Formative Nasogastric Tube

Adult Nasogastric Tube

MonthDayYearHourMinutes

What class is the student in?*

ACEvening

A Shift*

B Shift*

C Shift*

Evening Class*

Who is the Evaluator?*

InstructorA Shift Student EvaluatorC Shift Student EvaluatorEvening Class Evaluator

Instructor*

A Shift Student Evaluator*

B Shift Student Evaluator*

C Shift Student Evaluator*

Evening Class Student Evaluator*

Selects, checks, assembles equipment

NG tube of the proper sizeWater based lubricantSyringeStetoscope

Prepares patient

Takes or verbalizes appropriate PPE precautionsGathers and prepares equipment

Performs Intubation

Lubricates tubeInserts tube to desired lengthConfirms tube placement via auscultationSecures tube

Affective

Accepts evaluation and criticism professionallyShows willingness to learnInteracts with simulated patient and other personnel in professional manner

Critical Criteria

Interrupts ventilations at any time when SpO2 is less than 90%Failure to take or verbalize appropriate PPE precautionsFailure to measure NG tubeFailure to assure proper tube placement by auscultation bilaterally and over the epigastriumInsertion or use of any adjunct in a manner dangerous to the patientFailure to demonstrate the ability to manage the patient as a minimally competent EMTExhibits unacceptable affect with patient or other personnelUses or orders a dangerous or inappropriate intervention

Evaluator Comments

Was the student successful or unsuccessful in this skill?*

SuccessfulUnsuccessful

Signature*