NEW ERA UNIVERSITY

College of Nursing
PERFORMANCE EVALUATION TOOL

Foreign Body Airway Obstruction Management

Name:___________________________________Date: _______________Grade: _________________

DIRECTION: Rate the student’s performance utilizing the scale below:

3 – Demonstrated procedure accurately, correctly stated rationale.

2 – Demonstrated procedure accurately, incomplete rationale stated.
1 – Demonstrated procedure inaccurately, incorrect/no rationale stated.
0 – Not Demonstrated.

COMPETENCIES 3 2 1 0 Remarks
Adult
1. Assesses signs for choking (hands clutched to the throat) other
indicators:
1.1 Inability to talk
1.2 Difficulty breathing or noisy breathing
1.3 Inability to cough forcefully
1.4 Skin, lips and nails turning blue or dusky
1.5 Loss of consciousness
2.Stands behind the client.
3. Wraps arms around the waist.
4. Tips/Leans/tilts the client forward slightly.
5. Makes a fist with one hand and position it slightly above the person's
navel.
6. Grasps the fist with the other hand.
7. Presses hard into the abdomen with a quick inward and upward thrust.
8. Performs a total of 5 abdominal thrusts, if needed.
9. Repeats the five-and-five cycle if blockage still not dislodged.
10. Performs standard CPR with chest compressions and rescue breaths if
client becomes unconscious.
Infant
1. Assumes a seating position.
2. Holds the infant face down on forearm, which is resting on thigh.
3. Blows gently but firmly five times on the middle of the back of an
infant using heel of the hand.
4. Holds the infant face up on forearm with the head lower than the trunk.
5. Places two fingers at the center of the infant’s breastbone.
6. Gives five quick chest compressions.
7. Checks for foreign body in the mouth and utilizes finger sweep if the
foreign body is visualized.
8. Repeats the back blows and chest thrusts if needed.
9. Starts CPR if needed.
TOTAL SCORE: 69

EVALUATED BY:

_________________________ ___________________
Clinical Instructor’s Signature Student’s Signature