EXTUBATION

© These competencies are protected by United States Copyright © 1999 - 2002 and

the clinical database system is Patent Pending to UTMB (University of Texas Medical Branch at Galveston)

EQUIPMENT AND PATIENT PREPARATION

1. Evaluates indication for procedure based on patient assessment (see Assessment of Need CPG ref. 1) including reversal of underlying indication for intubation (2 pts)_____

2. Reviews patient chart for significant findings and data (2 pts)_____

3. Identifies and gathers the necessary equipment (gloves, suction equipment, oxygen and aerosol therapy equipment, manual resuscitator, appropriate sized mask, oxygen source, and intubation tray) (4 pts)_____

4. Set up and confirm operation of oxygen and/or aerosol delivery device to be used post extubation (4 pts)_____

5. Applies 3 or more mL of an alcohol-based hand rub to palm and rub hands together covering all surfaces of each hand until hands are dry (Caution: should take at least 15 seconds for hands to become dry); or if hands are visibly dirty or contaminated perform hand wash using a vigorous rubbing action for at least 10 seconds; and uses appropriate isolation precautions (CDC-ref. 2) (3 pts)_____

6. Introduces self to the patient, stating name, department; confirms patient identification. (2 pts)_____

7. Explains the purpose of the procedure, including risks and safety precautions (2 pts)_____

8. Confirms patient and/or family understanding of the procedure (1 pt)_____

IMPLEMENTATION OF PROCEDURE

1. Preoxygenate and follow with endotracheal suctioning (5 pts)_____

2. Return to mechanical ventilator and suction oropharynx and hypopharynx to help remove secretions above the cuff;

(5 pts)_____

3. Perform cuff leak test if appropriate to detect potential glottic edema or stridor following extubation (ref. 3) (3 pts)_____

4. Preoxygenate for 1 – 2 minutes using 100% oxygen (ref. 3) (4 pts)_____

5. Prepare suction equipment for retrieval of oral secretions post extubation (3 pts)_____

6. Deflate the cuff (4 pts)_____

7. Using manual resuscitator give a large breath and remove the tube at peak inspiration (8 pts)_____

8. Assist patient with cough and removal of secretions (4 pts)_____

9. Apply oxygen and aerosol device as appropriate (6 pts)_____

10. Evaluate patient for post extubation edema or stridor and follow up with small volume nebulizer treatment as necessary

(4 pts)_____

FOLLOW-UP

1. Evaluates breath sounds respiratory rate, saturation, heart rate, color, and blood pressure (4 pts)_____

2. Confirm adequate oxygenation and humidification in use (3 pts)_____

3. Evaluate need for secretion removal and instruct patient in oral secretion removal (3 pts)_____

4. In 15-30 minutes re-evaluate patient ventilatory status (i.e. arterial blood gas to assess changes in oxygenation and ventilation, frequency/tidal volume ratio to assess ventilatory stability, heart rate, saturation, color, and blood pressure) (3 pts)_____

5. If assessment yields adverse results notify physician and follow with appropriate clinical action (2 pts)_____

6. Decontaminates hands with an alcohol-based hand rub or performs a 15 second hand wash (3 pts)_____

7. Records relevant data in patient chart and appropriate departmental records (2 pts)_____

8. Retain mechanical ventilator in patient room for back-up ventilation (1 pt)_____

DEMONSTRATES KNOWLEDGE OF FUNDAMENTAL CONCEPTS

1. Describe complications associated with removal of the endotracheal tube (ref. 1) (1 pt)_____

2. Can identify appropriate indications for extubation (1 pt)_____

3. Describe cuff leak test for predicting the presence of glottic edema or stridor following extubation (ref. 3) (1 pt)_____

4. Describe therapy and appropriate medication for treatment of glottic edema (1 pt)_____

5. Identify parameters and thresholds for determining respiratory failure following extubation (1 pt)_____

CLINICAL COMPETENCY PERFORMANCE CRITERIA

1. Displays rational judgment and is able to explain the relationship between theory and clinical practice. (2 pts)_____

2. Performs procedure in a reasonable time frame and with attention to appropriate detail (2 pts)_____

3. Maintains aseptic technique and takes appropriate safety precautions (2 pts)_____

4. Communicates clearly, and in a courteous manner (2 pts)_____

Additional Comments: include errors of oversight or sequence, strengths and weaknesses during procedure (i.e. knowledge, communication skills, and patient interaction skills)

References:

1) AARC Clinical Practice Guideline: “Removal of the Endotracheal Tube” RC 1999;44(1):85-90

2) CDC, Guideline for Hand Hygiene in Healthcare Settings. MMWR Oct. 25, 2002; vol. 51(No. RR-16)

3) Scanlan CL, Spearman CB, Sheldon RL: "Egan's Fundamentals of Respiratory Care” Mosby 7th, 1999, Ch. 29

FINAL EVALUATION

SCORE __________

If a score of 70 or more is not achieved, the evaluation will have to be repeated with the score achieved on any repeat evaluation being multiplied by 0.7 for the final score.

STUDENT SIGNATURE ______________________________________________________

INSTRUCTOR SIGNATURE _____________________________________________________

9/03

Summative Performance Evaluation:

Satisfactory ______

Minor Unsatisfactory ______

Major Unsatisfactory ______

___________________________________

Name of person being evaluated

___________________________________ ________________________

Signature of Direct Supervisor Date