CALAMBA DOCTORS’ COLLEGE
Virborough Subdivision, Parian, Calamba City, Laguna
Performance Evaluation Checklist
Name: ________________________ Date:_______________
Year and Section: _______________
PERFORMING
EQUIPMENT
Bedside table
Towel
Tracheostomy suction supplies
Sterile tracheostomy care kit, if available (be sure to collect
supplies listed that are not available in kit), or two sterile
4 × 4–inch gauze pads
Sterile cotton-tipped applicators
Sterile tracheostomy dressing (precut and sewn surgical dressing)
Sterile basin
Small sterile brush (pipe cleaner) (or disposable inner cannula)
Roll of twill tape, tracheostomy ties, or tracheostomy holder
Scissors
Pulse oximeter
Clean gloves (two pair)
Mask, goggles, or face shield
INSTRUCTION: Rate the nursing skill performance of the student based as follows:
5 = Perfect (91-100)
4 = Very Satisfactory (85-90)
3 = Satisfactory (80-84)
2 = Poor (79-75)
1 = Need Improvement (74 and below)
PROCEDURE 5 4 3 2 1 Comments
Identify the patient
Observe for excess peristomal secretions, excess intratracheal
secretions, soiled or damp tracheostomy ties, soiled or damp
tracheostomy dressing, diminished airflow through tracheostomy
tube, or signs and symptoms of airway obstruction requiring
suctioning.
Perform hand hygiene, and apply clean gloves and face shield if
applicable.
Apply pulse oximeter sensor. Provides monitoring for oxygen
desaturation during procedure.
Suction tracheostomy. Before removing gloves, remove soiled
tracheostomy dressing, and discard in glove with coiled catheter.
6. Perform hand hygiene. Prepare equipment on bedside table.
Allows for smooth, organized completion of tracheostomy care.
a. Open sterile tracheostomy kit. Open two 4 × 4–inch gauze
packages using aseptic technique, and pour normal saline on
one package. Leave second package dry. Open two cotton-
tipped swab packages, and pour normal saline on one
package. Do not recap normal saline.Open sterile
tracheostomy dressing package.
b. Unwrap sterile basin, and pour about 1 to 2 cm ( 12 to 1
inch) of normal saline into it.
c. Open small sterile brush package, and place aseptically into
sterile basin.
d. Prepare length of twill tape long enough to encircle patient’s
neck 2 times, about 60 to 75 cm (24 to 30 inches) for an
adult. Cut ends on diagonal. Lay aside in dry area. Cutting
ends of tie on diagonal aids in inserting tie through eyelet.
e. If using commercially available tracheostomy tube holder,
open package according to manufacturer’s directions.
7. Hyperoxygenate patient’s lungs using ventilator setting or by
applying oxygen source loosely over tracheostomy.
8. Apply sterile gloves. Keep dominant hand sterile throughout
procedure.
9. Care of tracheostomy with inner cannula:
a. While touching only the outer aspect of tube, unlock and
remove inner cannula with nondominant hand. Drop inner
cannula into normal saline basin.
b. Place tracheostomy collar, T tube, or ventilator oxygen
source over outer cannula. (NOTE: May not be able to
attach T tube and ventilator oxygen devices to all outer
cannulas when the inner
c. cannula is removed.)
d. To prevent oxygen desaturation in affected patients, quickly
pick up inner cannula and use
e. small brush to remove secretions inside and outside inner
cannula.
f. Hold inner cannula over basin, and rinse with normal saline,
using nondominant hand to pour normal saline.
g. Replace inner cannula, and secure “locking” mechanism .
10. Tracheostomy with disposable inner cannula:
a. Remove new cannula from manufacturer’s packagingWhile
touching only the outer aspect of the tube, withdraw inner
cannula, and replace with new cannula. Lock into position.
b. Dispose of contaminated cannula in appropriate receptacle,
and reconnect to ventilator or oxygen supply
11. Using normal saline– saturated cotton-tipped swabs and 4 ×
4–inch gauze, clean exposed outer cannula surfaces and stoma
under faceplate extending 5 to 10 cm (2 to 4 inches) in all
directions from stoma. Clean in circular motion from stoma site
outward using dominant hand to handle sterile supplies.
12. Using dry 4 × 4–inch gauze, pat lightly at skin and exposed
outer cannula surfaces.
13 Secure tracheostomy.
Tracheostomy tie method:
(1) Instruct assistant, if available, to apply gloves and securely
hold tracheostomy tube in place. With assistant holding
tracheostomy tube, cut old ties
(2) Take prepared tie, insert one end of tie through faceplate
eyelet, and pull ends even
(3) Slide both ends of tie behind the head and around neck to
other eyelet, and insert one tie through second eyelet.
(4) Pull snugly. Secures tracheostomy tube.
(5) Tie ends securely in double square knot, allowing space for
only one loose or two snug finger widths in tie.
(6) Insert fresh 4 × 4– inch tracheostomy dressing under clean ties
and faceplate.
Tracheostomy tube holder method:
(1) While wearing gloves, maintain secure hold on the
tracheostomy tube. This can be done with an assistant or, when an
assistant is not available, by leaving the old tracheostomy tube
holder in place until the new device is secure. Prevents incidental
dislodgment of tube.
(2) Align strap under patient’s neck. Be sure that the Velcro
attachments are on either side of the tracheostomy tube.
(3) Place narrow end of ties under and through the faceplate
eyelets. Pull ends even, andsecure with the Velcro closures.
(4) Verify that there is space for only one loose or two snug
finger widths under neck strap
14.Position patient comfortably, and assess respiratory status.
15.Be sure that oxygen or humidification delivery sources are in
place and set at correct levels.
16.Assess fit of new tracheostomy ties and ask patient if tube
feels comfortable.
17.Inspect inner and outer cannulas for secretions. Presence of
secretions on cannulas indicates need for more frequent
tracheostomy care.
18.Assess stoma for signs of inflammation, edema, or discolored
secretions. Broken skin places patient at risk for infection. Stoma
infection necessitates change in tracheostomy skin care plan.
19.Document and Evaluate the patient’s response to procedure.
TOTAL RATING
STUDENT SIGNATURE: __________________________
CLINICAL INSTRUCTORS SIGNATURE: ____________
