FOOTHILL COLLEGE
Candidate Name: _________________________________________ Date: ______________________
Examiner Name and Signature: _________________________________________________________
Time Started: __________ Time Ended: __________ Points: _____/18 PASS/FAIL (Circle One)
| Points Possible | Points Awarded | |
| Takes or verbalizes appropriate PPE precautions | 1 | |
| Prepares Medication | ||
| Right patient, Right Medication, Right Dose, Right Route, Right time | 5 | |
| Administration of Epinephrine | ||
| Explain procedure to patient | ||
| Remove medication from the package. DO NOT TEST THE DEVICE | 1 | |
| Select and prepare appropriate injection site | 1 | |
| Hold device without putting fingers on either end of auto-injector | 1 | |
| Remove safety device from auto-injector | 1 | |
| Securely Immobilize leg particularly in children | 1 | |
| Place tip of auto-injector against patients lateral mid-thigh at 90 degree angle | 1 | |
| In quick motion, presses hard onto thigh until auto-injector mechanism functions, holds injector in place for 3-10 seconds (Device Dependent) | 1 | |
| Withdraw auto-injector and apply pressure to injection site using dressing/bandage. Massage area for 10 seconds | 1 | |
| Dispose of auto-injector in a sharps container | 1 | |
| Evaluation and Support | ||
| Obtain Vital signs | 1 | |
| Monitor patient for desired effects | 1 | |
| Monitor patient for adverse effects | 1 |
Points Possible: 18 Total Points Awarded_______________
Critical Criteria
____ Failure to take appropriate PPE precautions
____ Failure to dispose of the needle in the proper container at the proper time
____ Failure to correctly prepare site and administer medication appropriately
____ Failure to reassess the patient and provide supportive care
____ Failure to manage patient as a competent EMT