JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Intubation
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
First name-Last name
*
Your answer
Date
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Verification
*
Did you get an order for Ventilation,verify the right patient and notify the nurse of what the patient needs
Choose
Yes
No
PPE
*
Personal Protection Equipment. Did you use universal precautions, wash your hands, glove and wear eye protection for this procedure?
Choose
Yes
No
Laryngoscope
*
Size and type of blade. State if you used a glydescope
Your answer
PreOxygenate
*
Pre oxygenated/ventilated pt?
Yes
No
Technique
*
What is the technique of the intubator
Choose
Appropriate
Tramatic
Did not see intubation
Breathsounds
*
What is the patients baseline breath sounds post intubation
Your answer
ET Tube Depth
*
Marking of ET tube at lip in cm (example 24 cm)
Choose
20
21
22
23
24
25
26
27
28
29
Sp02
*
What is the patient's baseline Sp02?
Your answer
Initiation
*
Position and place on patient. How is the patient tolerating ventilation?
Choose
Without complications
With complications (see notes)
Adverse Affects
*
Chart any adverse affects
Your answer
Adjustments
*
Chart any ventilator adjustments and why you made them.
Your answer
Notify
*
Did you notify the nurse/M.D. of the results and an make the appropriate respiratory therapy changes?
Choose
Yes
No
Clean Up
*
Did you clean up the mess you made?
Choose
Yes
No
Comments
*
Chart any significant concerns
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of weber.edu.
Report Abuse
Forms
