Securing Artificial Airway/Cuff Management
Click here on how to use this to chart using this form
Sign in to Google to save your progress. Learn more
Email *
First name-Last name *
Type in your Last Name then first intial
Email
Type in email for confirmation of charting
Program *
Choose your Program
Verification *
Did you check the most recent CXR to verify tube placement and notify the nurse that your are performing Airway Management?
Equipment *
Did you collect your equipment before you went to the patient's room? Pressure manometer, three way stopcock, connecting tubing, 20 cc syringe, adhesive tape (Assemble and check equipment).
PPE *
Personal Protection Equipment. Did you use universal precautions, wash your hands, glove and wear eye protection for this procedure?
Explain *
Did you explain this procedure to the patient and the family if the family was in the room during this procedure?
Suction *
Did you suction the patient?
Position Pt. *
Did you place the patient in semi fowlers?
Oral Care *
Did you perform oral care on the patient?
Airway *
What type of airway does the patient have?
Airway Size *
What is the airway size
Secure Tube *
Did you prepare the ET tube and secure with new twill tape?
Skin *
Did you need to notify the nurse of face or mouth sores from airway pressure or tape skin damage?
Marking at Lip *
Chart the cm marking at the patients teeth.
Cuff Pressure *
Chart the Airway cuff pressure in cmH20. Normal is  20 mmHg / 25 cmH20 or less
Adjust *
Did you adjust the ventilator circuit for patient comfort and to prevent extubation?
Retraints *
Did you check patient restraints?
Notify *
Did you notify the nurse/M.D. of the results and an make the appropriate respiratory therapy changes?
Clean Up *
Did you clean up the mess you made?
Comments
Chart any significant concerns
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of weber.edu. Report Abuse