SCHOOL OF NURSING

General Luna Road, Baguio City Philippines 2600

Telefax No.: (074) 442-3071 Website: www.ubaguio.edu E-mail Address: nursing@ubaguio.edu

PERFORMANCE CHECKLIST ON INTUBATION

Name of Student: _____________________________________________________ Date: ________________________

Year &Section / Group: _______________ Clinical Instructor: _____________

Direction:
Please check the appropriate box below to describe verbalized or demonstrated competence level using the following criteria:
0 = Did not Perform 1 = Not Yet Competent 2 = Competent
PROCEDURE 0 1 2 Comments
PREPARATION
1 Check that all necessary equipment is available        
2 Check / validate doctor's order.        
Obtain informed consent
3  Indication for test
 Complications – pain from lead removal or rash        
4 Identify / verified client's identity.
     
5 Perform hand hygiene        
A
6 Wear Gloves for protection        
Explain procedure to patient to reduce anxiety and to encourage
7
cooperation.        
Instruct the client to remove any metal object in the body (coins, wrist
8
watch and dentures)
8 Prepare the skin if required (dry with gauze pads or washcloth).
9 Place the patient in the supine position if possible and provide Privacy
Procedure
B 10 Checked the Oxygen Saturation (80% and Below oxygen saturation)      
11 Open the Airway using Head-tilt-chin-lift- maneuver
Hyper Ventilate the patient at least 3-5 ventilations with an interval of 5-6
12
seconds before intubating
13 Performed aseptic handwashing and done sterile gloves      
Apply water-based lubricant to the tip of the endotracheal tube before
14
insertion.
15 Insert Laryngoscope to visualize the airway
Insert the endotracheal tube at a length of 18-22cms (length of ET Tube
16
is dependent on the body structure and size of the ET tube used)
In case of unsuccessful ET Tube insertion, removed laryngoscope and
hyperventilated before attempting to re-insert ET tube. (if ET tube
17
insertion is unsuccessful for 2 attempts, perform 5 cycles of CPR before
reinserting ET tube.
18 Remove gently the Laryngoscope after insertion of the ET tube.      
19      
Connect Bag-Mask Ventilation (BVM) to the ET tube.
Assessed for the placement of the ET tube by auscultating for the
20
presence of bilateral air entry at the chest and abdominal areas.
21 Prevent premature removal of ET tube during ventilation

SN 4-NCENL05-01 Page 1 of 3
 SCHOOL OF NURSING
General Luna Road, Baguio City Philippines 2600

Telefax No.: (074) 442-3071 Website: www.ubaguio.edu E-mail Address: nursing@ubaguio.edu

Anchor the ET tube by injection 10cc of air to inflate the balloon while
22
checking for the patency of the balloon.
Secure properly the ET tube with a micro pore and marked proximal end
23
for proper positioning
24 Continue Ambu bagging with a 5-7 seconds interval
25 Check and monitor the oxygen saturation
26 Maintained composure all throughout the procedure
27 Perform After Care properly      
28 Endorse Client properly for further care and management      

Total:56

___________________________________________________ _________________________________ 
Name and Signature of Clinical Instructor Date

Updated by:

SN Clinical Instructors

Checked by:

Elton John Delos Santos, MA ED, MAN, RN

RLE Coordinator, BSN and HCS

Noted by:

Evangeline I. Soliba, RN, MAN

Program Chair, BSN and HCS

Approved by:

Helen D. Alalag, RN, MAN

Dean, School of Nursing

Version 1: September 10, 2021

References:
American Heart Association Basic Life Support Provider Manual
https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.105.166553

SN 4-NCENL05-01 Page 2 of 3
 SCHOOL OF NURSING
General Luna Road, Baguio City Philippines 2600

Telefax No.: (074) 442-3071 Website: www.ubaguio.edu E-mail Address: nursing@ubaguio.edu

https://ahainstructornetwork.americanheart.org/idc/groups/ahaecc-
public/@wcm/@ecc/documents/downloadable/ucm_481402.pdf

SN 4-NCENL05-01 Page 3 of 3