Formative King LT (S)-D

King LT (S)-D
MonthDayYearHourMinutes
What class is the student in?*

ABCEvening
A Shift*
B Shift*
C Shift*
Evening Class*
Who is the Evaluator?*

InstructorA Shift Student EvaluatorB Shift Student EvaluatorC Shift Student EvaluatorEvening Class Student Evaluator
Instructor*
A Shift Student Evaluator*
B Shift Student Evaluator*
C Shift Student Evaluator*
Evening Class Student Evaluator*
Prepares patient

Takes or verbalizes appropriate PPE precautionsInserts adjunct (nasopharyngeal airway)Ventilates at a rate of 10 - 12/minute and sufficient volume to make chest riseAttaches pulse oximeter and notes SpO2Preoxygenates patient using BVM and NODESAT methodAuscultates breath sounds
Performs Intubation

Gathers and checks equipmentRemoves oral adjunct airway (if in place)Positions head properly (sniffing)Performs a tongue-jaw liftAligns blue orientation line with corner of the mouthAdvances tube, rotates back to midlineInserts device until base of connector aligns with teethInflates cuff with proper volume and immediately removes syringeVentilates patient and confirms proper ventilation [correct lumen and proper insertion depth] by auscultation bilaterally over lungs and over epigastriumComfirm correct placement via ETCOWithdraws tube while bagging until ventilation is easy and free flowingSecure device
Affective

Accepts evaluation and criticism professionallyShows willingness to learnInteracts with simulated patient and other personnel in professional manner
Critical Criteria

Interrupts ventilations at any time when SpO2 is less than 90%Failure to take or verbalize appropriate PPE precautionsIf used, suctions the patient for more than 10 secondsFailure to preoxygenate patient prior to intubationFailure to disconnect syringe immediately after inflating cuff of either tubesFailure to properly inflate either cuffFailure to assure proper tube placement by auscultation bilaterally and over the epigastriumFailure to voice and ultimately provide high oxygen concentration [at least 85%]Failure to ventilate the patient at a rate of at least 10/minute and no more than 12/minuteFailure to provide adequate volumes per breath [maximum 2 errors/minute permissible]Insertion or use of any adjunct in a manner dangerous to the patientFailure to demonstrate the ability to manage the patient as a minimally competent EMTExhibits unacceptable affect with patient or other personnelUses or orders a dangerous or inappropriate intervention
Evaluator Comments
Was the student successful or unsuccessful in this skill?*

SuccessfulUnsuccessful
Signature*
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