NURSING EDUCATION ADMINISTRATION

COMPETENCY ASSESSMENT TOOL

TITLE: Oxygen therapy.

Staff name: Job number: Job title: Unit:

Qualification: Diploma: ( ) BSN: ( ) Post-graduate: ( ) Contract date:

Self-assessment key: Evaluation: Validation:

0 – No experience/not competent M – Met V – Verbal
1 – Satisfactory/requires further development NM – Not met DO – Direct observation
2 – Competent R – Refer to improvement plan SP- Simulation Practice

Please tick (√) the appropriate box depending on the self-assessment key indicated above.
Self- EVALUATION
PERFORMANCE CRITERIA
assessment (ASSESSOR)
Date
0 1 2 KNOWLEDGE Validation M NM R &
Initial
1. States the definition of oxygen therapy.
2. Verbalizes the purpose of oxygen therapy.
3. Verbalizes the indication of oxygen therapy.
4. States the different types of oxygen devices.
SKILLS
5. Physician's order was checked.
6. Patient's identification done according to the hospital
policy.
7. Pulse oximetry was applied and resting SPO2 was
obtained.
8. Procedure was explained to the patient.
9. Appropriate supplies were assembled.
10. Patient's condition was assessed.
11. Hands were washed.
12. Smoking danger was explained & non-smoking sign
were displayed.
13. The humidification jar was filled with sterile water
when indicated.
14. The oxygen delivery system was assembled:
14.1 One end of oxygen tubing was attached to the device
and other end of tubing to the oxygen outlet source.
15. The oxygen flow rate was turned on and adjusted as
prescribed.
16. The device applied to the patient:
17. Nasal cannula:
17.1 The tip of the cannula was inserted into the patient's
nose and the tubing was placed over the ears then
placed under the chin.
1
 NURSING EDUCATION ADMINISTRATION

18. Simple face mask:

18.1 Mask was placed over the patient's face and the strap
behind the head or over the ears then both ends were
pulled through the front of the mask until secured.

19. Venturi mask:

19.1 The mask to the appropriate venturi barrel was
attached firmly into the mask inlet oxygen tubing
was fastened.
20. Oxygen delivery device was checked according to the
condition of the patient.
21. ABG levels were monitored and oxygen saturation
was observed.
22. Hands were washed.
23. The following were documented:
23.1 Date and time of oxygen therapy initiation.
23.2 Patient's assessment.
23.3 O2 flow rate and delivery device.
23.4 SPO2 changes.
23.5 Patient's response.
23.6 Patient/family education.

ATTITUDE
24. Privacy of the patient was provided.
25. Provides teaching and psychological support for
patient and family.

Comments:

Improvement plan:

Recommendation:

Evaluator’s Signature over printed name: Date: ________________________

Staff printed signature over printed name: Date: ________________________