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PERFORMANCE CHECKLIST

BATHING OF THE NEWBORN


PROCEDURE

DONE SCORE

1. Introduce yourself, Inform the parents about the


procedure.
2. Gather the materials needed. Lay out what youll
need after the bath.

NOT
DONE

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3. Handwashing

4. Set up the tub.

5. Fill the tub with 2-3 inches of warm water.

6. Wash and Shampoo the hair.


7. Clean the eyes starting to inner to outer canthus.

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3

8. Clean the face.

9. Remove the clothes.

10. Lay your baby in the tub feet first.


11. Begin washing the baby from neck downwards.

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3

12. Lift the baby from the tub

13. Pat dry the baby with a towel.


14. Apply alcohol/betadine to the cord if necessary.

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3

15. Diaper first, and clothe the baby

16. Swaddle the baby.


TOTAL

50

Name: ____________________

Score: _______________

Section: ___________________

Date: _______________

Instructor:__________________

PERFORMANCE CHECKLIST
CHANGING DIAPER TO THE BABY
PROCEDURE

DONE SCORE

1.
Unfasten the diaper tabs and fasten them
back on themselves so they don't stick to your
baby, but don't remove the dirty diaper yet.

NOT
DONE

2.
Wipe away any stool with the diaper.
3.
Lift the baby's bottom off the table using
the graceless-yet-effective ankle hold.
4.
Fold the dirty diaper in half under the baby,
clean side up.
5. Use a baby wipe, moistened cotton ball, or wet
cloth to clean your baby's front thoroughly.
6. Lift both of your baby's legs and clean his
bottom.
7. Swap a clean diaper for the dirty one.
The clean diaper's top half (the half with the
tabs) should go under your baby's rear, and
the bottom half should come up between his
legs (which should be spread as widely as is
comfortable for your baby).
8. For newborns, avoid covering the umbilical
cord.
9. Fasten the diaper at both sides with the tapes,
making sure it's snug, but not so tight that it
pinches his skin.
10. Dress the baby, and wash hands
thoroughly.
TOTAL

3
3
3
3
3

3
3
3
3
50

Name: ____________________

Score: _______________

Section: ___________________

Date: _______________

Instructor:__________________

PERFORMANCE CHECKLIST
INFANT BASIC LIFE SUPPORT
PROCEDURE

1. Survey the scene


2. The scene is safe
3. Introduce yourself, hi Im _______, a trained first
aider, I have my I.D. and my BSIP (PPE) can I help?
4. Check for the responsiveness of the baby baby,
baby are you okay? (3x)
5. The baby is unresponsive, Shout for help! Activate
medical assistance, Call 117 as I further assess the
baby.
6. Check the airway (no obstruction seen).
7. Check for breathing, LLF for 5 seconds (1001, 1002,
1003, 1004, 1005).
8. The baby is breathless, I will give 2 initial blows
(blow LLF, blow LLF).
9. Air bounces back, Re-activate medical assistance,
call 117 again as I perform 5 back blows and 5 chest
thrust. I suspect the baby is suffering from choking.
10. Put the baby in a stable area.
11. Check the airway again (obstruction seen).
12. Remove obstruction by using finger sweep.
13. Set aside for documentation.
14. Check the pulse or circulation (brachial pulse) count
10 seconds (1001-1010).
15. The baby has (-) negative pulse and (-) breathing.
16. Re-activate medical assistance, call 117 again while
I perform CPR, I suspect that the baby is having
cardiac arrest
17. Blow, LLF 2x (1-20) = (1-9=1) for 5 cycles.
18. Check for circulation or pulse for 10 secs. (10011010).
19. The baby has positive pulse, negative breathing.
20. Re-activate medical assistance, call 117 again as I
perform rescue breathing. I suspect victim is
suffering from respiratory arrest.
21. Start with a BLOW
1, 1001, BLOW
1, 1002, BLOW (up to 40 cycles)
22. Check for pulse or circulation (brachial pulse) count
10 sec (1001-1010).
23. Baby is (+) pulse, (+) breathing.
24. The baby is revived!

DONE SCORE

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3
3
3
3
3
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3
3
3
3
3
3
3
3
3
3
3
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3

NOT
DONE

25. Put the baby in a recovery position, burping, tummy


to tummy, tummy to lap.

26. Put the baby in stable area.


27. Do secondary survey (care for shock, check for vital
signs, rush the baby to the nearest hospital.)

3
3
3

28. Do documentation.
TOTAL

50

Name: ____________________

Score: _______________

Section: ___________________

Date: _______________

Instructor:__________________

PERFORMANCE CHECKLIST
INFANT FOREIGN BODY AIRWAY OBSTRUCTION (FBAO)
PROCEDURE

DONE SCORE

NOT
DONE

1. Survey the scene


2. The scene is safe
3. Introduce yourself, hi Im _______, a trained first aider, I
have my I.D. and my BSIP (PPE) can I help?
4. Check for the responsiveness of the baby baby, baby are
you okay? (3x)
5. The baby is unresponsive, Shout for help! Activate medical
assistance, Call 117 as I further assess the baby.

3
3
3
3
3

6. Check the airway (no obstruction seen).

7. LLF for 5 secs. (1001-1005).


8. The baby is breathless, I will give 2 initial blows (blow LLF,
blow LLF).
9. Air bounces back. Reactivate medical assistance, call 117
again. I suspect the baby is suffering from choking. I will
perform (5 back blows and 5 chest thrust).

3
3
3

10. Put the baby in a stable area.

11. Check the airway again (obstruction seen).

12. Remove obstruction by using finger sweep.


13. Set aside for documentation.
14. Check for the pulse or circulation (brachial pulse) count 10
secs (1001-1010).

3
3
3

15. (+) Pulse , (+) Breathing.

16. The baby is revived!


17. Put the baby in a recovery position. Burping, Tummy to
tummy, tummy to lap.
18. Do the secondary survey (care for shock, check the vital
signs, rush the baby in the nearest hospital).

3
3
3

19. Do documentation.
TOTAL

50

Name: ____________________

Score: _______________

Section: ___________________

Date: _______________

Instructor:__________________

PERFORMANCE CHECKLIST
INFANT FOREIGN BODY AIRWAY OBSTRUCTION (FBAO)
PROCEDURE

20.

DONE SCORE

Survey the scene

21.
The scene is safe
22.
Introduce yourself, hi Im _______, a trained first aider,
I have my I.D. and my BSIP (PPE) can I help?
23.
Check for the responsiveness of the baby baby, baby
are you okay? (3x)
24.
The baby is unresponsive, Shout for help! Activate
medical assistance, Call 117 as I further assess the baby.
25.

NOT
DONE

3
3
3
3
3

Check the airway (no obstruction seen).

26.
LLF for 5 secs. (1001-1005).
27.
The baby is breathless, I will give 2 initial blows (blow
LLF, blow LLF).
28.
Air bounces back. Reactivate medical assistance, call
117 again. I suspect the baby is suffering from choking. I
will perform (5 back blows and 5 chest thrust).

3
3
3

29. Put the baby in a stable area.

30. Check the airway again (obstruction seen).

31. Remove obstruction by using finger sweep.


32. Set aside for documentation.
33. Check for the pulse or circulation (brachial pulse) count 10
secs (1001-1010).

3
3
3

34. (+) Pulse , (+) Breathing.

35. The baby is revived!


36. Put the baby in a recovery position. Burping, Tummy to
tummy, tummy to lap.
37. Do the secondary survey (care for shock, check the vital
signs, rush the baby in the nearest hospital).

3
3
3

38. Do documentation.
TOTAL

50

Name: ____________________

Score: _______________

Section: ___________________

Date: _______________

Instructor:__________________

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