Far Eastern University

Institute of Nursing

PERFORMANCE EVALUATION TOOL FOR

TRACHEOSTOMY CARE

NAME: _____________________________________________________________ SCORE: _________________

SECTION / GROUP NO: _______________________ CONCEPT: _____________________________________
FACULTY: ___________________________________ DATE: ______________ ROOM NO: ______________

NUMERICAL
QUANTITATIVE DESCRIPTION
RATING

3 Acceptable Demontrates expected procedures/behavior correctly.

2 Moderately Acceptable Demonstrates expected procedure/behavior with minimal error

1 Slightly acceptable Demonstrates expected procedure/behavior with many errors

0 Unacceptable Missed procedure or procedure done but entirely incorrect.

NURSE AS PRACTITIONER RATING REMARKS

Demonstrate responsible citizenship and pride in being a Filipino.
Demonstrate the core values of FEU (Fortitude, Excellence, and Uprightness) in the practice of the nursing
profession.
1. Reports on time and attends to activities punctually 0 1 2 3
2. Displays proper grooming and wears complete well pressed
uniform 0 1 2 3
3. Observes proper decorum at all times 0 1 2 3
4. Accepts constructive criticism 0 1 2 3
5. Handles mannequin/patient with care and respect 0 1 2 3
Perform safe, appropriate, and holistic care to individuals, families, population groups, and communities utilizing
the nursing process
Practice nursing in accordance with existing laws, legal, ethical and moral principle
Communicate effectively in writing, speaking, and presenting using culturally-appropriate language.
Document and report on client care accurately and comprehensively.
Adopt the nursing core values in the delivery of nursing care.
A. PREPARATION
1. Introduces self to patient and verifies patient’s name 0 1 2 3
2. Informs patient of the procedure and its importance 0 1 2 3
3. Performs handwashing 0 1 2 3
4. Assembles articles and equipments needed to the bedside 0 1 2 3
5. Position patient in comfortable position & lay towel over
patient’s chest. 0 1 2 3
6. Turn sunction on and set appropriate pressure (50-100mmHg
for small children; 100-120mmHg for older children and adults) 0 1 2 3
7. Hyper oxygenates patients (Ambu bag3-5 breaths) 0 1 2 3
8. Provides privacy 0 1 2 3

B. PROCEDURE
1. Connect sunction tubing to the machine 0 1 2 3
 2. Opens steril suction kit and prepares materials 0 1 2 3
3. Attaches suction catheter to suction tubing 0 1 2 3
4. Puts on sterile gloves 0 1 2 3
5. Holds catheter in dominant hand and the connector in non
dominant hand. Attach catheter to the Y-connector 0 1 2 3
6. Using the steriled gloved hand, puts the catheter tip in the
sterile saline solution and suction a small amount of sterile
solution through the catheter. 0 1 2 3
7. Hyper oxygenates the patient 0 1 2 3
8. Remove oxygen delivery device with non-sterile hand 0 1 2 3
9. With non-dominant thumb turns off the suction port, quickly
but gently insert the catheter into the trachea thru the
tracheostomy tube. Insert the catheter about 10 to 12.5 cm (4 to
5 in) or until the patients cough. 0 1 2 3
10. Apply suction for 5-10 secs. By occluding the thumb port with
the non-dominant thumb. Allows 20-30 secs rest between
suction. 0 1 2 3
11. Rotates catheter by rolling it between thumb and forefinger
while slowly withdrawing it. 0 1 2 3
12. Withdraws the catheter completely & release the suction 0 1 2 3
13. If secretions are thick, flushes the tracheostomy tube with
approximately one ml sterile saline, then suction 0 1 2 3
14. Encourage patient to breath deeply and cough. Repeat the
suction until the air passage is clear and the breathing is
relatively effortless and quite. 0 1 2 3
15. Assesses patient’s cardio-pulmonary status between each
suctioning 0 1 2 3
16. Turn off suction machine 0 1 2 3
C. PROCEDURE FOR TRACHEOSTOMY CARE
1. Opens tracheostomy set, hydrogen Peroxide and sterile saline 0 1 2 3
2. Dons sterile gloves keeping dominant hand sterile 0 1 2 3
3. Pours Hydrogen Peroxide into one tray and sterile NaCl into
other tray using non dominant hand 0 1 2 3
4. Puts sterile brush & pipe cleaners into H2O2 tray using sterile
gloves 0 1 2 3
5. Puts 4X4s and 1 cotton swab into H2O2 tray and Na Cl tray,
keeping two 4x4s dry 0 1 2 3
6. Instructs re: deep breathing then removes oxygen source if
present, with non-dominant hand 0 1 2 3
7. Removes inner cannula; If disposable, dispose 0 1 2 3
8. If not disposable, puts in hydrogen peroxide with brush 0 1 2 3
9. Washes inner cannula with brush 0 1 2 3
10. Holds cannula (sterile) over basin and pours NaCl over cannula
to rinse 0 1 2 3
11. Shakes off excess saline 0 1 2 3
12. Using 4x4s and cotton swab from H2Os tray, cleans outer
cannula and stoma in circular motion 4-8 cm from stoma 0 1 2 3
13. Uses 4x4s and swab from saline tray to rinse area and pat dry
0 1 2 3

D. CHANGING TRACHEOSTOMY TIES

1. Ties ends securely in double square knot allowing space for
only one finger in tie or attaches Velcro strips 0 1 2 3
2. Inserts fresh tracheostomy dressing under clean ties and 0 1 2 3
 faceplate
E. AFTER CARE
1. Positions client comfortably 0 1 2 3
2. Performs hand hygiene 0 1 2 3
3. Performs after care of all articles and equipments used 0 1 2 3
F. DOCUMENTATION
Documents the procedure and all nursing assessment
• Time tracheostomy care was done
• Condition of tracheostomy
• If cannula was changed
• Effect of tracheostomy care to patient 0 1 2 3

______________________________________
Signature of Student Signature of Faculty