Performs skill in Requires further

accordance to instruction &

OXYGEN ADMINISTRATION BY NASAL written
CANNULA supervision
SKILLS CHECKLIST guidelines
(To be performed by licensed medical personnel as designated
Date in their job description)
Date
Name: _____________________________________ School: _________________________
SKILL

1. Assemble equipment :
• Oxygen cylinder, tank or canister.
• Cannula and tubing.
• Check that the tank has enough oxygen.

2. Wash hands.

3. Attach cannula tubing securely to oxygen

source.

4. Set liter flow on the flow meter as prescribed.

Never change this setting without and
order.

5. Check the cannula prongs to make sure that air

is coming out.

6. Insert prongs gently into the student’s nose.

Make sure both prongs are in the nostrils.

7. Loop tubing over each ear and then under the

chin; secure by sliding the clasp up under the
chin.

8. Wash hands.

9. Monitor student continuously for respiratory

distres s. Initiate emergency procedures as
indicate d.

10. Document oxygen administration and any

observation s.

Preceptor’s Signature _____________________________________ Initials _______ Date ___________

Preceptee's signature _____________________________________ Initials _______ Date ___________
*Initial and date in space beside each skill indicates procedure has been demonstrated in a competent manner.

Distribution: Original to preceptee, one copy in the Health Room, copy to Sherri Reynolds/PSS Landings