Adult Non-Rebreather Evaluation

Email(Required)

Employed by:(Required)

Equipment and Patient Preparation

1. Verifies physician's order for appropriateness or evaluates procedure based on hospital protocol. (see Indications CPG ref#1)(Required)

2. Reviews patient chart for significant findings and data.(Required)

3. Identifies and gathers the necessary equipment.(Required)

4. Applies 3 or more mL of an alcohol-based hand rub to palm and rub hands together covering all surfaces of each hand until hands are dry (Caution: should take at least 15 seconds for hands to become dry); or if hands are visibly dirty or contaminated perform hand wash using a vigorous rubbing action for at least 10 seconds; and uses appropriate isolation precautions. (CDC-ref#2)(Required)

5. Introduces self to the patient, stating name, department; confirms patient identification.(Required)

6. Explains the purpose of the procedure, including risks and safety precautions.(Required)

7. Confirms patient and/or family understanding of the procedure.(Required)

Patient Evaluation

1. Measures pulse, respiratory rate and saturation; assesses color and level of dyspnea (ref #3, 4).(Required)

Implementation of Procedure

1. Assembles the oxygen delivery device (flow meter, non-rebreather mask and humidification device) without error or corrects assembly as necessary.(Required)

2. Checks for proper function (presence of adequate oxygen flow, pressure pop-off, functioning bag outlet valve and bag inflates. appropriately)(Required)

3. Properly places the administration device; evaluates fit and patient comfort.(Required)

4. Adjusts flow rate to keep reservoir bag inflated, but without excessive flow. (note - see References #1 and #5 for approximate oxygen concentrations)(Required)

Follow-up

1. Evaluate therapy with pulse oximetry measurement or blood gas as appropriate.(Required)

2. Adjusts flow rate per patient demand.(Required)

3. Decontaminates hands with an alcohol-based hand rub or performs a 15 second hand wash.(Required)

4. Records relevant data in patient chart and appropriate departmental records.(Required)

5. Provides modifications to patient care plan as needed, and reports this to appropriate personnel.(Required)

Demonstrates Knowledge of Fundamental Concepts

1. Identifies the patient specific indication for oxygen therapy.(Required)

2. Identifies partial pressure and oxygen saturation level that defines hypoxemia.(Required)

3. Identifies additional clinical indications for oxygen therapy.(Required)

4. Identifies potential complications with higher oxygen concentration and inadequate flow rates.(Required)

5. Can explain difference between high flow and low flow system.(Required)

6. Identifies approximate oxygen percentages associated with this device. (ref#5)(Required)

Clinical Competency Performance Criteria

1. Displays rational judgment and is able to explain the relationship between theory and clinical practice(Required)

2. Performs procedure in a reasonable time frame and with attention to appropriate detail(Required)

3. Maintains aseptic technique and takes appropriate safety precautions.(Required)

4. Communicates clearly, and in a courteous manner(Required)

Additional comments: include errors of oversight or sequence, strengths and weaknesses during procedure (i.e. knowledge, communication skills, and patient interaction skills)

Summary performance evaluation

Please use the following criteria and select the appropriate pop-up menu.
Satisfactory - ready for clinical application with minimal supervision. Performed procedure accurately, or was able to correct performance without injury to the patient or decreasing effect of therapy being given.
Unsatisfactory performance - not ready for clinical application. Requires remediation under one of the following categories
Minor - Unsatisfactory: Needs to review fundamental concepts or requires re-evaluation of minor deficiency(s) (ex. forgets to wash hands during the Follow-up stage. Must be re-evaluated on this step not the whole procedure).
Major - Unsatisfactory: Requires additional supervised clinical practice and complete re-evaluation of the procedure

Summary Performance Evaluation:

References

1.AARC Clinical Practice Guideline: "Oxygen Therapy in the Acute Care Facility – 2002 Revision & Update" RC 2002;47:(6) p717-720
2.CDC, Guideline for Hand Hygiene in Healthcare Settings. MMWR Oct. 25, 2002; vol. 51(No. RR-16)
3.Mahler, D; Weinberg D, Wells C, and Feinstein A. The measurement of dyspnea: contents, interobserver agreement and physiologic correlates of two new clinical indexes. Chest 1984; 85:751-758
4.Joint ACCP/AACVPR Pulmonary Rehabilitation: Evidenced-Based Guidelines Chest 1997; 112:1363-1396
5.Branson R.D.; Hess D.R.; Chatburn, R.L.: "Respiratory Care Equipment" Lippincott 2nd, 1999 p75

Type the characters from the image below.