PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)

Intramuros, Manila

College of Nursing

Skills Laboratory Checklist

(ENDOTRACHEAL CARE)

NAME: ______________________________ DATE: ________________________

YEAR LEVEL AND BLOCK: ______________ CLINICAL INSTRUCTOR: _________________

RATING SCALE:
4 – Performed correctly, systematically according to standard with correct rationale
3 - Performed correctly, not systematically with correct rationale
2 - Performed correctly, not systematically with inadequate rationale
1 – Performed incorrectly

Objectives:
1. To secure and maintain a clear airway that will promote good ventilation.
2. To prevent aspiration.
3. To provide oral hygiene.
4. To decrease the risk of ventilator associated infections such as pneumonia.

Materials:
 Protective equipments: Goggles or glasses, cup and mask
 Bite-block or oral airway if needed
 Suction machine
 Adhesive or twill tape; commercial endotracheal tube holder (design must ensure ability to provide oral
care and suctioning)
 2 × 2 Gauze or cotton swab
 Normal saline solution
 Oral cleansing solution
 Soft pediatric/adult toothbrush or suction toothbrush
 Toothettes/oral swab/oral suction swab

Procedure 4 3 2 1 Comments

1 Identify the patient and the orders to be done.

Rationale:
 Verify the patient’s name and the procedure to be
done.

2 Provide client privacy.

Rationale:
 Ask the relatives to leave the room or if they would
like, they may help us in the procedure.

3 Explain procedure to patient and family as appropriate

 including how they can assist procedure.

Gather the equipments needed for the care placing on a

4 table beside the bed of the patient. Be sure that the suction
device is working perfectly.
Rationale:
 To provide easy access for the materials of the
procedure.

5 Note the proper tube level of insertion in “cm” (gums / teeth

in adults, and upper lip in pediatrics) as landmark.
Rationale:
 The tube must not move back or forward during the
procedure. Thus, patient may not receive the
recommend oxygen intake.

6 Auscultate air entry prior to procedure for comparison post

procedure.
Rationale:
 Ensure that the tube is in proper place. If not,
reposition the tube properly.

7 Perform medical hand washing and don personal protective

equipments (gown, mask, googles and gloves).
Rationale:
 This will protect the patient from cross contamination
and will also protect the nurse.

8 Place a linen or a towel in the patient’s chest.

Rationale:
 The towel or linen to keep the patient from being
soiled.

9 Turn on the suction device and adjust to appropriate setting.

10 Start by suctioning patient’s mouth and airway prior to

procedure.
Rationale:
 To remove excess secretions. Make sure to protect
and secure the suctioning device after use.

11 Remove the gloves and perform hand hygiene.

12 Prepare the tape to be used for resecuring the tube or a

commercially prepared securing device.

13 With one nurse securely holding Endotracheal Tube, the

 second nurse carefully loosens securement device attached
to the patient. If using adhesive tape method remove any
excessive adhesive with adhesive tape remover and wipe
off with wet face cloth.

14 Inspect the condition of face, lips and oropharynx for any

break in integrity.

15 Beginning on the side opposite to the placement of the

endotracheal tube, clean the patient’s mouth, gums, and
teeth.
 Use soft bristle brush/oral swab and a 10cc syringe
with saline solution/oral cleaning solution.
 Use the suction catheter as needed to remove
secretions.
 While cleaning, check for any pressured area
around the mouth.

16 Note the endotracheal tube marking at the patient’s lips,

teeth or mouth and carefully move to the endotracheal tube
to the other side of the mouth making sure its depth remains
the same. Clean the patient’s mouth, gums and teeth on this
side of the mouth. Suction if necessary.

17 Wash patient’s face and neck as needed. For male patient’s

shave required area if necessary, being mindful of patient’s
cultural norms.

18 If tape is used, clean the area where the tape is attached

and apply skin protectant as indicated.

19 Reposition Endotracheal Tube to opposite side of mouth or

center. Prior to moving the tube, if patient is able to, ask
patient to open his/her mouth. If not, gently open mouth with
tongue depressor.

20 Re-secure the tube by the securing device or tape. Confirm

tube at required centimeter marking prior to re-securing.

21 Ensure that the tube is secure. It should not move forward in

the patient’s mouth or backward down the throat. While
ensuring, check for any pressure on the mucosa and around
occipital region on the head.
 If tape is used to secure the tube, place a long tape
underneath the patient’s neck with the double
portion resting from ear to ear. Secure one side of
the tape over the lip and tube (or from ear to nares).
 Tear the remaining half lengthwise, secure the
 buttom half of the tape against the lower lip (or
across the top of the nose), wrap the top half of the
tape around the tube twist to secure the
endotracheal tube. Gently pull the other side of the
tape that is around patient’s neck and secure to the
opposite side of the patient’s face and the
endotracheal tube.
 With the device secure and the endotracheal tube
stabilized, reattached the suction source to the tube.

22 Remove the linen from the patient and dispose properly all
materials used.

23 Remove protective equipments and wash hands.

24 Assess vital signs continually during procedure.

Monitor for any air leak, obstruction and displacement.

25 Document appropriate informations. Including time of the

procedure, type of suctioning performed, description of the
secretion including the amount, color, odor and consistency
and patient’s response to the procedure.

26 Continue to assess your patient for any changes as needed.

__________________________________________
Student’s Signature over Printed Name

Evaluated by:

_____________________________________
C.I’s Signature over Printed Name.