Lipa City Colleges

College of Nursing
(G.A. Solis St., Lipa City, (043)756-5974, www.lipacitycolleges.net)
Performance Evaluation
In Accordance with PRC Board of Nursing Memorandum No. 01, Series 2009

Name of Student:
Year/Clinical Group:
School Year:
Semester:/ Term first Semester Second Semester Summer
Inclusive Dates of Clinical Rotation:

APPLYING AN OXYGEN DELIVERY DEVICE

Performance Checklist Skill 19.1

4 3 2 1 0
ASSESSMENT
1. Identified patient using at least two identifiers.
2. Performed respiratory assessment.
3. Observed for behavioral changes.
4. Observed for patent airway, removed air-
way secretions by having patient cough or by
suctioning.
5. Noted patient's most recent ABG results or
Spo2 value.
6 Reviewed patients’ medical record for order
for oxygen.
PLANNING
1. Identified expected outcomes.
2. Explained procedure to patient and family.
3. Gathered equipment and completed necessary
charges.
IMPLEMENTATION
1. Performed hand hygiene, applied face shield
and gloves if indicated.
2. Adjusted bed to appropriate height, lowered
side rails, checked locks on bed wheel.
3. Attached oxygen delivery device to oxygen
tubing, attached to humidified oxygen source
adjusted to prescribed flow rate.
4. Applied oxygen device:
a. Placed tips of cannula into patient's nares,
looped tubing over patient's ears, adjusted
lanyard.

b. Applied mask over patient's mouth and

nose, brought straps overhead.
5. Maintained sufficient slack on oxygen tubing
secured to patient's clothes.
6. Observed for proper function of oxygen deliv-
ery device.
7. Verified setting on flowmeter and oxygen
source for proper setup and prescribed flow
rate.
8. Checked cannula/mask every 8 hours, kept
humidification container filled at all times.
9. Posted Oxygen in Use" signs as needed.
10. Disposed of gloves properly, performed hand
hygiene.
EVALUATION
1. Monitored patient's response to changes in
flow rate with SpO2.
2. Observed for improvement in physical signs
and symptoms.
3. Assessed adequacy of oxygen flow each shift.
4. Observed patient's ears, nose, nares, and
nasal mucous membranes for evidence of skin
breakdown.
5. Asked patient to explain why oxygen is
beneficial.
6. Identified unexpected outcomes.
RECORDING AND REPORTING
1. Recorded all pertinent information in the ap-
propriate log.
2. Documented evaluation of patient learning.
3. Reported unexpected outcomes to health care
provider or nurse in charge.
 Lipa City Colleges
College of Nursing
(G.A. Solis St., Lipa City, (043)756-5974, www.lipacitycolleges.net)
Performance Evaluation
In Accordance with PRC Board of Nursing Memorandum No. 01, Series 2009

Name of Student:
Year/Clinical Group:
School Year:
Semester:/ Term first Semester Second Semester Summer
Inclusive Dates of Clinical Rotation:

ADMINISTERING OXYGEN THERAPY TO A

PATIENT WITH AN ARTIFICIAL AIRWAY
Performance Checklist Skill 19.2

4 3 2 1 0
ASSESSMENT
1. Identified patient using at least two identifiers.
2. Assessed patient's respiratory status.
3. Observed for patent airway, removed airway
secretions by having patient cough and by
suctioning.
4. Monitored SpO2, noted patient's most recent
ABG levels.
5. Reviewed patient's medical record for order for
oxygen; noted delivery method, flow rate, and
duration of oxygen therapy.
PLANNING
1. Identified expected outcomes.
2. Explained purpose of T tube or tracheostomy
collar to patient and family.
IMPLEMENTATION
1. Gathered equipment, completed necessary
charges.
2. Performed hand hygiene, applied clean gloves
and other appropriate PPE.
3. Attached T tube or tracheostomy collar to oxy-
gen tubing and to humidified air or oxygen
source if indicated.
4. Adjusted flow rate properly if oxygen was or
dered, adjusted nebulizer to proper FiO2, setting
attached T tube to artificial airway, placed tra-
cheostomy collar over tracheostomy tube.
5. Observed that T tube does not pull on artificial
airway or cause pressure on skin, suctioned
secretions as necessary.
6. Observed oxygen tubing for accumulation
of fluid, drained tube away from patient if necessary,
disconnected from collar or T tube, discarded fluid
in proper receptacle.
7. Set up suction equipment at patient's bedside.
8. Removed gloves and goggles, performed hand.
EVALUATION
1. Monitored patient's ABG levels or measured
SpO2.
2. Performed respiratory assessment.
3. Observed position of oxygen delivery device,
ensured it was not pulling on the artificial airway.
4. Asked patient and family to explain why oxygen
is attached to tracheostomy tube.
5. Identified unexpected outcomes.
RECORDING AND REPORTING
1. Recorded respiratory findings and all pertinent
information in the appropriate log.
2. Documented evaluation of patient learning.
3. Reported unexpected outcomes to health care
provider or nurse in charge.
 Lipa City Colleges
College of Nursing
(G.A. Solis St., Lipa City, (043)756-5974, www.lipacitycolleges.net)
Performance Evaluation
In Accordance with PRC Board of Nursing Memorandum No. 01, Series 2009

Name of Student:
Year/Clinical Group:
School Year:
Semester:/ Term first Semester Second Semester Summer
Inclusive Dates of Clinical Rotation:

USING INCENTIVE SPIROMETRY

Performance Checklist Skill 19.3

4 3 2 1 0
ASSESSMENT
1. Identified patient using at least two identifiers.
2. Identified patients who would benefit from
incentive spirometry.
3. Assessed patient for confusion, malnutrition,
cognitive impairment, and decreased necessary
motor skills.
4. Assessed patient's respiratory status.
5. Assessed level of pain.
6. Reviewed health care provider's order for incen-
tive spirometry.
PLANNING
1. Identified expected outcomes.
2. Explained procedure to patient and family.
3. Indicated to patient where the target volume is
on the IS, demonstrated use if possible.
IMPLEMENTATION
1. Gathered equipment, completed necessary
charges.
2. Performed hand hygiene.
3. Positioned patient in appropriate position.
4. Instructed patient to hold IS upright, exhale com-
pletely, and place lips tightly around mouthpiece.
5. Instructed patient to take slow, deep breath
and maintain a constant flow, removed mouth-
piece at point of maximal inhalation, had pa-
tient hold breath for 3 seconds and exhale
normally.
6. Had patient repeat maneuver, encouraged pa-
tient to reach prescribed goal.
7. Encouraged patient to independently use IS at
prescribed frequency.
8. Performed hand hygiene.
EVALUATION
1. Observed patient's ability to use incentive
spirometer by return demonstration.
2. Assessed if patient was able to achieve target
volume or frequency.
3. Auscultated chest during respiratory cycle,
obtained pulse oximeter reading.
4. Asked patient to show how to use IS and how
frequently to use it.
5. Identified unexpected outcomes.
RECORDING AND REPORTING
1. Recorded lung sounds before and after incentive
spirometry, frequency of use, volumes achieved,
and adverse effects in appropriate log.
2. Documented evaluation of learning.
 Lipa City Colleges
College of Nursing
(G.A. Solis St., Lipa City, (043)756-5974, www.lipacitycolleges.net)
Performance Evaluation
In Accordance with PRC Board of Nursing Memorandum No. 01, Series 2009

Name of Student:
Year/Clinical Group:
School Year:
Semester:/ Term first Semester Second Semester Summer
Inclusive Dates of Clinical Rotation:

USE OF A PEAK FLOWMETER

Performance Checklist Procedural Guideline 19.1

4 3 2 1 0
PROCEDURAL STEPS
1. Reviewed medical record for patient's
baseline PEFR.
2. Assessed previous PEFR readings and target
set by patient's health care provider.
3. Helped patient to appropriate position.
4. Assessed patient's baseline knowledge of
When and how to use PEFR.
5. Slid mouthpiece into base of numbered scale.
6. Instructed patient to take deep breath.
7. Had patient place meter mouthpiece in mouth
and close lips firmly.
8. Had patient blow out hard and fast in one
breath through mouth.
9. Monitored PEFR results, assessed if patient
Is in expected range.
10. Informed patient of his or her acceptable
range.
11. Asked patient to demonstrate recording
PEFR using traffic light pattern if patient is to
record
at home.
12. Asked patient to demonstrate how to use
PEFR device.
13. Compared patient's PEFR with personal
best.
14. Recorded PEFR measurement before and
After therapy and patient's ability to perform
PEFR.
15. Instructed patient to clean unit weekly
following manufacturer's instructions.