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(Please check one) 90 Day Probation [ ] Annual KV Interim [ ] Competency Statement: Criteria Code: Demonstrates proper procedure of 1 =Criteria met treating adult choking victim 2=Did not meet criteria 3 =Met criteria after instruction # CRITERIA Results(See Criteria Code) RESPONSIVE RESIDENT 1 2 3 1 Look For Signs and Symptoms of Distress Mild Airway Obstruction a. Good air exchange [ [ ] [ b. Responsive and can cough forcefully [j/[ ] [ ] c. May wheeze between coughs W[ ] [ ] Severe Airway Obstruction a. Poor or no air exchange b. Weak,ineffective cough or no cough at all [% [ ] [ ] c. High-pitched [itched noise while inhaling or no noise at all [J [ ] [ d. Increased respiratory difficulty [ ] [ e. Possible cyanosis(turning blue) [ [ [ ] f. Unable to speak ] [ ] g. Clutching the neck with the thumb and fingers, [ir J [ ] [ ] universal choking sign making [ [ ] [ ] h. Unable to move air 2 Stand or kneel behind the victim and wrap [� [ ] [ ] victim's waist your arms around the V [ ] [ ] 3 Make a fist with one hand 4 Place the thumb side of your fista4,6 [ ] [ ] in the mid-line, slightly above theaval and well below the [ [ ] [ breastbone 5 Grasp your fist with your other hand and press your fist into the [ti[ ] [ ] victim's abdomen with a quick upward thrust 6 Repeat thrusts until the object in expelled from the airway or the [f[ ] [ victim becomes unresponsive 7 Give each new thrust with,a separate,distinct movement to relieve the obstruction [ [ ] [ Page 2—Licensed Nurse I C.N.A. Rescue of Adult Choking Victim UNRESPONSIVE RESIDENT-LYING DOWN (UNCONSCIOUS) 1 If the adult victim is unresponsive,activate the emergency response system,open the airway,remove an object if you see it, K,14] [ and begin CPR 2 Every time you open the airway to give breaths,open the victim's mouth wide and look for the object. If you see an K.14 ] [ object,remove it with your fingers. If you do not see an object, keep doing CPR 3 You can tell you have successfully removed an airway obstruction in the unresponsive victim if you - Feel air movement and see the chest rise when [\34 j [ you give breaths - See and remove a foreign body from the victim's [d[ 1 [ pharYnx 4 Follow these steps after you relieve choking in the unresponsive victim: [V1/4[ ] [ a. Provide 2 breaths [4"[ j [ b. Check for pulse Then You Should Pulse—No Breathing—No I Perform chest compressions and / ] I attach the AED [1'j' [ [ Pulse-Yes Breathing-No � Conue rescue breathing and check for pulse every 2 minutes [J[ j [ Pulse—Yes Breathing—Yes I Place the victim in the recovery I position and continue monitoring [J"[ ] [ ] I until EMS personnel arrive. You I will learn more about the I recovery position later 5 If you successfully relieve choking with abdominal thrusts, encourage the victim to seek immediate medical attention to ensure that the victim does not have a complication from abdominal thrusts Method Code: Return Demonstration Exam Other(specify) Plan of Action if Needed: I , 1%" { Date: ��Ar Employee NameALC/11 Li >—� Date: Evaluator �` . _ L�I�- Competency Evaluation RESCUE OF ADULT CHOKING VICTIM Position: Licensed Nurse/C.N.A. (Please check one) 90 Day Probation [ ' Annual [1Y Interim [ ] Competency Statement: Criteria Code: Demonstrates proper procedure of 1 =Criteria met treating adult choking victim 2=Did not meet criteria 3 =Met criteria after instruction # CRITERIA Results(See Criteria Code) RESPONSIVE RESIDENT 1 2 3 1 Look For Signs and Symptoms of Distress Mild Airway Obstruction a. Good air exchange [' [ ] r ] b. Responsive and can cough forcefully [J/ [ } [ c. May wheeze between coughs E% [ } [ 1 Severe Airway Obstruction a. Poor or no air exchange [q/[ 1 [ b. Weak, ineffective cough or no cough at all [t' [ ] [ c. High-pitched noise while inhaling or no noise at all [L / [ 1 [ d. Increased respiratory difficulty [J' [ ) [ e. Possible cyanosis(turning blue) f. Unable to speak [U" [ ] [ g. Clutching the neck with the thumb and fingers,making [%' [ J [ universal choking sign h. Unable to move air rur/ [ [ 2 Stand or kneel behind the victim and wrap your arms around the _ [v]' [ j [ victim's waist 3 Make a fist with one hand [vi/ [ ] [ 1 4 Place the thumb side of your fist against the victim's abdomen, t j in the mid-line, slightly above the naval and well below the [� [ breastbone 5 Grasp your fist with your other hand and press your fist into the [di ] [ victim's abdomen with a quick upward thrust 6 Repeat thrusts until the object in expelled from the airway or the [, "[ [ victim becomes unresponsive 7 Give each new thrust with a separate,distinct movement to _ [/[ } [ relieve the obstruction Page 2—Licensed Nurse/C.N.A. Rescue of Adult Choking Victim UNRESPONSIVE RESIDENT-LYING DOWN (UNCONSCIOUS) 1 If the adult victim is unresponsive,activate the emergency [ ] [ ] response system,open the airway,remove an object if you see it, and begin CPR 2 Every time you open the airway to give breaths,open the victim's mouth wide and look for the object. If you see an [Y[ ] [ object,remove it with your fingers. If you do not see an object, keep doing CPR 3 You can tell you have successfully removed an airway obstruction in the unresponsive victim if you - Feel air movement and see the chest rise when [vi' [ ] [ you give breaths - See and remove a foreign body from the victim's [ [ ] [ pharYnx 4 Follow these steps after you relieve choking in the unresponsive �/ victim: [v1 [ ] [ a. Provide 2 breaths [ [ ] [ b. Check for pulse Then You Should Pulse—No Breathing—No l Perform chest compressions and attach the AED [' [ ] [ Pulse-Yes Breathing-No I Continue rescue breathing and check for pulse every 2 minutes E% [ ] [ Pulse—Yes Breathing—Yes I Place the victim in the recovery I position and continue monitoring Ky[ ] [ ] I until EMS personnel arrive. You I will learn more about the I recovery position later 5 If you successfully relieve choking with abdominal thrusts, encourage the victim to seek immediate medical attention to [l.1' I ] [ ] ensure that the victim does not have a complication from abdominal thrusts Method Code: Re tu> monstration Exam Other(specify) Plan of Action if Needed: Employee Name: Date: Z- yZd� � Evaluator: /�-=��` `S — Date: _ ' Competency Evaluation RESCUE OF ADULT CHOKING VICTIM Position: Licensed Nurse/C.N.A. (Please check one) 90 Day Probation [ Annual K,]� Interim [ ] Competency Statement: Criteria Code: Demonstrates proper procedure of 1 =Criteria met treating adult choking victim 2=Did not meet criteria 3 =Met criteria after instruction Results(See # CRITERIA Criteria Code) 1 2 3 RESPONSIVE RESIDENT 1 Look For Signs and Symptoms of Distress Mild Airway Obstruction a. Good air exchange [9[ ] [ b. Responsive and can cough forcefully [J/ [ ] [ ] c. May wheeze between coughs [4/ [ ] [ ] Severe Airway Obstruction a. Poor or no air exchange [' ' ] [ ] b. Weak, ineffective cough or no cough at all [ ] [ ] c. High-pitched noise while inhaling or no noise at all [t[ ] [ d. Increased respiratory difficulty [ ] [ e. Possible cyanosis(turning blue) [ r [ ] [ f. Unable to speak [LK;[ ] [ g. Clutching the neck with the thumb and fingers,making [d[ ] [ ] universal choking sign h. Unable to move air [ i/ ] [ 2 Stand or kneel behind the victim and wrap your arms around the [J[ ] [ ] victim's waist 3 Make a fist with one hand [j ] [ 4 Place the thumb side of your fist against the victim's abdomen, [k,]/'[ ] [ ] in the mid-line, slightly above the naval and well below the breastbone 5 Grasp your fist with your other hand and press your fist into the [,,1/[ ] [ ] victim's abdomen with a quick upward thrust 6 Repeat thrusts until the object in expelled from the airway or the [V[ ] [ ] victim becomes unresponsive 7 Give each new thrust with a separate,distinct movement to [q [ ] [ ] relieve the obstruction Page 2—Licensed Nurse/C.N.A. Rescue of Adult Choking Victim UNRESPONSIVE RESIDENT-LYING DOWN (UNCONSCIOUS) 1 If the adult victim is unresponsive,activate the emergency response system,open the airway,remove an object if you see it, [ [ ] [ ] and begin CPR 2 Every time you open the airway to give breaths,open the victim's mouth wide and look for the object. If you see an [J [ ] [ ] object,remove it with your fingers. If you do not see an object, keep doing CPR 3 You can tell you have successfully removed an airway obstruction in the unresponsive victim if you - Feel air movement and see the chest rise when [v([ ] [ ] you give breaths - See and remove a foreign body from the victim's [I[[ ] [ ] pharynx 4 Follow these steps after you relieve choking in the unresponsive victim: ,f/' a. Provide 2 breaths [v1 ] H ] b. Check for pulse [J [ ] [ ] Then You Should Pulse—No Breathing—No J Perform chest compressions and attach the AED [ ' [ ] [ ] Pulse-Yes Breathing-No i Continue rescue breathing and J check for pulse every 2 minutes Kt[ ] [ ] Pulse—Yes Breathing—Yes I Place the victim in the recovery I position and continue monitoring [v([ ] [ ] I until EMS personnel arrive. You J will learn more about the I recovery position later 5 If you successfully relieve choking with abdominal thrusts, Vi encourage the victim to seek immediate medical attention to ] [ ] ensure that the victim does not have a complication from abdominal thrusts Method Code: Retun Den nstratii ) Exam Other(specify) Plan of Action if Needed: Employee Name: ')1144 ' — Date: —i i I Evaluator: £2L 1' 2 l (jJ Date: ar Competency Evaluation RESCUE OF ADULT CHOKING VICTIM Position: Licensed Nurse/C.N.A. (Please check one) 90 Day Probation [ ] Annual Interim [ ] Competency Statement: Criteria Code: Demonstrates proper procedure of 1 =Criteria met treating adult choking victim 2=Did not meet criteria 3 =Met criteria after instruction Results(See # CRITERIA Criteria Code) 1 2 3 RESPONSIVE RESIDENT 1 Look For Signs and Symptoms of Distress Mild Airway Obstruction a. Good air exchange [ ] [ ] b. Responsive and can cough forcefully kr,.[ ] [ ] c. May wheeze between coughs [v.1' [ ] [ Severe Airway Obstruction a. Poor or no air exchange ["[ ] [ ] b. Weak, ineffective cough or no cough at all ['d/ [ ] [ [ ] c. High-pitched noise while inhaling or no noise at all VI [ ] [ d. Increased respiratory difficulty [L [ ] [ e. Possible cyanosis(turning blue) s f. Unable to speak [Le [ ] [ ] g. Clutching the neck with the thumb and fingers,making [LK[ ] [ ] universal choking sign h. Unable to move air [A/ ] [ ] 2 Stand or kneel behind the victim and wrap your arms around the [Y[ ] [ victim's waist 3 Make a fist with one hand [ ] [ 4 Place the thumb side of your fist against the victim's abdomen, [s%[ ] [ ] in the mid-line, slightly above the naval and well below the breastbone 5 Grasp your fist with your other hand and press your fist into the [ifi ] [ ] victim's abdomen with a quick upward thrust 6 Repeat thrusts until the object in expelled from the airway or the [e[ ] [ ] victim becomes unresponsive 7 Give each new thrust with a separate,distinct movement to [‘17[ ] [ ] relieve the obstruction Page 2—Licensed Nurse/C.N.A. Rescue of Adult Choking Victim UNRESPONSIVE RESIDENT-LYING DOWN (UNCONSCIOUS) 1 If the adult victim is unresponsive,activate the emergency response system,open the airway,remove an object if you see it, [ ] [ ] and begin CPR 2 Every time you open the airway to give breaths,open the victim's mouth wide and look for the object. If you see an ['44 ] [ object,remove it with your fingers. If you do not see an object, keep doing CPR 3 You can tell you have successfully removed an airway obstruction in the unresponsive victim if you - Feel air movement and see the chest rise when [4[ ] [ ] you give breaths '/' - See and remove a foreign body from the victim's [v1 [ ] [ ] pharynx 4 Follow these steps after you relieve choking in the unresponsive victim: a. Provide 2 breaths [ ,<1 ] [ b. Check for pulse [v1 [ ] [ Then You Should Pulse—No Breathing—No I Perform chest compressions and I attach the AED [\f[ ] [ Pulse-Yes Breathing-No Continue rescue breathing and I check for pulse every 2 minutes KA/[ ] [ ] Pulse Yes Breathing—Yes I Place the victim in the recovery I position and continue monitoring W[ ] [ ] until EMS personnel arrive. You will learn more about the recovery position later 5 If you successfully relieve choking with abdominal thrusts, '/' encourage the victim to seek immediate medical attention to [\./ [ ] [ ensure that the victim does not have a complication from abdominal thrusts •Method Code: ReDemonstration Exam Other(specify) Plan of Action if Needed: Employee Name: Date: 1�� Evaluator: dr/ ,A . ./o !ate: Competency Evaluation RESCUE OF ADULT CHOKING VICTIM Position: Licensed Nurse/C.N.A. (Please-check one) 90 Day-Probation --f Annual Interim [ ) Competency Statement: Criteria Code: Demonstrates proper procedure of 1 =Criteria met treating adult choking victim 2=Did not meet criteria 3 =Met criteria after instruction Results(See # CRITERIA Criteria Code) 1 2 3 RESPONSIVE RESIDENT 1 Look For Signs and Symptoms of Distress Mild Airway Obstruction a. Good air exchange [q/[ ] [ ) b. Responsive and can cough forcefully N/ ] [ c. May wheeze between coughs [U [ ] [ ] Severe Airway Obstruction a. Poor or no air exchange [If[ ) [ ] b. Weak, ineffective cough or no cough at all [0 [ ] [ c. High-pitched noise while inhaling or no noise at all [L 4"/[ ] [ ] d. Increased respiratory difficulty [ [ ] [ ] e. Possible cyanosis(turning blue) Ref[ ] [ ] f. Unable to speak ["[ ] [ g. Clutching the neck with the thumb and fingers,making [t1[ ] [ ] universal choking sign h. Unable to move air RA/ ] [ ] 2 Stand or kneel behind the victim and wrap your arms around the victim's waist [ [ ) [ ) 3 Make a fist with one hand 4 Place the thumb side of your fist kir[ ] [ ] against the victim's abdomen, [ [ ] [ ] in the mid-line, slightly above the naval and well below the breastbone 5 Grasp your fist with your other hand and press your fist into the [ ] [ ] victim's abdomen with a quick upward thrust 6 Repeat thrusts until the object in expelled from the airway or the [d[ ] [ ] victim becomes unresponsive 7 Give each new thrust with a separate,distinct movement to [t�1" [ ] [ ] relieve the obstruction 1 Page 2—Licensed Nurse/C.N.A. Rescue of Adult Choking Victim UNRESPONSIVE RESIDENT-LYING DOWN (UNCONSCIOUS) 1 If the adult victim is unresponsive,activate the emergency response system,open the airway,remove an object if you see it, [v]./[ ] [ ] and begin CPR 2 Every time you open the airway to give breaths,open the Cu ( ] ( ] victim's mouth wide and look for the object. If you see an object,remove it with your fingers. If you do not see an object, keep doing CPR 3 You can tell you have successfully removed an airway obstruction in the unresponsive victim if you �] ( ] - Feel air movement and see the chest rise when [t. [ you give breaths - See and remove a foreign body from the victim's [v]j[ ] [ ] pharynx 4 Follow these steps after you relieve choking in the unresponsive victim: a. Provide 2 breaths [ [ ] ( ] b. Check for pulse (u1/[ ] [ Then You Should Pulse—No Breathing—No I Perform chest compressions and attach the AED [lily [ ] [ Pulse-Yes Breathing-No I Continue rescue breathing and check for pulse every 2 minutes [v]/[ 1 [ ] Pulse—Yes Breathing—Yes I Place the victim in the recovery I position and continue monitoring [t,]"[ ] [ ] I until EMS personnel arrive. You I will learn more about the I recovery position later 5 If you successfully relieve choking with abdominal thrusts, encourage the victim to seek immediate medical attention to [ ( ] [ ensure that the victim does not have a complication from abdominal thrusts Method Code: Return Demonstration Exam Other(specify) Plan of Action if Needed: Employee Name: / Date: Evaluator: Cif v Date: AC�