Assessment Form

Thank you for agreeing to participate in this survey. Individuals participating in this survey are not specifically identified in reporting the results. Please follow the instructions that include your participation in a three-step process. You are being asked to read Vignette One and then respond to three multiple choice questions. Proceed to Part II, you will again be asked to read the Vignette Two and respond to four multiple-choice questions. Proceed to Part III that will require you to type a narrative response that is designed to collect data about signs/symptoms that occur in patients whose tracheotomy tubes comes out. Please answer all questions in this survey. Your responses are very important. Please select or enter the best answer to each question. After reading the vignette’s below, specific questions will be asked concerning each scenario. Please read questions carefully before responding.

Part I

Vignette One: Mr. J., age 40 had a tracheotomy performed three days ago to treat his obstructive sleep apnea. You are the registered nurse speaking to Mr. J. In your conversation with Mr. J. he speaks without placing his finger over his tracheotomy tube opening, and remarks to you that his voice is much improved, and sounds just like it did before he had the tracheotomy performed. You examine his tracheotomy site, the tube is secured, he has equal and bilateral chest expansion, his lungs are clear to auscultation, and Mr. J is breathing normally.

1. What is the best comment to make to Mr. J at this point?

A. You are progressing much better than expected?
B. Let me show you how to use the decannulation plug.
C. You will not need to use a decannulation plug since your voice is normal.
D. Let me suction your tracheotomy.

2. Mr. J’s tells you he is afraid he may cough his tube out. What signs and/or symptoms would you tell Mr. J. to expect immediately if he was to have an accidental decannulation?

A. difficulty breathing, weak or absent voice
B. dyspnea, restlessness, urticaria
C. improved or normal voice
D. hypoxemia, aphonia, cyanosis
E. Both A and D
F. Both B and D

3. Just as you are about to leave Mr. J’s room, you observe his accidentally decannulation, what action would you take?

A. Attempt to reinsert tracheotomy tube
B. Administer oxygen
C. Manual ventilate via face mask using resuscitation (ambu) bag
D. Manual ventilate while occluding tracheotomy using resuscitation (ambu) bag

Part II

Vignette 2 Mrs. M. is a 57 year old admitted for acute upper airway obstruction and had a tracheotomy performed. This is her first postoperative day. Before you make your rounds you read the note the physician has just written concerning Mrs. M. The note states that her upper airway remains completely obstructed with no evidence of respiratory distress at this time. You enter Mrs. M’s room, to start your assessment. Mrs. M. has oxygen going via her tracheotomy mask. You suspect that Mrs. M. tracheotomy tube is displaced.

4. .What signs and symptoms would you expect if Mrs. M’s tube were displaced?

A. difficulty breathing, absent voice
B. dyspnea, restlessness, urticaria
C. improved or normal voice
D. hypoxemia, aphonia, cyanosis
E. Both A and D
F. Both B and D

5. What is the most immediate means for any nurse to verify Mrs. M’s tracheotomy tube is displaced?

A. Increase oxygen flow rate
B. Insert suction catheter into tracheotomy tube
C. Send for chest x-ray
D. Place decannulation plug in tracheotomy tube

6. If you confirm Mrs. M’s tracheotomy tube is displaced, what action would you take?

A. Attempt to reinsert tracheotomy tube
B. Increase oxygen flow rate
C. Manual ventilate via face mask using resuscitation (ambu) bag
D. Manual ventilate while occluding tracheotomy using resuscitation (ambu) bag

7. What signs and/or symptoms would you expect if Mrs. M. were to have an accidental decannulation?

A. difficulty breathing, normal voice
B. dyspnea, restlessness, urticaria
C. improved or normal voice
D. hypoxemia, aphonia, cyanosis
E. Both A and D
F. Both B and D

Part III

Please answer the following general question related to a patient with a tracheotomy.

8. If a tracheotomy patient has an unobstructed upper airway, what signs and/or symptoms would you expect if the entire tracheotomy tube set came completely out?

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