SETTING UP AN IV SET EXCELENT SATISFACTORY NEEDS
(3 points) (2 points) PRACTICE
Republic of the Philippines
PALAWAN STATE UNIVERSITY
College of Nursing and Health Sciences
NCM 106 SKILLS LABORATORY
PERFORMANCE CHECKLIST
IV THERAPY
NAME:__________________________________________SCORE:_______________
BSN 4 DATE:________________
DIRECTIONS: GIVEN ACTUAL OR MODEL CLIENT, EVALUATE THE STUDENT’S
PERFORMANCE ACCORDING TO THE FOLLOWING CRITERIA:
QUALITATIVE NUMERICAL DEFINITION
DESCRIPTION DESCRIPTION
Excellent 3 points Safe, accurate performance accord-
ing to accepted standards; affect is
appropriate, the student is profi-
cient, coordinated, confident; occa-
sional expenditure of excess energy
is noted; task is completed within
reasonable time period; no sup-
porting cues are needed.
Satisfactory 2 points Safe, accurate performance accord-
ing to accepted standards; the de-
sired outcome is obtained most of
the time; affect is approariate most
of the time; skilful in parts of the
behaviour; the student is inefficient
and uncoordinated; student ex-
pends excess energy to accomplish
the task; task is completed within a
delayed time period; frequent ver-
bal and occasional physical di-
rective cues are needed in addition
to supportive cues.
Needs Practice 1 point Unsafe, unable to demonstrate
behaviour; student lacks confi-
dence, coordination, efficiency,
continuous, verbal and physical
cues are needed.
Page 1 (1 point)
1. Verify written prescription.
Ensures correct procedure to correct patient with correct
solution.
2. Observe ten (10) Rs when preparing and administering
IVF.Ensures correct procedure to correct patient with
correct solution.
3. Explain procedure to reassure patient and/or signifi-
cant other, secure consent if necessary.To allay patient’s
anxiety and foster his/her cooperation.
4. Assess patient’s vein; choose appropriate site, location,
size/condition.The selection of an appropriate site de-
creases discomfort and possible damage to patient’s body
tissue.
5. Prepare necessary materials for procedure:
IV solution prescribed, Infusion set, IV cannula, Mi-
cropore or IV dressing, disposable gloves, IV stand, IV
tray, kidney basin.Having equipment available saves time
and facilitates accurate skill performance.
6. Check the sterility and integrity of the IV solution, IV
set and other devices.To prevent administration of ex-
pired or unsterile solution to patient.
7. Place IV label on IVF bottle duly signed by RN who
prepared it (patient’s name, room no., solution, time and
date). Indicate the medication if added to the solution
and include time-tape label on the container.This pro-
vides correct solution with prescribed medication. Time
tapping permits immediate evaluation of IV infusion ac-
cording to schedule.
8. Do hand hygiene before and after the procedure.To
prevent spread of infection.
9. Open IV administration set aseptically and close the
roller clamp and spike the infusate container aseptically
following the infection control measures.This punctures
the seal in the IV bag maintaining the sterility.
10. Fill drip chamber to at least half and prime it with IV
fluid aseptically.Suction effects cause to move fluids into
drip chamber and prevents air entrance in the tubing.
11. Expel air bubbles if any and put back the cover to the
distal end of the IV set.This removes air from tubing that
can in larger amounts act as air embolus.
SUBTOTAL SCORE
Comments:___________________________________________________________________
____________________________________________________________________________ CHANGING AN IV SOLUTION EXCELENT Page 2NEEDS
SATISFAC-
(3 points) TORY PRACTICE
____________________________________________________________________________ (1 point)
(2 points)
Noted by: Evaluated by: 11. Reiterate assurance to patient and significant
______________________________ ________________________________ others.Appropriate instructions and information
(Sign over printed name of Student) (Sign over printed name of Instructor) enhances cooperation.

Date:_________________________ Date:___________________________ 13. Discard all waste materials according to

CHANGING AN IV SOLUTION
1. Verify doctor’s prescription in doctor’s order
sheet; countercheck IV label, IV tag, infusate/
solution sequence, type, amount, additives (if any),
and duration of infusion.Ensures correct procedure
to correct patient with correct solution.
2. Observe 10 Rs.To prevent error in administration.
3. Explain procedure to reassure the patient and
significant others and assess IV site for redness,
swelling, pain etc.To check complications of IV
therapy and assess for patient’s need for further in-
structions.
Health Care Waste Management (DOH/
DENR).To prevent spread of microorganisms.
14. Document and endorse accordingly.This pro-
EXCELENT SATISFAC- NEEDS vides communication among the health care
(3 points) TORY PRACTICE
(1 point)
team.
(2 points)
SUB-TOTAL SCORE
Comments:___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Noted by: Evaluated by:
______________________________ ________________________________
(Sign over printed name of Student) (Sign over printed name of Instructor)
Date:_________________________ Date:___________________________

4. Change IV tubing and cannula within 72 hours

after IV insertion or upon the discretion of the at-
tending medical doctor.Changing of the cannula DISCONTINUING AN IV INFUSION EXCELENT SATIS- NEEDS
and dressing prevents infection in the IV site. (3 points) FACTORY PRACTICE
5. Wash hands before the procedure.To prevent (2 points) (1 point)
spread of microorganisms. 1. Verify written doctor’s order to discontinue IV in-
6. Prepare necessary materials; place on an IV cluding IV medications.To check correct prescription.
tray.To save time, effort and energy of the nurse.
2. Observe the 10 Rs.

7. Check sterility and integrity of IV solution.To 3. Assess and inform the patient of the discontinuation
avoid infusion of expired and contaminated solution of IV infusion.

8. Place IV label on the bottle.For immediate evalu- 4. Prepare the necessary materials.Organization facili-
ation of infusion according to prescription. tates accurate skill performance.

9. Close the roller clamp. Open and connect the IV 5. Wash hands.
tubing into the solution bottle.To maintain the ste- 6. Close the roller clamp of the IV administration set.
rility of the tubing.
10. Regulate the flow according to the prescribed
infusion rate. Expel bubbles, if evident.To prevent
air in the administration set.
 DISCONTINUING AN IV INFUSION
7. Moisten adhesive tapes around the IV
catheter with cotton ball with alcohol; re-
move plaster gently.This loosens the adhe-
sion of the tape to the skin.
8. Place a dry cotton ball over the puncture
site without applying pressure and remove
the needle or IV catheter. Immediately ap-
ply slight pressure and ask patient to apply
pressure for at least 2 minutes.To avoid bleed-
ing from the site. Normal coagulation time is 2-5
minutes.
9. Inspect IV catheter for completeness.To
prevent injury to the patient.
10. Place dressing over the venipuncture
site.
11. Reassure patient.
12. Discard all waste materials including the
IV cannula according to Health Care Waste
Management (DOH/DENR).
13. Document time of discontinuance, status
of insertion site and integrity of IV catheter
and endorse accordingly.
SUBTOTAL
Comments:___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Noted by:
______________________________
(Sign over printed name of Student)
Date:_________________________
EXCELENT SATISFACTO- NEEDS PRAC- INITIATING IV LINE EXCELENT SATISFAC- NEEDS
PagePRACTICE
3
(3 points) RY TICE (3 points) TORY
(2 points) (1 point)
(2 points) (1 point)
1. Check doctor’s order, identify the client and se-
cure consent.. IV insertion can’t be performed with-
out doctor’s order. Proper identification ensures that
the procedure is done to the right client. Initiating IV
therapy through IV insertion is an invasive procedure
that needs client consent
2. Wash hands and prepare all equipment at bed-
side such as IV tubing, IV cannula, tourniquet, alco-
holized cotton, plaster, markers, receptacle, clean
gloves. Ensures asepsis and a smooth flow of proce-
dure.
3. Explain procedure and answer client’s question
and worries. Decreases fears and anxiety.
4. Select the IV site.Choose distal veins so that once
damaged, the proximal part of the vein can still be
used. Avoid areas that bends to prevent infiltration.
Use non dominant hand for freedom of movement.
Avoid extremity with low sensation or poor integrity.
5. Ask client to rest arm of selected vein. Makes the
veins more visible.
6. Put on gloves. Maintains asepsis.
7. Cleanse insertion site from starting in the middle
of the site going outward. Reduces transmission of
microorganism. Be sure to leave the area dry before
insertion.
8. Apply tourniquet 5-6 inches above the selected
site. Engorges the vein for easier IV insertion.
9. Anchor vein by placing thumb over vein and
stretching the skin against the direction of inser-
tion. Stabilizes the vein and aids in IV insertion.
10. Insert the stylet catheter, with bevel up at 20 to
Evaluated by:
30-degree angle.
_______________________________
(During IV insertion on elderly clients use a 5-15
(Sign over printed name of Instructor)
degree angle because their veins are more superfi-
cial.) Prevent damage to the posterior wall of the
Date:__________________________
vein.

INITIATING IV LINE
11. Check for blood backflow. Pressure from tourni-
quet causes quick backflow of blood into the cathe-
ter.
12. Loosen stylet and advance catheter into the
vein until hub rests on the IV site. Ensures proper
placement of catheter. Note: Do not reinsert stylet
after loosening to prevent puncture to the cathe-
ter.
13. Hold thumb over the vein above catheter tip
and release tourniquet. Prevents blood leaking and
reestablishes venous blood flow.
14. Quickly release pressure over the vein and con-
nect needle adapter of the IV set to the hub of the
catheter. Prompt connection reduces blood loss or
leakage.
15. Begin infusion at slow rate or KVO or per insti-
tution policy. Keeps vein open and ensures paten-
cy of IV .
16. Tape over the hub of the catheter. Place trans-
parent dressing over the site. Secure catheter in
place and controls bleeding and infection.
17. Secure tubing in loop fashion. Prevent tubing
dislodgement.
18. Remove gloves and do aftercare. Prevents
transmission of microorganisms.
19. Label the site with date and time of insertion
and the size and gauge of catheter. Serves as guide
for next dressing change. It is recommended to
change IV site every 3 days to avoid infection and
other IV complications.
DOCUMENTATION: Make sure to document the
following after procedure:
1. Date and time of IV insertion
2. Size and gauge of catheter
3. Client’s untoward reaction to the procedure.
4. Type of fluid infused and prescribed rate
5. Additives, i.e. contrast amount and type.
SUB-TOTAL SCORE
Comments:___________________________________________________________________
EXCELENT SATISFAC- NEEDS ____________________________________________________________________________
(3 points) TORY PRACTICE Page 4
(1 point) ____________________________________________________________________________
(2 points)
Noted by: Evaluated by:
______________________________ ________________________________
(Sign over printed name of Student) (Sign over printed name of Instructor)
Date:_________________________ Date:___________________________
PREPARING MEDICATIONS FROM AMPULES EXCELENT SATISFAC- NEEDS
(3 points) TORY PRACTICE
(2 points) (1 point)
1. Verify the medication order in the Doctor’s or-
der sheet. Follow the three checks for correct med-
ication and dose. Read the label on the medication
(1) when it is taken from the medication cart, (2)
before withdrawing the medication, and (3) after
withdrawing the medication. • Calculate medica-
tion dosage accurately. • Confirm that the route is
correct.
2. Organize the equipment.
Equipment: Ampule, File (if ampule is not scored)
and small gauze square or plastic ampule opener •
Antiseptic swabs ,syringe ,needle for administering
the medication
3.Perform hand hygiene and observe other appro-
priate infection prevention procedures.
4. Prepare the medication ampule for drug with-
drawal. Flick the upper stem of the ampule several
times with a fingernail. This will bring all medica-
tion down to the main portion of the ampule. .
5. • Use an ampule opener or place a piece of ster-
ile gauze or alcohol wipe between your thumb and
the ampule neck or around the ampule neck, and
break off the top by bending it toward you to en-
sure the ampule is broken away from yourself and
away from others. The sterile gauze
protects the fingers from the broken glass, and any
glass fragments will spray away from the nurse.
OR Place the antiseptic wipe packet over the
top of the ampule before breaking off the top. This
method ensures that all glass fragments fall into the
packet and reduces the risk of cuts. • Dispose of the
top of the ampule in the sharps container.
 PREPARING MEDICATIONS FROM AMPULES EXCELENT SATISFAC- NEEDS NEEDS
PREPARING MEDICATIONS FROM VIALS EXCELENT SATISFAC-
(3 points) TORY PRACTICE Page 5 PRACTICE
(3 points) TORY
(2 points) (1 point) (2 points) (1 point)
6. Place the ampule on a flat surface. • Attach the 5. Remove the protective cap, or clean the rubber
filter needle/straw to the syringe. The filter needle/ cap of a previously opened vial with an antiseptic
straw prevents glass particles from being wipe by rubbing in a circular motion. The antiseptic
withdrawn with the medication. cleans the cap and reduces the number of microor-
7. • Remove the cap from the filter needle and insert ganisms.
the needle into the center of the ampule. Do not 6.Drawback an amount of air into the syringe that is
touch the rim of the ampule with the needle tip or equal to the specific dose of medication to be with-
shaft. This will keep the needle sterile. drawn.
8. Withdraw the amount of drug required for the 7. Pierce the rubber stopper in the center with the
dosage. needle tip and inject the measured air into the space
above the solution. The vial may be positioned up-
9. Dispose of the filter needle by placing in a sharps
right on a flat surface or inverted. Allows particulate
container.
matter to precipitate out of the solution.
10. Perform hand hygiene.
8. Invert the vial and withdraw the needle tip slight-
SUB-TOTAL SCORE ly so that it is below the fluid level. This prevents air
from being aspirated into the syringe.
Comments:___________________________________________________________________ 9. Draw up the prescribed amount of medication
____________________________________________________________________________ while holding the syringe at eye level and vertically.
This facilitates accurate reading ,and vertical position
Noted by: Evaluated by: makes removal of air bubbles from the syringe easy.
______________________________ ________________________________
10. .Remove any bubbles accumulate in the syringe
(Sign over printed name of Student) (Sign over printed name of Instructor)
by tapping the barrel of the syringe sharply and
move the needle past the fluid into the air space to
Date:_________________________ Date:___________________________
re-inject the air bubble into the vial. Return the nee-
PREPARING MEDICATIONS FROM VIALS EXCELENT SATISFAC- NEEDS dle tip to the solution and continue withdrawing the
(3 points) TORY PRACTICE medication.
(2 points) (1 point)
11.Remove the needle from the vial and carefully
1. Verify the medication order in the Doctor’s order replace the cap over the needle. This prevents con-
sheet. tamination of he needle and protects the nurse
against accidental needle sticks
2. Organize the equipment.
Equipment: vial of sterile medication, antiseptic 12. If a multi dose vial is being used, label the vial
swabs ,syringe ,needle for administering the medica- with the date and time opened, and store the vial
tion, sterile water. containing the remaining medication according to
agency policy.
3.Perform hand hygiene and observe other appropri-
ate infection prevention procedures. 13. Perform hand hygiene.

4. Prepare the medication vial for drug withdrawal. SUB-TOTAL SCORE

Mix the solution by rotating the vial between the
palms of the hands. Some vials contain aqueous sus-
pensions, which settle when they stand. In some in-
stances, shaking is contraindicated because it may
cause the mixture to foam.
Comments:___________________________________________________________________ ADMINISTERING INTRAVENOUS MEDICA- EXCELENT SATISFAC- NEEDS
____________________________________________________________________________ (3 points) Page 6
TORY PRACTICE
TIONS USING IV PUSH (1 point)
____________________________________________________________________________ (2 points)

 Observe the area above the IV catheter for

Noted by: Evaluated by:
______________________________ ________________________________
(Sign over printed name of Student) (Sign over printed name of Instructor)
Date:_________________________ Date:___________________________
EXCELENT
ADMINISTERING INTRAVENOUS MEDICATIONS
(3 points)
USING IV PUSH
1. Verify the medication order in the Doctor’s order
sheet.
2. Organize the equipment.
Equipment: Client’s chart, prescribed medication
Sterile syringe (3 to 5 mL) , Sterile needles, #21 to #25
gauge, Antiseptic swabs , Clean gloves, watch wit
second hand, kidney tray, IV tray, Vial of normal
saline to flush the IV catheter or vial of heparin flush
solution or both depending on agency practice. These
maintain the patency of the IV lock. Saline is common-
ly used for peripheral locks.
3.Perform hand hygiene and wear clean gloves.
4. Provide for client privacy.
5. Prepare the client. Explain the purpose of the medica-
tion and how it will help, using language that the client
can understand.
6. Prepare the medication. If necessary, withdraw
from an ampoule or a vial.
7. Clean the injection port with the antiseptic swab.
8. 1 Administer the medication by IV push.
IV Lock with Needle
 Insert the needle of the syringe containing nor-
mal saline through the injection port of an IV
lock and aspirate for blood.
 In some situations, blood will not return even
though the lock is patent. Flush the lock by in-
jecting 1 mL of saline slowly. This removes blood
and heparin (if present) from the needle and the
lock. •
puffiness or swelling. This indicates infiltra-
tion into tissue, which would require removal
of the IV catheter.
 Inject the medication slowly at the recom-
mended rate of infusion. Use a watch or digi-
SATISFAC- NEEDS tal to time the injection.
TORY PRACTICE
(1 point)  Clean the injection port of the lock. . Attach
(2 points)
the second saline syringe, and inject 1 mL of
saline.
 The saline injection flushes the medication
through the catheter and prepares the lock for
heparin if this medication is used. Heparin is
incompatible with many medications. f heparin
is to be used, insert the heparin syringe and
inject the heparin slowly into the lock.
8.2 Administer the medication by IV push.
IV Lock with Needleless System
 Clean the injection port of the lock.
 Insert syringe containing normal saline into
the injection port. •
 Flush the lock with 1 mL of sterile saline. This
clears the lock of blood.
 Remove the syringe.
 Insert the syringe containing the medication
into the port and inject the medication slowly.
 Withdraw the syringe. • Repeat injection of 1
mL of saline.
8.3 Administer the medication by IV push.
Existing Line
 Clean the port closest to the client with an
antiseptic swab.
 Stop the IV flow by closing the clamp or
pinching the tubing above the injection port.
 Connect the syringe to the IV system.
A. NEEDLE SYSTEM:
 Hold the port steady.
 Insert the needle of the syringe that contains
the medication through the center of the port. This
prevents damage to the IV line and to the dia-
phragm of the port.
ADMINISTERING INTRAVENOUS MEDICATIONS EXCELENT SATISFAC- NEEDS
(3 points) TORY PRACTICE Page 7
USING IV PUSH (1 point)
(2 points)
SUMMARY OF SCORES
B. NEEDLELESS SYSTEM:
 Remove the cap from the needleless injection
port. SKILLS PERFORMANCE OF : RAW SCORE/ TRANSMUTED CLINICAL
 Connect the tip of the syringe directly to the SCORE
port. TOTAL NUMBER INSTRUCTOR’S
 Inject the medication at the ordered rate. OF ITEMS SIGN
 Use the watch or digital readout to time the SETTING UP IV
medication administration. This ensures safe
drug administration because a too rapid injection
CHANGING IV
could be dangerous.
 Release the clamp or tubing. SOLUTION
 After injecting the medication, withdraw the
needle and activate the needle safety device. DISCONTINUING IV
9. Dispose equipment according to agency practice. INFUSION
10. Remove and discard gloves INITIATING IV LINE
11. Observe the client closely for adverse reactions
PREPARING MEDICA-
12. Document the date, time drug, dose and route; TIONS FROM AMPULES
client response ans assessments of infusion or heparin
PREPARING MEDICA-
lock site.
TIONS FROM VIALS
SUB-TOTAL SCORE
ADMINISTERING INTRA-
VENOUS MEDICATIONS
Comments:________________________________________________________________ USING IV PUSH
__________________________________________________________________________
_____

Noted by: Evaluated by:

______________________________ ________________________________
(Sign over printed name of Student) (Sign over printed name of Instructor)

Date:_________________________ Date:___________________________