No.

Ruangan :
No. Urut Absen :
FR-FK-20-06/RO

FACULTY OF MEDICINE UNIVERSITAS TARUMANAGARA

CLINICAL SKILL

STUDENT’S NAME :
PASS / FAIL
STUDENT’S NIM :
STUDENT’S SIGNATURE :

OROPHARYNGEAL INTUBATION CLINICAL SKILL

CHECKLIST
Score
No. Checklist Points
0 1 2
Preparation
1 Uses gloves & mask
2 Assesses/Evaluates for presence of difficult airway. Proceed to the next step if
no difficult airway detected (LEMON method)
3 Positions patient such that head, mouth, pharynx and trachea is in a straight line
to facilitate optimal viewing of vocal cords (sniffing position)
4* Pre oxygenates with ventilation bag and face mask for 30 – 60 seconds with the
rate of 1 breath per 2 seconds
5 Asks assistant to prepare equipment on the tray table covered by a sterile drape
• Laryngoscope handle and blade Macintosh/Miller
• Endotracheal tube and stylet
• Suction machine and catheter
• Oropharyngeal airway (Guedel)
• Oxygen connector tube
• Adhesive tape
• Infusion set
• 10cc syringe
• Jelly
• Stethoscope
6* Asks assistant to prepare necessary medication
• Induction medication (Etomidate, Propofol, Sodium Thiopental,
Ketamine) and muscle relaxant (succinylcholine, rocuronium,
atracurium, vecuronium
• Emergency medication (Lidocain, atropine sulfas, Epinephrine)
7 Inserts an IV line
8 Gives intra venous sedation and muscle relaxant if needed
Endotracheal tube insertion
9 Holds laryngoscope in left hand, inserts laryngoscope blade in right corner of
mouth and moves it to the left to push away tongue
10* Lifts the laryngoscope blade upwards. Does not push the handpiece too hard
and does not use the incisors as leverage or patient’s face as support
11 After identifying the vocal cords, inserts ETT with right hand until cuff passes
vocal cords
12 Carefully takes out laryngoscope outside patient’s mouth
13 Takes out stylet out of endotracheal tube
14 Connects ETT with ventilation bag
15* Inflates ETT cuff with 5 cc of air
16* Ventilates patient with two blows of air
17 Examines whether ETT placement is correct by: observing the chest wall
movement after each blow and auscultating on both lungs & stomach
18 Inserts oropharyngeal airway (guedel)
19 Fixates ETT with adhesive tape
20 Ventilates patient (rate 8 -10 breathing/minute) and does suctioning when
needed
TOTAL

Checklist points with * is a must, failure to do so will be considered as a fail

Note:
0 : not done
1 : done imperfectly
2 : done perfectly

SCORE : _______ X 100 =

40

Block Coordinator Examiner

(Alya Dwiana, dr., M.Sc.) (......................................)