OUR LADY OF FATIMA UNIVERSITY

College of Nursing – Valenzuela City

PROGRAM Bachelor of Science in Nursing STUDENT

NAME
COURSE NCMB-312 YEAR &
Care of client with problems in SECTION
oxygenation, fluids and electrolytes, INSTRUCTO
infectious, inflammatory and R
immunologic responses, cellular DATE
aberrations, acute and chronic
(SKILLS LABORATORY)

PROCEDURE : ENDOTRACHEAL SUCTIONING

EXPECTED OUTCOME : The student should be able to do endotracheal suctioning correctly.
ASSESSMENT TASK : Return Demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(4) (3) (2) (1)
Properly assessed Properly assessed Properly Failed to assess
the patient’s the patient’s assessed the the patient’s
1.
needs for needs for patient’s needs needs for
Determine client’s need
suctioning. suctioning with for suctioning suctioning.
for suctioning.
minimal error. with maximal
error.
2. Explained the Explained Explained Failed to
Explain to the client the procedure procedure but procedure but in explain the
procedure and the need thoroughly. lacks some details. an unclear procedure.
for suctioning to allay manner.
any fears or anxiety may
have.
Prepared the Gathered Some procedure Failed to gather
materials procedure materials are procedure
3.
completely. materials lacking and materials and
Prepare equipment and
Placed the patient completely but improperly placed the
materials needed and
in an appropriate disorganize. placed the patient in an
place client to an
position. Placed the patient patient in an appropriate
appropriate position.
in an appropriate appropriate position.
position. position.
Sets and stated Sets and stated Sets and stated Failed to sets
the pressure the pressure the pressure and stated the
gauge for adult, gauge for adult, gauge for adult, pressure gauge
children and children and children and for adult,
4.
infant using infant using infant using children and
Sets the pressure on the
portable and wall portable and wall portable and wall infant using
suction gauge.
mounted suction mounted suction mounted suction portable and
machine. machine with machine with wall mounted
minimal error. maximal error. suction
machine.
Properly observed Properly observed Properly Failed to opens
and opens sterile and opens sterile observed and sterile package
5. package with package with opens sterile with
Opens the sterile appropriate size appropriate size package with appropriate
package and uses the of suction tube. of suction tube appropriate size size of suction
appropriate size of the Placed towel on with minimal of suction tube tube and
suction tube. Place a the chest. supervision. with maximal placed towel
linen-saver pad or towel Placed towel on supervision. on the chest.
on the patient’s chest. the chest. Placed towel on
the chest.
 Tested the suction Tested the suction Tested the Failed to test
6.
equipment by equipment by suction the suction
. Test the suction
occluding the occluding the equipment by equipment by
equipment by occluding
connection connection occluding the occluding the
the connection tubing.
tubing. Opened tubing. Opened connection connection
Opens the sterile water
sterile package sterile package tubing. Opened tubing and
and the gauze pack. Don
and don sterile and don sterile sterile package opens sterile
sterile gloves. Consider
gloves properly. gloves improperly. and don gloves package and
the dominant hand
with maximal don gloving.
sterile and the non-
supervision.
dominant hand non-
sterile.
7. Used sterile hand Used sterile hand Used sterile hand Failed to use
With the sterile glove gloved to pick-up gloved to pick-up gloved to pick-up sterile hand
hand, pick up the the catheter and the catheter and the catheter and gloved to pick-
catheter and connect it connected to connected to connected to up the catheter
to the suction machine. suction machine. suction machine suction machine and connected
with little error. with some error. to suction
machine.
Poured sterile Poured sterile Poured sterile Failed to
saline in sterile saline in sterile saline in sterile perform the
8.
container and container and container and steps
Pour sterile saline into
lubricated with lubricated with lubricated with completely.
the sterile container,
sterile water and sterile water and sterile water and
using the non-dominant
introduced the introduced the introduced the
hand. Lubricate and
catheter correctly catheter correctly catheter
introduce the catheter
without applying without applying correctly without
correctly without
suction. suction with little applying suction
applying suction.
error. with some error.

9. Performed the Performed the Performed the Failed to

step properly. step with minimal step with perform the
Hyper-oxygenate the supervision. maximal step.
patient according to supervision.
agency policy:

a. Patient Requiring
Mechanical Ventilation:

Press the 100% O2

button on the ventilator
or attach the
resuscitation bag to the
endotracheal tube or
tracheostomy tube and
manually hyper-
oxygenate the patient
by compressing the
resuscitation bag 3 to 5
times as the patient
inhales. Remove the
resuscitation bag and
place it next to the
patient when finished.

b. Patient Not Requiring

Mechanical Ventilation:

Attach the resuscitation

bag to the tracheostomy
or endotracheal tube
and hyper-oxygenate
the patient by
compressing the
resuscitation bag 3 to 5
times. Remove the
resuscitation bag and
place it next to the
patient when finished.
10. Performed Performed Performed Failed to
Using the dominant suctioning by suctioning by suctioning by perform the
hand, gently but quickly applying pressure applying pressure applying pressure steps
insert the suction on the suction on the suction on the suction completely.
catheter into the control and gently control and gently control and
endotracheal tube or rotates the rotates the gently rotates
tracheostomy tube. catheter with catheter with the catheter with
Performs suctioning by ease. minimal maximal
applying pressure on supervision. supervision.
the suction control and
gently rotates the
catheter.
Applied Applied Applied Failed to
intermittent intermittent intermittent perform the
11. suction for 5-10 suction for 15-20 suction for 25-30 steps
Apply intermittent seconds, rotates seconds, and seconds, and completely.
suction for 5-10 seconds the catheter, then rotates the rotates the
and not more than 10 removes finger catheter, then catheter, then
seconds, rotates the from the suction removes finger removes finger
catheter, then removes control and from the suction from the suction
finger from the suction removes the control and control and
control and removes the catheter with no removes the removes the
catheter. difficulty. catheter with little catheter with
error. some error.

12. Performed the Performed the Performed the Failed to

Advance again the step properly. step with minimal step with perform the
suction catheter, with supervision. maximal step.
suction off, gently supervision.
aiming downward and
being careful not to
force the catheter.
Repeat suctioning as
needed, allowing at
least 30-second
intervals between
suctioning. Cleans the
catheter by wiping off
thick secretions or
flushing it with sterile
water.
13. Performed the Performed the Performed the Failed to
Hyper-oxygenate the step properly. step with minimal step with perform the
patient in between each supervision. maximal step.
pass. Replace the supervision.
oxygen source, if the
patient was removed
from the source during
suctioning. Coil the
suction catheter in the
dominant hand
(alternatively, wrap it
around the dominant
hand). Pull the sterile
glove off over the coiled
catheter.
 Properly disposed Properly disposed Improperly Failed to
14. soiled materials soiled materials disposed soiled disposed and
Dispose soiled materials and ensured but did not ensure materials but ensured
and ensure availability availability of availability of ensure materials for
of materials for the next materials for the materials for the availability of the next
suction. next suction. next suction. materials for the suctioning.
next suction.
Assessed the Assessed the Assessed the Failed to assess
effort, depth, effort, depth, effort, depth, for the
rhythm, and rate rhythm, and rate rhythm, and rate effectiveness
15. of respiration, skin of respiration, O2 of respiration, O2 of suctioning
Assess the effectiveness color, O2 saturation, but saturation and
of suctioning. saturation and failed to assessed skin color but
blood pressure. skin color, pulse failed to assessed
rate, and blood pulse rate and
pressure. blood pressure.
16. Performed the Performed the Performed the Failed to
Discard the gloves and step properly. step with minimal step with perform the
catheter in a receptacle supervision. maximal step.
designated by the supervision.
agency. Provide mouth
care.

17. Documented Some of the Most of the Documentation

Documents procedure procedure with details of details of was not done
done and relevant data relevant data procedure were procedure were
observed. properly. not documented. not documented.

OVERALL SCORE: ______________

Target Raw Score: 51 out of 68. If raw score is less than 51, repeat the return demonstration.

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FACULTY SIGNATURE OVER PRINTED NAME