DAVAO DOCTORS COLLEGE

Nursing Program
PERFORMANCE EVALUATION CHECKLIST
OXYGEN ADMINISTRATION BY NASAL CANNULA

NAME: GROUP: RATING: 40

Note: Type "1"

PREPARATION 5 4 3 2 1
1 Determines the need for oxygen therapy, and verifies the order for the therapy. (Verifying the Dr.’s order
by means of checking it in the patient’s chart. The purpose of it is for us to make sure of the
order that we are going to deliver to our patients and to avoid errors.)
2 Performs a respiratory assessment to develop baseline data if not already available. (This is by means of
getting the respiratory rate of the patient without him/her noticing it to avoid the patient being
conscious. The purpose of doing it is for us to have a baseline data which we are going to use
for us to know if the treatment is effective or not.)
3 Prepares the client and support people:
a. Assists the client to a semi-flower's position if possible. (To provide patient’s comfort and improve
oxygenation through lung expansion and increase oxygen saturation during the procedure.)
b. Explains that oxygen is not dangerous when safety precautions are observed. (To gain patient’s
cooperation and to reduce anxiety)
c. Informs the client and support people about the safety precautions connected with oxygen use. (This is by
means of placing a “No Smoking” signage at the patient’s door or at the footboard of the
patient’s bed or informing the watcher/s. To provide safety for oxygen supports combustion.)
PERFORMANCE

1 Prior to performing the procedure, introduces self and verifies the client's identity using agency protocol. (To
reduce patient’s anxiety and for us to make sure that we are delivering the right treatment to
the right patient.)
a. Explains to the client what you are going to do, why is it necessary, and how he or she can participate. (For
the patient to be informed and for him/her to reduce anxiety.)
b. Discusses how the effects of the oxygen therapy will be used in planning further care or treatments. (To
make the patient feel at ease and for the patient to feel that he/she is involved in her recovery
and that she’s being valued.)
2 Performs hand hygiene and observes other appropriate infection prevention procedures. (To deter the
spread of microorganisms that might cause diseases and/or cross contamination.)
3 Provides client privacy, appropriately. (To provide comfortability that reduces patient’s anxiety)
4 Setting up the oxygen equipment and the humidifier:

a. Attaches the flow meter to the wall outlet or tank. The flow meter should be in the off position. (This is to
reset the setting of the L/min of the oxygen that’s specific for the patient’s need.)
b. If needed, fills the humidifier bottle. (done before coming to the bedside) (This is in preparation when
we are going to attach it to the base of the flow meter.)
c. Attaches the humidifier bottle to the base of the flow meter. (The purpose of the humidifier is to
avoid dryness by means of moisturizing the mucous membrane while administering oxygen)
d. Attaches the prescribed oxygen tubing and delivery device to the humidifier. (For effective oxygenation
while avoiding dryness of the mucosa)
5 Turns on the oxygen at the prescribed rate and ensures proper functioning. (To avoid errors and to make
sure that oxygen is administered as prescribed.
a. Checks that the oxygen is flowing freely through the tubing.
 d. Reviews oxygen saturation or arterial blood gas results if available. (To have a background of the
patient’s condition and again, to make sure that the oxygen administered is as prescribed.)
8 Assessment for Nasal Cannula:
a. Assesses the client's nares for encrustations and irritation. (To clear the airway for effective
oxygenation and to provide patient’s comfort.)
b. Applies a water-soluble lubricant as required to soothe the mucous membranes. (To provide patient’s
comfort and to avoid dryness of the mucous membrane)
c. Assesses the top of the client's ears for any signs of irritation from the cannula tubing. If present, padding
with a gauze pad may help relieve the discomfort. (This is for us to provide patient comfortability by
means of choosing an alternative position of the tubing that’s best for the patient.)
9 Inspects the equipment on a regular basis.
a. Checks the liter flow and the level of water in the humidifier in 30 minutes and whenever providing care to
the client. (For this is us being consistent in providing care to our patients and to avoid errors.)
b. Makes sure the safety precautions are being followed. (To ensure patient safety and promote
recovery.)
10 Performs hand washing/hand hygiene and aftercare. (To deter the spread of microorganisms that might
cause diseases and/or cross contamination. Also, in preparation in attending the next patient.)
Documents findings in the client record using forms or checklists supplemented by narrative notes when
11
appropriate. (For it is a reflection that the procedure has been done and for other healthcare
professionals to have a baseline data which will be use in planning specific treatment for the
patient.)
TOTAL 0 0 0 0 0

Clinical Instructor's Comment(s): 0

= 40
155

CI's NAME and SIGNATURE

kms/dts/bbn
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