NAME: ____________________________________ DATE: _____________________

YEAR & SECTION: ___________________________ SCORE: _______________/13

CLINICAL PERFORMANCE EVALUATION CHECKLIST

OXYGEN ADMINISTRAION (NCM 109 SL)
Legend: Done Student performs consistently in an effective and efficient manner
Not Done No progress in performance has been demonstrated and/or
Performance is consistently ineffective and inefficient

EQUIPMENT Done Not done REMARKS

Flow meter connected to oxygen supply
Humidifier with sterile distilled water (Optional for
low-flow system)
Nasal cannula and tubing/facemask specified by
physician
Gauze to pad tubing over ears (optional)/to pad
elastic band (optional)
PROCEDURE
1. Explain the procedure to the patient and review
the safety precautions necessary when oxygen is
in use. Place “NO SMOKING” signs in
appropriate areas
2. Perform hand hygiene
3. Correct the appropriate O2 equipment:
a. Connect the nasal cannula to the oxygen set-
up with humidification, if one is in use.
Adjust the flow rate as ordered by the
physician. Check that oxygen is flowing out
of prongs.
b. Attach the face mask to the oxygen set-up
with humidification. Start the flow of oxygen
at the specified rate. For a mask with a
reservoir, allow O2 to fill the bag before
placing the mask over the patient’s nose and
mouth.
4. Place the prongs to the patient’s nostrils.
 Adjust according to type of the equipment.
a. Over and behind each ear with adjuster
comfortably under chin; or
b. Around the patient’s head
Position the face mask over the patient’s nose
and mouth. Adjust the elastic strap so that the
mask fits snugly but comfortably on the face.
5. Use gauze pads at ear beneath the tubing as
necessary to reduce irritation.
6. Encourage patient with nasal prongs to breathe
through his/her nose with mouth closed.
7. Perform hand hygiene
8. For nasal prongs:
a. Remove and clean cannula and assess nares at
least every 8 hours or according to agency
policy. Check nares for evidence of irritation
or bleeding.
For face mask:
a. Remove facemask and dry the skin every 2-3
hours if the oxygen is running continuously.
Do not powder around the mask.
9. Assess and chart patient’s response to therapy.
Assess respiratory rate and pattern and chest
movements, and color.

STUDENT’S SIGNATURE: CLINICAL INSTRUCTOR’S

SIGNATURE:
____________________ _______________________________