F-CON-049-2014

SAINT PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

OXYGEN THERAPY : PERFORMANCE RATING SCALE

Name: ______________________________ Yr/ Sec.: __________ Date: ________ Score: _________

CI: _________________________________Time Started: _______ Time Ended: _________

Direction: Please rate the student based on the competencies listed below.

Raw Score Critical Level Difficulty Level

0 = Unable to perform 1 = Least Critical 1 = Easy
1 = Performed with prompting 2 = Critical 2 = Moderate
2 = Satisfactory performance 3 = Very Critical 3 = Hard
3 = Very Good performance

CONTENTS ACTUAL HIGHEST REMARKS

R C D SCORE POSSIBLE
(RxCxD) SCORE
1. Introduce self and identify patient. 2 1 6
2. Perform respiratory assessment. 3 2 18
3. Check doctor’s order for oxygen therapy . 2 1 6
4. Inform and explain the procedure. 2 1 6
5. Observe and discuss about safety precautions when 3 2 18
oxygen is in use.
6. Gather the necessary materials. 2 1 6
7. Wash hands. 1 1 3
8. Assist client to a semi-fowler’s position. 2 1 6
9. Attach the flow meter to the oxygen source. Flow meter 3 2 18
should be in off position.
10. Attach the humidifier to the base of flow meter. 3 1 9
11. Attach the oxygen tubing to the humidifier. 3 1 9
12. Adjust flow rate as ordered by the physician. Check if 3 2 18
oxygen is flowing out of the outlet.
13. Apply appropriate oxygen delivery device. 3 2 18
14. Adjust the fit at the nasal cannula or the elastic strap of 3 1 9
the mask so that it fits snugly but not tight.
15. Wash hands. 1 1 3
16. Document. 2 2 12
17. Wash hands. 3 2 18
18. Reassess patient’s respiratory status. 2 1 6
19. Inspect the equipment to ensure its functioning. 1 1 3
20. Put on clean gloves. 2 1 6
21. A. assess the nares for evidence of irritation or bleeding. 3 1 9
B. remove the mask and dry the skin.
TOTAL SCORE 201

Clinical Instructor’s General Remarks:

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Date & Clinical Instructor’s Signature_____________________

Student’s Remarks:
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Date & Student’s Signature _____________________________