Patient J – Initial Assessment and Management

ATLS Instructor Evaluation Form

Patient J – Initial Assessment and Management

Faculty *

Performer *

Critiquer *

Critical Treatment Decisions (check yes or no): The students must: *

	YES	NO
Perform the assessment and management phases properly and in the correct sequence.	YESPerform the assessment and management phases properly and in the correct sequence. YES	NOPerform the assessment and management phases properly and in the correct sequence. NO
Recognize the need to assist the patient's ventilations to ensure adequate oxygenation and ventilation	YESRecognize the need to assist the patient's ventilations to ensure adequate oxygenation and ventilation YES	NORecognize the need to assist the patient's ventilations to ensure adequate oxygenation and ventilation NO
Recognize that the patient's respiratory distress is due to the left pneumothorax, and appropriately insert a chest tube	YESRecognize that the patient's respiratory distress is due to the left pneumothorax, and appropriately insert a chest tube YES	NORecognize that the patient's respiratory distress is due to the left pneumothorax, and appropriately insert a chest tube NO
Recognize that the patient is in a coma, has a chest injury, and requires endotracheal intubation to maintain a patent airway	YESRecognize that the patient is in a coma, has a chest injury, and requires endotracheal intubation to maintain a patent airway YES	NORecognize that the patient is in a coma, has a chest injury, and requires endotracheal intubation to maintain a patent airway NO
Recognize the patient's hypothermia by indicating the need to deliver warmed IV fluids and place the patient on a warming blanket	YESRecognize the patient's hypothermia by indicating the need to deliver warmed IV fluids and place the patient on a warming blanket YES	NORecognize the patient's hypothermia by indicating the need to deliver warmed IV fluids and place the patient on a warming blanket NO
Identify and manage the conditions requiring critical treatment decisions in the order listed	YESIdentify and manage the conditions requiring critical treatment decisions in the order listed YES	NOIdentify and manage the conditions requiring critical treatment decisions in the order listed NO

Potentials for Adverse Outcome: If the student’s performance is borderline and the student fails to recognize or perform one or more of the items below, the instructor may determine that the student’s overall performance is unsuccessful.

Observed List of Maneuvers (Decisions) *

	YES	NO
Recognized pneumothorax in a timely fashion	YESRecognized pneumothorax in a timely fashion YES	NORecognized pneumothorax in a timely fashion NO
Did not intubate with aggressive ventilation before tube thoracostomy	YESDid not intubate with aggressive ventilation before tube thoracostomy YES	NODid not intubate with aggressive ventilation before tube thoracostomy NO
Did not rely on the pulse oximeter in the patient with hypothermia	YESDid not rely on the pulse oximeter in the patient with hypothermia YES	NODid not rely on the pulse oximeter in the patient with hypothermia NO
Did not delay transfer while attempting to warm the patient	YESDid not delay transfer while attempting to warm the patient YES	NODid not delay transfer while attempting to warm the patient NO
Did not delay in instituting aggressive rewarming measures	YESDid not delay in instituting aggressive rewarming measures YES	NODid not delay in instituting aggressive rewarming measures NO
Monitored the patient's temperature while rewarming	YESMonitored the patient's temperature while rewarming YES	NOMonitored the patient's temperature while rewarming NO
Recognized the patient's ischemic right foot	YESRecognized the patient's ischemic right foot YES	NORecognized the patient's ischemic right foot NO
Realigned the right femur and restored circulation	YESRealigned the right femur and restored circulation YES	NORealigned the right femur and restored circulation NO
Performed a neurovascular exam before and after leg immobilization	YESPerformed a neurovascular exam before and after leg immobilization YES	NOPerformed a neurovascular exam before and after leg immobilization NO
Considered the need for tetanus prophylaxis	YESConsidered the need for tetanus prophylaxis YES	NOConsidered the need for tetanus prophylaxis NO
Did not delay in recognizing the need for transfer	YESDid not delay in recognizing the need for transfer YES	NODid not delay in recognizing the need for transfer NO
Did not delay transfer to perform diagnostic tests	YESDid not delay transfer to perform diagnostic tests YES	NODid not delay transfer to perform diagnostic tests NO
Adequately prepared for contingencies during the transfer process, such as continuing the rewarming process to prevent further hypothermia, endotracheal tube malposition, recurrent pneumothorax or tension pneumothorax, and neurologic deterioration	YESAdequately prepared for contingencies during the transfer process, such as continuing the rewarming process to prevent further hypothermia, endotracheal tube malposition, recurrent pneumothorax or tension pneumothorax, and neurologic deterioration YES	NOAdequately prepared for contingencies during the transfer process, such as continuing the rewarming process to prevent further hypothermia, endotracheal tube malposition, recurrent pneumothorax or tension pneumothorax, and neurologic deterioration NO

Comments

Instructor Potential *

Rating – Completed only during the initial examination *

Successful
Incomplete/remedial
Incomplete/repeat course

Remedial Rating-Completed only during the review *

Successful
Incomplete/repeat course