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FUNDAMENTAL OF NURSING PRACTICE SKILL EVALUATION TOOL
Name of Student: ________________________________________ Student Number: ______________
Year/Clinical Group ___________ School Year: ______________ Term: _________
Inclusive Dates of Clinical Rotational: ____________________________

General Instructions: Please put a check (/) for the procedures performed and (X) for the not performed procedures by
the student. Each check has a corresponding point of 1.

OBE CODE PROCEDURE: OXYGENATION

Performed Comments
Preparation
Yes No
1. Assess:
• The client for the presence of congestion on auscultation of the
thorax.
• Note the client’s ability or inability to remove the secretions
through coughing.
2. Determine:
• If the client has been suctioned previously; if so, review the
documentation of the procedure.
3. Assemble equipment:
• Resuscitation bag connected to 100 percent oxygen
• Sterile towel (optional)
• Equipment for suctioning
• Goggles and mask, if necessary
• Gown (if necessary)
• Sterile gloves
• Moisture-resistant bag
ASSESSMENT PROCEDURE
1. Introduce yourself and verify the client's identity. Explain to the client
what you are going to do, why it is necessary, and how the client can
cooperate. Inform the client that suctioning usually causes some
intermittent coughing, and that this assists in removing the
secretions.
2. Perform hand hygiene and observe other appropriate infection
control procedures.
3. Provide for client privacy.
4. Prepare the client.
If not contraindicated because of health, place the client in the semi-
Fowler’s position.
If necessary, provide analgesia before suctioning.
5. Prepare the equipment.
Attach the resuscitation apparatus to the oxygen source. Adjust the
oxygen flow to 100 percent flush.
Open the sterile supplies.
Place the sterile towel, if used, across the client’s chest below the
tracheostomy.
 Turn on the suction, and set the pressure in accordance with agency
policy.
Put on your goggles, mask, and gown, if necessary.
Put on the sterile gloves.
Holding the catheter in your dominant hand and the connector in your
nondominant hand, attach the suction catheter to the suction tubing.
6. Flush and lubricate the catheter.
Using the dominant hand, place the catheter tip in the sterile saline
solution.
Using the thumb of the nondominant hand, occlude the thumb control, and
suction a small amount of the sterile solution through the catheter.
7. If the client does not have copious secretions, hyperventilate the lungs with a resuscitation bag
before suctioning.
Summon an assistant, if one is available, for this step.
Using your nondominant hand, turn on the oxygen to 12-15L/min.
If the client is receiving oxygen, disconnect the oxygen source from the
tracheostomy tube using your nondominant hand.
Attach the resuscitator to the tracheostomy or endotracheal tube.
Compress the resuscitation bag 3-5 times, as the client inhales.
Observe the rise and fall of the client’s chest to assess the adequacy of
each ventilation.
Remove the resuscitation device and place it on the bed or on the client’s
chest, with the connector facing up.
Variation: Using the Ventilator to Provide Hyperventilation
Procedure
If the client is on a ventilator, use the ventilator for hyperventilation and
hyperoxygenation.
8. If the client has copious secretions, do not hyperventilate with a resuscitator. Instead:
Keep the regular oxygen delivery device on, and increase the liter flow or
adjust the oxygen to 100 percent for several breaths before suctioning.
9. Quickly but gently insert the catheter without applying any suction.
With your nondominant thumb off the suction port, quickly but gently insert
the catheter into the trachea through the tracheostomy tube.
Insert the catheter about 12.5 cm (5 inches) for adults, less for children, or
until the client coughs or you feel resistance. To prevent damaging the
mucous membranes at the bifurcation, withdraw the catheter about 1-2 cm
(0.4-0.8 inches) before applying suction.
10. Perform the suctioning.
Apply suction for 5-10 seconds by placing the nondominant thumb over
the thumb port.
Rotate the catheter by rolling it between your thumb and forefinger while
slowly withdrawing it.
Withdraw the catheter completely, and release the suction.
Hyperventilate the client.
Then suction again.
11. Reassess the client’s oxygenation status, and repeat suctioning.
Observe the client’s respirations and skin color. Check the client’s pulse,
if necessary, using your nondominant hand.
Encourage the client to breathe deeply and to cough between suctions.
Allow 2-3 minutes between suctions, when possible.
Flush the catheter, and repeat suctioning until the air passage is clear and
 the breathing is relatively effortless and quiet.
After each suction, pick up the resuscitation bag with your nondominant
hand and ventilate the client with no more than three breaths.
12. Dispose of the equipment and ensure availability for the next suction.
Flush the catheter and suction tubing.
Turn off the suction, and disconnect the catheter from the suction tubing.
Wrap the catheter around your sterile hand, and peel the glove off so that
it turns inside out over the catheter.
Discard the glove and the catheter in the moisture-resistance bag.
Replenish the sterile fluid and supplies so that the suction is ready for use
again.
Be sure that the ventilator and oxygen settings are returned to
presuctioning settings.
13. Provide for client comfort and safety.
Assist the client to a comfortable, safe position that aids breathing. If the
person is conscious, a semi-Fowler’s position frequently is indicated. If the
person is unconscious, the Sims’ position aids in the drainage of
secretions from the mouth.
14. Document relevant data.
Record the suctioning, including the amount and description of suction
returns, and any other relevant assessments.
Variation: Closed Airway/Tracheal Suction System (In-Line Catheter)
Procedure
If a catheter is not attached, put on clean gloves, aseptically open a new
closed catheter set, and attach the ventilator connection on the T piece to
the ventilator tubing. Attach the client connection to the endotracheal tube
or tracheostomy.
Attach one end of the suction connecting tubing to the suction connection
port of the closed system, and the other end of the connecting tubing to
the suction device.
Turn suction on, occlude or kink tubing, and depress the suction control
valve (on the closed catheter system) to set suction to the appropriate
level. Release the suction control valve.
Use the ventilator to hyperoxygenate and hyperinflate the client's lungs.
Unlock the suction control mechanism, if required by the manufacturer.
Advance the suction catheter enclosed in plastic sheath with dominant
hand. Steady the T piece with the nondominant hand.
Depress the suction control valve and apply suction for no more than 10
seconds, then gently withdraw the catheter.
Repeat as needed, remembering to provide hyperoxygenation and
hyperinflation as needed.
When done suctioning, withdraw the catheter into its sleeve and close the
access valve, if appropriate.
Flush the catheter by instilling normal saline into the irrigation port and
applying suction. Repeat until the catheter is clear.
Close the irrigation port and close the suction valve.
REMARKS
TOTAL POINTS

Computation: Total number of points acquired by the student / Total Number of points for the procedure X 100 = Total points in
percentage
Remarks:

Passed (75 – 100%)

Annotation
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Conforme: ___________________________________ Clinical Instructor: _______________________________

Student’s Over Printed Name and Signature Over Printed Name and Signature