Universidad de Zamboanga

School of Allied Medicine

Nursing Department

EVALUATION CHECKLIST for Oxygen Administration

Name of Student: _____________________________________ Overall Rating: ________
Year and Section______________________________________ Date Performed: ___________________

Direction for Evaluator: Checkmark on the item that corresponds to the behavior coded as follows:
2 – performed correctly and completely 1 – performed incorrectly or incompletely 0 – did not
perform at all

Parameter 2 1 0

1. Checked Doctors Order

2. Assemble all Equipment

3. Identify patient

4. Perform Hand hygiene

5. Checked room for transmission based precaution

6. Use appropriate PPE base on identified standard precaution

7. Introduce your self to patient

8. Confirm Patients identification using the 2 identifiers (name tag/birthdate)

9. Explain the procedure to your client.

10.Provide privacy

11.Place patient on a semi or High Fowlers position as clinically appropriate

12. Perform a focus based respiratory assessment including (RR, Saturation, Lung
sound)

13.Checked and open the Oxygen cylinder clockwise (Determine oxygen Level)

14.Connect (Nasal/facemask, Non Rebreather Facemask) tubing to flow meter

15.Set Oxygen Flow at Prescribed rate.

16.When using a nasal cannula, place the prongs into patients nares and fit the tubing
around their ears.
When using a mask, place the mask over the patient's mouth and nose, secure a
firm seal and tighten the strap around the head.
If using a non rebreather mask, partially inflate the reservoir bag before applying
the mask .

17. Monitor patients response to oxygen therapy (RR, Saturations, reported dyspnea)
 18. Assist patients to a comfortable position and ask if they have questions and
clarifications.

19. Ensure safety measures when leaving the room.

Call light within the reach
Keep bed on lowest position and brakes locked
Side rails up and secured
Room risk for fall

20. Remove and discard PPE to its appropriate waste receptacle.

21. Perform Hand Hygiene

22. Document assessment Findings.

Comments/ Remarks:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Total Score: ________________ points Equivalent Grade: ___________________

Evaluated by: _____________________________ Conformed: __________________________

Name and Signature of Instructor Name and Signature of Student

Date: _________________________