Begin
cooling → Goal temperature 32–36°C for 24 hours.
h. If awake, perform other critical care management. Place patient on
semi-fowler’s position (if BP is stable)
i. Evaluate and treat rapidly reversible etiologies (H’s and T’s)
j. Sign “Code Blue Record Form”
Perfect score = 100 points Total score =
Passing rate = 86 points
*Based on American Heart Association (AHA) ACLS Algorithm 2020RMF
LEGEND: 2 PTS - P ERFORMED C ORRECTLY WITHOUT SUPERVISION (P.C.)
1 PT. - PERFORMED I NCORRECTLY AND/ OR NEED SUPERVISION (P.I.)
0 PT. - NOT P ERFORMED (N.P.)
D ATE / TIME
S ECTION / G ROUP #
STUDENT ’S NAME AND S IGNATURE
C LINICAL INSTRUCTOR’S NAME AND SIGNATURE
3
Student’s Name:________________ Evaluator:____________________
Section/Group#:________________ Date:________________________
ACLS-CPR Checklist
PERFORMANCE CRITERIA PC (2 pts.) PI (1 PT) NP (0) REMARKS
Immediate Recognition/Assessment
1. Check for unresponsiveness
2. Check pulse and breathing for
10 seconds
Activation of Emergency Response System (EMS)
3. Shout for “Code Blue”
Execution of CPR
4. Apply cardiac board once
available
5. Place dominant hand 2
fingerbreadths above the
xyphoid process and interlock
with the non-dominant hand
6. Lock elbows and maintain on
vertical line
7. Deliver 1st cycle of CPR
At least 100-120 chest
compression per minute x 2
minutes
8. Vertical angle of arms during
compression
9. Compress chest at the depth
of 2 inches per compression
(adult)
10. Allows full recoil of chest per
compression
11. Check pulse and breathing
after 5 cycles (approximately
2 minutes) for 10 seconds
12. Resume 2nd cycle of CPR if
needed
13. Discontinue CPR if with pulse
Perfect Score - 26 pts. TOTAL SCORE=
Passing score - 22 pts.
LEGEND: 2 PTS. - PERFORMED CORRECTLY WITHOUT SUPERVISION (P.C.) RMF
1 PT. - PERFORMED INCORRECTLY AND/ OR NEED SUPERVISION (P.I.)
0 PT. - NOT PERFORMED (N.P.)
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Student’s Name: ________________ Evaluator: ____________________
Section/Group#:________________ Date: ________________________
DEFIBRILLATION/SYNCHRONIZED CARDIOVERSION
Checklist
PERFORMANCE CRITERIA PC (2 PTS) PI (1 PT) NP (0) Remarks
FOR DEFIBRILLATION:
1. Press ON
2. Bares patient chest
3. Attaches ECG cable to the patient
4. Select appropriate energy level
5. Announce to team members:
“Charging defibrillator-stand clear”
6. Announce “360 joules available” (120-200
joules for synchronized cardioversion)
7. Apply gel to paddle pads
8. Position paddle on patient (sternum-apex)
9. State in a forceful voice the following
chant before each shock:
• I’m going to give shock on five.
One, I’m clear.
• Two, your clear.
• Three, everybody’s clear
• Four, O2 out.
• Five, still on…(rhythm)
• Clear?!
Code team’s response: CLEAR!!!
10. Apply 25 lbs. pressure on paddles
11. Press the ‘discharge’ buttons
simultaneously
12. Announce ‘Shock delivered’ ( Announce
“shock on R wave” for synchronized
cardioversion)
13. Check/Document the rhythm post
administration of shock
FOR SYNCHRONIZED CARDIOVERSION:
14. Engage the synchronization mode by
pressing the ‘SYNC’ control button
15. Look for markers on R waves indicating
sync mode (synchronized cardioversion)
(Repeat #4-14)
Perfect score – 30 pts TOTAL SCORE =
Passing score – 26 pts.
LEGEND: 2 PTS. - PERFORMED CORRECTLY WITHOUT SUPERVISION (P.C.) RMF
1 PT. - PERFORMED I NCORRECTLY AND / OR NEED SUPERVISION (P.I.)
0 PT. - NOT PERFORMED (N.P.)
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Student’s Name: ________________ Evaluator: ____________________
Section/Group#:________________ Date: ________________________
ET INTUBATION CHECKLIST
PC PI NP
PERFORMANCE CRITERIA Remarks
(2 pts.) (1pt) (0)
1. Hyperoxygenate using Bag-Valve-Mask
• Connect to O2 source
• Turn oxygen ON at 10L/min
2. Explain procedure to the client and his family and obtain
informed consent (verbalize “procedure explained and
consent signed”).
3. Wear gloves/protective goggles
4. Prepare Intubation Set
• Assemble laryngoscope
• Check laryngoscope light
5. Obtain the correct size for an oral ET tube. (Verbalize ET size)
6. Check ET balloon/inflate with 10cc syringe
7. Insert guide wire in ET tube
8. Hyperoxygenate using bag-valve-mask
9. Hyper -extend patient’s head
10. Perform tracheal intubation / proper handling of
laryngoscope and ET tube
11. Remove laryngoscope
12. Pull out guide wire
13. Inflate ET cuff using 10cc syringe
14. Auscultate breath sounds and watch for chest movement to
ensure correct placement and full lung ventilation.
15. Secure the tube firmly with tape (verbalized “ET tube
secured”)
Perfect score – 30 pts. TOTAL SCORE =
Passing score – 26 pts.
LEGEND: 2 PTS. - PERFORMED CORRECTLY WITHOUT SUPERVISION (P.C.) RMF
1 PT. - PERFORMED INCORRECTLY AND/ OR NEED SUPERVISION (P.I.)
0 PT. - NOT PERFORMED (N.P.)
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Student’s Name: ________________________ Evaluator: _____________________
Section/Group#:________________________ Date: _________________________
IV INSERTION CHECKLIST
PERFORMANCE CRITERIA PC (2 pts.) PI (1 pt.) NP (0) REMARKS
1. Prepare materials needed
2. Prime IV fluid
3. Apply tourniquet
4. Clean site with alcohol pad
5. Insert IV cannula (demonstrate the right
technique)
6. Secure IV cannula with tape
7. Hook IV tubing to cannula
8. Regulate IV PNSS to fast drip during code
blue
9. Verbalize “IV access available”
10. Verbalize given emergency medicine via IV
push / IV infusion (e.g. 1st Epi given or
Dopamine drip started)
11. Recorded time of administration
12. Regulated IV rate as ordered
Perfect score – 24 pts.
TOTAL SCORE =
Passing score – 21 pts.
LEGEND: 2 PTS. - PERFORMED CORRECTLY WITHOUT SUPERVISION (PC) RMF
1 PT. – PERFORMED I NCORRECTLY AND/ OR NEED SUPERVISION (RIS)
0 PT. - NOT P ERFORMED (N.P.)
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Student’s Name: ________________ Evaluator: ____________________
Section/Group#:________________ Date: ________________________
SUCTIONING SKILL CHECKLIST
PERFORMANCE CRITERIA PC (2 pts.) PI (1 pt.) NP (0) REMARKS
1. Hyperoxygenate using resuscitator
mask and bag
TO BE DONE ONCE INTUBATED:
2. Prepare suction machine and
suction catheters
3. Wear gloves
4. Turn on suction machine and
checks for function
5. Attaches top of catheter to suction
tubing
6. Hyperventilate using the
resuscitator bag (request other
member to perform the task)
7. Inserts and advances catheter into
endotracheal (ET) tube without
suction
8. Applies suction intermittently on
suction catheter adapter while
withdrawing the catheter
9. Coil catheter between fingers as it
is pulled out of ET tube, staying in
no more than 10 seconds
10. Hook back to resuscitator bag after
catheter has been removed from
ET tube
11. Rinse and flush suction catheter
12. Repeat suctioning in above order
(5-10) until secretions are removed
13. Suctions oral route
14. Completes suctioning, disconnects
catheter from suction tubing, wraps
catheter around gloved hand and
pulls glove off inside out
15. Turn off suction machine
Perfect score – 30 pts. Total Score =
Passing score – 26 pts
LEGEND: 2 PTS - PERFORMED CORRECTLY WITHOUT SUPERVISION (P.C.) RMF
1 PT - PERFORMED INCORRECTLY AND/ OR NEED SUPERVISION (P.I.)
0 PT - NOT PERFORMED (N.P.)
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Student’s Name: ________________ Evaluator: ____________________
Section/Group#:________________ Date: ________________________
Perfect score – 30 pts (Passing score – 26 pts) Score: _______________________