Skills Evaluation Form

FOREIGN BODY AIRWAY OBSTRUCTION

(Adult)

Name _____________________________________ Date _____________________ Group : _________

RESPONSIVE ADULT POINTS √/x REMARKS

1. Proper use of PPE and assess for scene safety. 5
2. Introduce, ask for consent and determine Complete or Partial Airway
5
Obstruction
3. Get in position. Stand behind the patient and place one leg between
patient’s legs. 5
4. Reach around and locate the navel. 5
5. With the other hand, make a fist and place it against the abdomen, thumb
5
side in, just in above the navel.
6. Grasp your fist with first hand and give up to five abdominal thrusts/
Heimlich Maneuver in quick inward and upward direction. (J maneuver) 5
7. Observe if the patient will cough or speak if the object was removed or
dislodged. 2
8. If still obstructed repeat the thrusts until the airway is clear or the patient
5
becomes unconscious.

UNRESPONSIVE ADULT
1. Place the patient into supine position. 4
2. Activate EMS. 3
3. Perform thirty (30) chest compressions. 4
4. Open airway using the appropriate technique (Head-tilt, Chin-lift) 4
Proper head tilt 3
Fingers on chin 3
Hand position (forehead) 3
5. Give one ventilation. 4
While giving ventilation:
a. nose maintained pinched 2
b. full slow breaths (1 sec) 2
c. mouth seal 2
6. If unable to achieve adequate chest rise/air bounces back, reposition the
5
head.
7. Give again one ventilation. 4
8. If air still bounces back, perform thirty (30) chest compressions. 5
9. Check airway. If obstruction is visible, perform finger sweep. If
3
obstruction is not visible, go back to step 5.
10. If object was removed and patient still unconscious:
a. Give two (2) confirmatory blows. 3
b. Check Circulation, Airway and Breathing for ten (5) seconds. 3
c. If adequate breathing, put the patient into recovery position. 3
11. If object was removed and patient becomes conscious put him/her into
3
recovery position.
TOTAL 100

Minimum passing score: 80 points Score: _________________

Instructor’s Name: _______________________

Instructor’s Signature: ____________________

COMMENTS: __________________________