Skills

Question 1

CPR with AED (2 person)

Answer 1

1. Don PPE (gloves, glasses, N95 mask, face shield)
2. Note any of the following (unresponsive, apnea, ineffective respirations)
3. Send a second rescuer to get AED
4. Assess circulation at the radial and carotid pulse for no more than 10 seconds
5. NO PULSE: initiate CPR at 30 compressions, second rescuer to size and insert OPA/NPA, Second rescuer to provide 2 breathes with BVM with 15L/min O2 and 100%, post every 30 compressions
6. Ensure following (verbalize): 100-120 compressions provide with heel of hand on patients sternum and 2 finger widths above xiphoid process, 5-6 cm in depth allowing for full recoil, switching compressors every 2 mins
7. Turn AED on
8. Once AED on: second rescuer prepare skin for placement of pads, shave chest if needed, wipe fluids off chest, 2nd rescuer place pads on upper right chest and wall below patients clavicle and in mid-axillary line of chest, avoid scars an pacemaker area, Connect pads to AED
9. Stop CPR
10. press analyze button as soon as pads are connected (provide compressions during any waiting period)

Question 2

CPR with AED (Pediatric 1-8) (2 person)

Answer 2

1. Don PPE
2. Note: unresponsive, apnea, ineffective respirations
3. Send 2nd rescuer to get AED
4. Assess circulation at radial and carotid for no more than 10 seconds
5. NO PULSE: initiate CPR (1 person: 30 compressions/2 breathes, 2 person: 15 compressions/2 breathes) second rescuer size/insert OPA/NPA, provide breathes with BVM 15L/min O2 100%
6. ENSURE: 100-120 bpm with heel of hand on sternum and 2 finger widths above xiphoid process, 4-5 cm in depth or 1/3 chest, allow full recoil, switch compressors q 2 mins
7. Turn on AED
8. When AED arrives, 2nd rescuer prepare skin for pads, wipe fluid form chest, place pads on center of chest/upper right chest wall below patients clavicle and in left mid axillary line of chest, avoid scars and pacemaker area, connect AED pads to AED
9. Stop CPR
10. Press analyze as soon as AED pad connected
11. AED prompts “NO SHOCK ADVISED”: immediately resume CPR, look for signs of life while performing high quality CPR (movement, blinking, chest rise/fall, breathing)
    AED prompts “SHOCK ADVISED”: resume compressions while AED charges, push shock button on AED “I’m clear, you’re clear, Everybody clear OR HOOVER”, deliver shock , Resume CPR post any shock for 2 more minutes
12. Continue steps 5-11 as requires until: signs of life, ALS provider takes over
13. Document procedure

Question 3

Conduct Automated external Defibrillation

Answer 3

1. Don PPE
2. Turn on AED (follow prompts)
3. Expose chest, prepare for pad placement (shave excess hair, wipe fluids)
4. Attach pads with proper placement to chest. Avoid scars an pacemaker areas
5. Stop CPR and ask people to clear
6. Allow AED to analyze rhythm
7. Await AED outcome (resume CPR while charging)
8. When charged, clear contact “I’m clear, You’re clear, Everybody clear”
9. Press shock button
10. Resume CPR for 2 min and await further instructions per AED
11. Document procedure

Question 4

Suctioning- Electric with Yaunker Catheter

Answer 4

1. Don PPE (gloves, gown, glasses, N95, shield)
2. Ensure following are present: Wide-bore, thick walled, non-kinking tubing that fits standard suction, catheter, several sterile disposable suction catheters, unbreakable collection bottle/container, a supply of water for rinsing and clearing tubes/catheters, enough vacuum pressure and flow to effectively suction substances from the throat
3. Prepare suction equipment: turn on suction unit using the power button and test to 300mmHg, kink the tubing for 3-5 seconds and ensure vacuum pressure rises, if it does it is working properly
4. Attach the rigid catheter (yaunker) to the distal end of the tubing that is attached to suction chamber
5. Measure rigid catheter from patients earlobe to corner of mouth
6. Open patients mouth by using cross-finger technique or tongue jaw lift
7. Without applying suction, insert tip of catheter into patients mouth no farther than the base of tongue (or as far as you can see) DO NOT APPLY SUCTION WHILE INSERTING INTO OROPHARYNX
8. Once you have reached the pre-determined depth, cover the hole on the topof the suction catheter
9. Apply suction by simultaneously moving the catheter side to side and withdrawing from the patients mouth. Apply suction for:
   - Adults: 15 seconds
   - Children: 10 seconds
   - Infant: 5 seconds
10. Apply suction to following ranges for following ages:
    - Adults: 80-120 mmHg
    - Children and Infants: 60-80 mmHg
11. Reassess airway for fluids, reassess SPO2 , ensure SPO2 is >90%. if not, stop and provide O2 until SPO2 rises above 90%
12. Monitor the airway continuously for any further need to suction

* WATCH FOR RAPID/SLOW IRREGULAR HEART RATE CHANGES IN ADULTS AND DECREASED HEART RATE IN INFANTS, IF NEEDED, STOP SUCTIONING, APPLY O2 AND REASSESS*

Question 5

Maintain Airway- Head Tilt Chin Lift Maneuver

Answer 5

1. Don PPE
2. Place your hand that is closest to the patient’s head on the patients forehead
3. Apply firm, backward pressure with the palm of your hand to tilt the head back
4. Place the fingertips of your other hand near the chin under the bony part of the lower jaw. Child/Infant, place your finger under the jaw
5. Lift the chin upward. At the same time, support the jaw and tilt the head back as far as possible (the patients teeth should be almost together) Child/Infant, tilt head back only slightly, as if the child is “sniffing” Do not over extend the neck!
6. Continue to press the other hand on the patients forehead to keep the head tilted back

**Do not use this with suspected spinal injury

Question 6

Maintain Airway- Modified Jaw Thrust Maneuver

Answer 6

1. Don PPE
2. Kneel above patients head
3. Place your elbows on the surface where patient is supine
4. Place one hand each side of the head with your thumbs on the patients cheek bones
5. Grasp the angles of the patients lower jaw on both sides (CHILD/INFANT: place 2/3 fingers of each hand on angle of the jaw)
6. While keeping your thumbs on the cheeks, with both hands use a lifting motion to move the jaw up and away from you
7. Keep the patients mouth slightly open. If necessary, pull back the lower lip with the thumb of one of your gloved hands

Question 7

Suctioning- Manual with soft tip catheter

Answer 7

1. Don PPE
2. Prepare suction equipment. TYVEK suction device
3. Measure the soft flexible catheter from the patients earlobe to the corner of mouth
4. Open the patients mouth by using the cross-finger technique or tongue-jaw lift
5. Insert the tip of the catheter into the patients mouth no farther than the base of the tongue. Squeeze the bulb suction prior to inserting catheter into the oropharynx
6. Apply suction by simultaneously moving the catheter side to side and withdrawing from the mouth. Only apply suction for:
   - Adults: 15 seconds
   - Children: 10 Seconds
   - Infant: 5 seconds
7. Reassess airway for fluid
8. Monitor the airway continuously for any further need for suction

*** STOP SUCTIONING IF SUDDEN CHANGE IN BP< APPLY O2

Question 8

Oropharyngeal Airway Adjunct

Answer 8

1. Don PPE
2. To select the appropriate size, measure distance from patients earlobe to corner of mouth OR from middle of mouth to angle of jaw
3. Open the patients mouth using the cross-finger technique or tongue-jaw lift. Hold the airway upside down with your other hand. Insert airway the with the tip facing root of mouth
4. Rotate the airway 180 degree, rotating it over the top of the tongue. When inserted properly, the airway will rest on the mouth with the curvature of the airway the contour of teeth. The flange should rest against the lips with the distal end in the superior pharynx
5. Monitor the patient. If patient gags during insertion or at any point when OPS is in place, remove the OPA by pulling it out following the, normal anatomy. You do NOT need to rotate it to take it out

Question 9

Nasopharyngeal Airway Adjunct

Answer 9

1. Don PPE
2. Select proper size NPA. Measure from patients tip of nostril to earlobe. The diameter should be the diameter of the patients little finger or one of the patients nares
3. Lubricate nasal airway with water soluble gel
4. Place the airway in the larger nare (generally starting with right nare) with:
   - curvature of the device following the curvature of the floor of nose
   - Bevel facing septum
5. Place the bevel toward the septum an insert it gently along the nasal floor, parallel to the mouth, using a gentle twisting motion if any resistance met
6. If resistance continues. reattempt insertion in other nare following the same steps
7. When completely inserted, the flange should rest against the nare opening. The distal end of the airway will be situated into the posterior pharynx, behind the tongue

Question 10

Remove Foreign Bodied via Chest Compressions (Conscious adult/child)

Answer 10

1. Don PPE
2. Confirm the patient is choking:
   - Ask the patient “are you choking?”
   - Patient coughing (encourage patient to cough)
3. If unable to talk, but still conscious:
   - Perform abdominal J thrusts, two finger widths above umbilicus and below the xiphoid process at 45 degree angle until object is expelled or they patient becomes un conscious
   - Before chest thrusts on sternum if patient is obese or pregnant in lieu of abdominal thrusts

Question 11

Remove Foreign Bodies via Chest Compressions (Unconscious adult/child)

Answer 11

1. Don PPE
2. Open the airway with the head-tilt chin lift maneuver and look into the patients mouth If you see the object, roll the patient to their side and carefully remove it by getting behind the object and sliding it out of the mouth, confirm all pieces are removed and repeat is necessary
3. Attempt to ventilate the patient once. If unsuccessful, re-adjust the airway and attempt to ventilate a second time, If unable to ventilate, proceed to next step
4. Perform 30 chest compressions if:
   - 1 or 2 rescuers and patient is an adult
   - 1 rescuer and patient is a child
5. Perform 15 compressions if:
   - 2 rescuers and the patient is a child
6. After every set of compressions, open the airway with the head-tilt chin lift and look into patients mouth.
   - If you see the object, roll the patient to their side and perform finger sweep to carefully remove
   - Confirm that all foreign object pieces are removed, repeat if necessary
   - If you do not see the object and are unable to successfully ventilate, repeat steps 3-5 until successful
   *Considered successful:
   - Feel air movement and see the chest rise when you give breaths
   - See and remove a foreign body from the patients mouth
7. Reassess LOC, ABC’s once you have successfully removed FB

Question 12

Remove Foreign Body via Chest Compressions (conscious infant)

Answer 12

1. Don PPE
2. Kneel or with infant in your lab
3. If easy to do, remove clothing from infants chest
4. Hold infant face down with the head slightly lower than the chest, resting on your forearm
5. Support the infants head and jaw with you outstretched hand by ensuring that your thumb and pointer finger are on the mandible
6. Rest forearm on your lap or thigh to support the infant. Trap one or both of their legs to your body to prevent them from falling off forearm
7. Perform 5 back blows forcefully between infants shoulder blades, using the heel of your hand. Ensure that you do not slip and strike infants head
8. Place your free hand on the infants back and support head with the palm of your hand and turn the infant to face up, keeping the infants head lower than the trunk and trapping the legs to your body
9. Perform 5 forceful, downward chest thrusts with your index and middle fingers, over the lower half of the breast bone at a rate of 1 per second
10. Repeat step 7-9 until the object is:
    - Expelled
    - Infant becomes unresponsive

Question 13

Remove Foreign Body via Chest Compressions (unconscious infant)

Answer 13

1. Don PPE
2. Place infant on a firm,, flat surface
3. Open the airway with slight extension of the neck and look in the mouth. If you see the object, carefully remove it from the infants mouth (DO NOT PERFORM BLIND FINGER SWEEP)
4. Attempt to ventilate once. If unsuccessful, re-adjust airway and try a second time
5. Perform 30 chest compressions if:
   - 1 rescuer
6. Perform 15 chest compressions if:
   - 2 rescuers
7. After every set of compressions:
   - Open the airway, look for object at the back of the throat
   - Remove the object if possible
8. Continue steps 5-7until object has been removed

Question 14

Delivery O2 via BVM

Answer 14

1. Don PPE
2. Prepare ventilation equipment:
   - mask, BVM, O2
   - Connect HEPA filter
   - PEEP and diverter set up at 5-10cm H2O pressure
   - Set flow to 15L/min
3. Position patients head and open airway:
   - if no suspect spinal injury, head-tilt chin lift
   - If suspect spinal injury, jaw thrust maneuver
4. Open patients airway
5. Insert OPA/NPA
6. Select proper size mask
7. Position mask on patients face:
   - Form “C” around ventilation port with your thumb and index fingers
   - Use your middle finger spread under the jaw to maintain a chin lift and complete seal
8. Use your rings and little fingers to bring the jaw up to the mask, avoiding pushing the mask down onto patients face
9. Connect the mask to bag, if not already done
10. Squeeze the bag with your other hand
    - Deliver 10-12 bpm (1 breath q 5-6 seconds), each time squeezing the bag for a full second
11. Observe for:
    - Good chest rise and fall
    - Increased SPO2 saturations
    - Improved skin colour
    - Decreased heart rate
    - Improved LOC

Question 15

Obtaining Heart Rate

Answer 15

1. Don PPE
2. Explain procedure to patient
3. Direct or assist patient into seated position
4. Determine which is the most appropriate pulse point to locate
   - Radial
   - Carotid
   - Brachial
   - Posterior tibialis
   - Dorsal pedis
5. Gently touch pulse point wit tips of 2-3 fingers (not thumb)
6. Count the number of beats felt in one minute:
   - Regular pulse: count number of beats felt in 15 seconds and multiply by 4
   - Irregular pulse/difficult to find: Count the number of beats felt in 30 seconds and multiply by 2
7. Assess rhythm of beats felt
   - regular (consistent)
   - irregular (inconsistent)
8. Assess quality of beats (strong, weak, bounding, thready)
9. Document pulse rate accurately
   - 24 hour clock
   - rate, rhythm, quality

Question 16

Assessing Respirations

Answer 16

1. Don PPE
2. Count respirations by performing one of the following maneuvers:
   - watching the chest rise and fall
   - Place stethoscope over the chest and counting respirations with auscultation (commonly used in infants)
   - Place your hand on the patients chest or abdomen
3. Measure rate:
   - Count the number of times the chest rises and falls over 15 seconds and multiply by 4
   - If irregular/difficult to obtain, count the number of times chest rises and falls in 30 seconds and multiply by 2
4. Measure rhythm:
   - Observe the chest rises and falls in a regular or irregular pattern
5. Measure depth (quality):
   - Observe if the quality of breathes is normal, deep, shallow
6. Document respirations accurately:
   - Using 24 hour clock
   - Rate, rhythm, depth

Question 17

Conduct Non-Invasive Temperature Monitoring

Answer 17

1. Don PPE
2. Explain procedure to patient
3. Clean temperature monitor and/or apply disposable cover over probe
4. Apply temperature monitor to forehead following the manufacturers recommended method for obtaining accurate temp.
   - Push the button and place against forehead on left or right side
   - Drag across forehead in opposite direction of your starting point
   - Drag monitor (still holding button down) behind ear
   - Let go of button
   - Read temperature
5. Clean temperature monitor
6. Document and interpret temperature measurement
7. Suggest therapies based on finding where applicable

Question 18

Obtaining a Blood Pressure by Auscultation

Answer 18

1. Don PPE
2. Explain the procedure to the patient.
3. Direct or assist patient into seated position or supine
4. Ensure the arm being evaluated is supported at the level of the heart
5. Choose the correct sized blood pressure cuff
   - Must encircle the arm so the Velcro strips on opposite ends meet and fasten securely
   - Cuff’s bladder should cover half the circumference of the arm
   - Lower edge of the cuff should be 2-3cm above the ante-cubital space
   - Bladder should be centred over the brachial artery
   - Ensure you can fit one finger easily under the bottom edge of the bladder to ensure it is
   not too tight on the patient’s arm
6. Inflate the cuff rapidly with the rubber bulb while simultaneously palpating the radial pulse until it
   can no longer be felt. Without stopping, continue to inflate the cuff to 30mmHg above the level where the pulse disappeared.
7. Apply the stethoscope over the brachial artery and hold the diaphragm with your thumb
8. Deflate the cuff approx. 2mmHg per second (faster if skill permits). Watch the mercury column/needle drop
9. Listen for 2 or more consecutive beats. This is the “systolic pressure”
10. Continue releasing air from the bulb at a rate of 10mmHg per second. Once the last beat is heard,
    make note of it; this is the “diastolic pressure”
11. Document the auscultated blood pressure accurately and completely:
    - Which limb the blood pressure was taken
    - The position the patient was in when the blood pressure was taken
    - Record the size of the cuff
    - Value obtained (systolic pressure/diastolic pressure Ex: 120/80)

Question 19

Obtaining a Blood Pressure by Palpation

Answer 19

1. Don PPE
2. Explain procedure to patient
3. Direct or assist patient to seated or supine position
4. Ensure the arm being evaluated is supported at the level of the heart
5. Choose the correct BP cuff:
   - Must encircle the arm so the Velcro strips on opposite ends meet and fasten securely
   - Cuff’s bladder should cover half the circumference of the arm
   - Lower edge of the cuff should be 2-3cm above the ante-cubital space
   - Bladder should be centred over the brachial artery
   - Ensure you can fit one finger easily under the bottom edge of the bladder to ensure it is
   not too tight on the patient’s arm
6. Inflate the cuff rapidly with the rubber bulb while simultaneously palpating the radial pulse until it
   can no longer be felt. Without stopping, continue to inflate the cuff to 30mmHg above the level where the pulse disappeared
7. Deflate the cuff approx. 2mmHg per second (faster if skill permits). Watch the mercury column/needle drop
8. Feel at the radial pulse for 2 or more consecutive beats. This is the “systolic pressure”
9. Document the palpated blood pressure accurately and completely:
   - Which limb the blood pressure was taken
   - The position the patient was in when the blood pressure was taken
   - Record the size of the cuff
   - Value obtained (systolic pressure/palpation Ex: 120/P)

Question 20

Obtaining Blood Pressure by NIBP

Answer 20

1. Position patient appropriately for presenting condition.
2. Applies correct size cuff appropriately (relative to the brachial artery)
   - One half to two thirds the size of the upper arm
3. Explains procedure to the patient:
   - Remain as still as possible while obtaining BP
   - Keep the arm with the BP cuff on straight and relaxed
   - Limits any further movement of the patient during obtaining of BP
4. Press the NIBP button on the Lifepack 12/15
5. Correctly interprets BP based on patient condition.

Question 21

Assessing Skin Colour and Condition

Answer 21

1. . Don PPE
2. Explain procedure to patient and direct/Assist them into position where you can easily access the forehead and ear
3. Assess skin condition:
   - Feel the patient’s skin on their forehead with the back of your hand
   - Assess for dryness or moistness
4. Assess for skin colour:
   - Paleness
   - Redness
   - Cyanosis (blue colour)
   - Jaundice (yellow colour)
   - Mottling (black and blue colour)
5. Assess the skin temperature:
   - Is it warm?
   - Is it hot?
   - Is it cool?
   - Is it cold?
6. Assess the relative skin temperature (via tympanic thermometer):
   - Turn the thermometer on and place the protective cover on (if available)
   - Place the thermometer directly into the ear canal and wait until it beeps
   - Assess for very high or very low temperatures
7. Document the skin colour, condition, and temperature:
   - Use the 24-hour clock
   - Record the temperature in degrees Celsius

Question 22

Assessing Pupils

Answer 22

1. Don PPE
2. Explain procedure to patient.
3. Examine the pupils for:
   0 Size (documented right and left, valued in millimeters)
   - Reactivity (reactive, non-reactive)
   - Equality (equal or not)
4. Test the pupils for their reaction to light.
   - Shine the penlight into one of the patient’s eyes and watch for the pupil to constrict in response to the light.
   - If outdoors in bright light, cover the patient’s eyes and observe for dilation of the pupils.
5. Do not expose the patient’s eyes to light for more than a few seconds.
6. Document the pupils size, reactivity, and equality:
   - 24-hour clock

Question 23

Obtaining Pulse Oximetry

Answer 23

1. Don PPE.
2. Explain procedure to patient.
3. Turns on the pulse oximetry device
4. Choose a site to evaluate:
   - Finger
   - Toe
   - Earlobe
   -Remove any nail polish with a commercially prepared nail polish remover if patient noted to have any on the nail to be assessed.
   - Do not evaluate fingers/toes with false nails. These will provide a false reading.
5. Place the oximeter on the patient’s finger
6. Observe for a light or a numerical reading.
   - Ensure it matches the patient’s pulse (taken manually) to ensure proper functioning of
   the meter
7. Observe and record the oxygen saturation readings.
8. Document oximetry value:
   - Use the 24-hour clock
   - Document value as “room air” or “with supplemental 02”

Question 24

Obtaining Blood Glucose

Answer 24

1. Don PPE
2. Gather appropriate equipment:
   - Glucometer with test strips
   - Alcohol wipe
   - Gauze pad
3. Explain the procedure to the patient.
   - Asks the patient which finger the patient would like poked
   - Advises the patient when the puncture will occur
4. Cleanse the puncture site with the alcohol swab in an outward circular motion. Allow the site to dry for 30 seconds before puncturing to ensure no contamination by the
   alcohol to the sample
5. Correctly lance finger.
   - Hold the finger at the base, gently squeeze the finger to make the blood pool at the puncture site
   - Post initial poke, squeeze the finger in a “milking” fashion to encourage more blood at the site.. Don’t contaminate the puncture site when performing “milking”
6. Insert test strip into glucometer device.
7. Place chemical test strip into blood.
8. Wait for glucometer to count down and display the result
9. Place gauze pad over the finger to stop bleeding
10. Provide patient with a bandaid when bleeding has ceased.
11. Document and interpret the glucometer results.
    - Uses 24-hour clock
    - Records the result using mmol/L

Question 25

Conduct a 4 Lead ECG

Answer 25

1. Don PPE.
2. Discuss the indications for 3 lead monitoring.
3. Perform a maintenance check to ensure proper functioning of the cardiac monitor.
4. Prepare the patient prior to attaching the cardiac monitor. Position patient properly:
   - Semi fowlers (45 degrees)
   - arms at side
   - legs uncrossed
5. Attach the electrodes to the appropriate locations on the patient.
   - RL Anywhere above the ankle and below the torso
   - RA Anywhere between the shoulder and the elbow
   - LL Anywhere above the ankle and below the torso
   - LA Anywhere between the shoulder and the elbow
6. Demonstrate a practical understanding of all lead placements.
7. Identified and corrected the following artifact on the ECG tracing:
   - Muscle tremors
   - AC\60 cycle interference
   - Loose electrodes
8. Obtain a legible ECG tracing.
9. Interpret the cardiac rhythm, including the following information:
   - Name of the rhythm
   - Rate (beats per minute)
   - Regularity (regular, irregular)
10. Document the procedure as per industry standards.

Question 26

Obtain 12 Lead ECG

Answer 26

1. Identify indications for 12 lead monitoring.
2. Perform a maintenance check to ensure proper functioning of the cardiac monitor.
3. Prepared the patient prior to attaching the cardiac monitor. Identify proper patient positioning:
   - Patient sitting up at 45-degree angle, hands at side, legs uncrossed.
4. Attach the electrodes to the appropriate locations on the patient:
   V1 4th Intercostal space to the right of the sternum
   V2 4th Intercostal space to the left of the sternum
   V3 Midway between V2 and V4
   V4 5th Intercostal space at the midclavicular line
   V5 Anterior axillary line at the same level as V4
   V6 Mid-axillary line at the same level as V4 and V5
   RL Anywhere above the ankle and below the torso
   RA Anywhere between the shoulder and the elbow
   LL Anywhere above the ankle and below the torso
   LA Anywhere between the shoulder and the elbow
5. Input patient information into LP15.
6. Obtain a legible ECG tracing.
7. Communicate to patient to “please remain still” and “please no talking for 10 seconds” and
   “please breathe calmly for 10 seconds”
8. Interpret the cardiac rhythm.
9. Document the procedure and assessment findings.