Did you check the most recent CXR to verify tube placement and notify the nurse that your are performing Airway Management?
Choose
Yes
No
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).
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
Explain *
Did you explain this procedure to the patient and the family if the family was in the room during this procedure?
Choose
Yes
No
Suction *
Did you suction the patient?
Choose
Yes
No
Position Pt. *
Did you place the patient in semi fowlers?
Choose
Yes
No
Oral Care *
Did you perform oral care on the patient?
Choose
Yes
No
Airway *
What type of airway does the patient have?
Choose
E.T. Tube
N. T. Tube
Trach
Trach Foam Cuff (Bivona)
Airway Size *
What is the airway size
Choose
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5
8.0
8.5
9.0
Secure Tube *
Did you prepare the ET tube and secure with new twill tape?
Choose
Yes
No
Skin *
Did you need to notify the nurse of face or mouth sores from airway pressure or tape skin damage?
Choose
Yes
No
Marking at Lip *
Chart the cm marking at the patients teeth.
Your answer
Cuff Pressure *
Chart the Airway cuff pressure in cmH20. Normal is 20 mmHg / 25 cmH20 or less
Choose
less than 25 cmH20 :)
greater than 25 cmH20 :(
less than 20 mmHg :)
greater than 20 mmHg :(
Adjust *
Did you adjust the ventilator circuit for patient comfort and to prevent extubation?
Choose
Yes
No
Retraints *
Did you check patient restraints?
Choose
Yes
No
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
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