PERFORMANCE EVALUATION CHECKLIST
PROCEDURE I.
A. Setting Up C. Changing an IV Solution
B. Inserting IV Utilizing the dummy D. Discontinuing an IV Infusion
Arm
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I.A. SETTING UP:
1. Verify written prescription and make IV label
2. Observe ten (10) Rs when preparing administering IVF
(Right patient, right drug, right dose, right route, right
time, right patient education, right documentation, right to
refuse, right assessment and right evaluation )
3. Explain procedure to reassure patient and/ or significant
others, secure consent if necessary
4. Assess patient’s vein; choose appropriate site location,
size/ condition
5. Do hand hygiene before after the procedure.
6. Prepare necessary material for procedure (IV tray with IV
solution, administration set, IV cannula, forceps soaked
in antiseptic solution, alcohol swabs or cotton balls
soaked in alcohol with cover (this should be exclusively
used for I.V.), plaster tourniquet, gloves, splint, and IV
hook), sterile 2x2 gauze set and other devices.
7. Check the sterility and integrity of the IV solution, IV set
and other devices.
8. Place IV label on IVF bottle duly signed by RN who
prepared it (patient’s name, room no., solution, drug
incorporation, bottle sequence and duration, time and
date.
9. Open the seal of the IV infusion aseptically and disinfect
rubber port with cotton ball with alcohol.
10. Open IV administration set aseptically and close the roller
clamp and spike the infusate container aseptically.
11. Fill drip chamber to at least half and prime it with IV fluid
aseptically.
12. Expel air bubbles if any and put back the cover to the
distal end of the IV set (get ready for IV insertion)
I.B. INSERTING IV UTILIZING THE DUMMY ARM
Prepare complete IV tray with IV infusions;
Dummy Arm and over – the- needle catheter or
Butterfly needle.
1. Verify the written prescription for IV therapy, check
prepared IVF and other things needed.
2. Explain procedure to reassure the patient & significant
others and observed the 10 R’s.
3. Do hand hygiene before & after the procedure.
4. Choose site for IV
5. Apply tourniquet 5 to 12 cm. (2-6 in.) above injection site
depending on condition of patient.
6. Check for radial pulse below tourniquet
7. Prepare site with effective topical antiseptic according to
hospital policy or cotton balls with alcohol in circular
motion and allow 30 seconds to dry. (No touch
techniques)
Note: CDC Universal precaution: Always wear gloves when
doing any venipuncture.
8. Using the appropriate IV cannula, pierce skin with needle
positioned on a 15 - 30-degree angle.
9. upon flashback visualization decrease the angle,
advance the catheter and stylet (1/4 inch) into the vein,
check tip of catheter can be rotated freely inside the vein.
10. Position the IV catheter parallel to the skin. Hold stylet
stationary and slowly advance the catheter until the hub
is 1 mm to the puncture site.
11. Slip a sterilize gauze under the hub. Release the
technique, remove the stylet while applying digital
pressure over the catheter with one finger about 1-2 inch
from the tip of the inserted catheter.
12. Connect the infusion tubing of the prepared IVF
aseptically to the IVF catheter.
Note: when steel-winged needle (butterfly) is used:
A. Connect the IV tubing to the steel-winged needle
connector & prime needle with IV fluid
B. Using the steel-winged needle, pierce skin with the
needle bevel up, positioned on a 5-10-degree angle
C. With steel-winged needle, parallel on the skin, enter
the vein directly and advance needle ¼ inch after
successfully performing venipuncture check for
backflow. Remove tourniquet.
13. open the clamp, regulate the flow rate.
Reassure patient.
14. anchor needle firmly in place with the use of:
a) Transparent type/ dressing directly on the puncture
site.
b) Tape (using any appropriate anchoring style)
c) Band – Aid
Note: never place unsterile tape directly on IV insertion site,
instead place a small piece of sterile OS & then secure it with
adhesive tape.
15. Tape a small loop of Tubing for additional anchoring;
apply splint (if needed)
16. Calibrate the IVF bottle and regulate flow of infusion
cording to prescribe duration.
17. Label on tape near the IV site to indicate the date of
insertion, type and gauge of IV catheter and
countersign.
18. Label with plaster on the IV tubing to indicate the date
the date when to change the IV tubing.
19. Observe patient and report any untoward effect.
20. Document in the patient’s chart and endorse to incoming
shift.
21. Discard sharp and waste according to health Care
Management Waste Management (DOH/DENR)
I.C. CHANGING AN IV SOLUTION
1. Verify doctor’s prescription in doctor’s order sheet;
countercheck IV label, IV card, infusate sequence, type,
amount, additives (if any), duration of infusion.
2. Observe ten (10) Rs.
3. Explain procedure to reassure the patient & significant
others & assess IV site for redness, swelling, pain & etc.
4. Change IV tubings & cannula if 48-72 hrs have lapsed
after IV insertion
5. Wash hands before and after procedure.
6. Prepare necessary materials
7. Check sterility and integrity of IV solution
8. Place IV label on the IV bottle
9. Calibrate new IV bottle according to duration of infusion
as per prescription
10. Open and disinfect rubber port or IV solution to follow.
11. Close the roller clamp and spike the container
aseptically.
12. Regulate the flow rate based on the prescribed infusion.
Expel air bubble (if any)
13. Reiterate assurance to patient and significant others
14. Discard all waste materials according to health care
waste management (DOH/DENR)
15. Document and endorse accordingly.
I.D. DISCONTINUING AN IV INFUSION
1. Verify written doctor’s order to discontinue IV including IV
medicines.
2. Observe ten (10) Rs.
3. Assess and inform the patient of the discontinuation of IV
infusion &of any medicine
4. Prepare the necessary materials; IV tray or injection tray
with sterile cotton balls with alcohol, plaster, pick – up
forceps in antiseptic solution, kidney basin band-aid.
5. Wash hands before and after procedure.
6. Close the roller clamp of the IV administration set.
7. Moisten adhesive tapes around the IV catheter with
cotton ball with alcohol; remove plaster gently.
8. Use pick – up forceps to get cotton ball with alcohol and
without applying pressure, remove needle or IV catheter
then immediately apply pressure over the venipuncture
site.
9. Inspect IV catheter for completeness
10. Place dressing over the venipuncture site
11. Discard all waste materials including the IV cannula
according to Health Care Waste Management
(DOH/DENR)
12. Reassure patient
13. Document time of discontinuance, status of insertion site
and integrity of IV catheter and endorse accordingly.
PERFORMANCE EVALUATION CHECKLIST
PROCEDURE III: ADMINISTERING IV DRUGS:
A. Incorporation into iv bottle/bag C. Incorporation into the volumetric
B. Iv push through the iv-port chamber or soluset
D. Iv push through the he herapin-lock
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Note: if the administration set has no airway, pull out
set and incorporate the prepared drug and re-spike the
IV set to the bottle then place the label. (all these should
be done aseptically).
9. Swirl the IV bottle to mix the drug with IVF and
regulate the flow rate accordingly.
10. observe for 5-10 minutes for any drug
Interaction while reassuring the patient;
monitor VS.
11. document in the patient’s chart
12. discard sharp and other wastes according to
Health Care Wastes Management
(DOH/DENR)
III.B. IV PUSH THROUGH IV PORT
1. Verify medication card against the written
doctor’s prescription
2. Observe ten Rs when preparing and
administering medication
3. Explain procedure to reassure patient and
significant others (the name of medicine and
action/interaction of medication) before
administration.
4. Do hand hygiene before and after the
procedure. (use gloves especially for
chemotherapeutic & other vesicant drugs)
5. check patency and other reaction signs of
swelling, redness, phlebitis, etc… do not give
the drug.
6. check for skin test result of drug for IV push,
drug-drug, drug IV fluid incompatibility,
dosage (computation)
7. prepare the necessary materials for the
procedure such as right drug, right diluent, vial
or ampule as appropriate
8. disinfect injection port of the diluent, vial or
ampule as appropriate.
9. aspirate right amount of diluent for the drug (if
the drug needs to be diluted)
10. aspirate the right drug dose; disinfect the Y-
injection port of the IV administration set/
catheter IV port.
11. Close the roller clamp of the IV tubing from
the bottle and push IV drug aseptically and
slowly or accordingly to the manufacturer’s
recommendation.
12. Using same syringe aspirate 1-2 cc of IVF to
flush the medicine given.
13. Regulate rate of IV fluid infusion as prescribe.
(if needed)
14. Reassure patient and observe for signs and
symptoms of adverse drug reaction.
15. discard sharp and other waste according to
Health Care Waste Management
(DOH/DENR)
III. C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER
1. Verify the written M.D. prescription and follow
hospital policy on drug administration
2. Observe ten Rs when preparing and administering
medications.
3. Explain procedure to patient (medicine and action) and
check IV site. Verify for skin test of the drug before IV
incorporation
4. Do hand hygiene before and after procedure
5. Prepare the necessary materials for the procedure such
as right drug and dose, right diluent needed, IV injection
tray, syringes and needle.
6. Check present IV fluid label, level and the incorporated
medicine in the volumetric chamber or IV bottle if with
incorporated medicine, check for drug – drug
incompatibility and if the on-going IV fluid in the
volumetric chamber is to be consumed in 6-8 hours,
request a prescription for IVP to be used solely for drug
administration and keep the whole set sterile for
succeeding does.
7. Aspirate prepared right drug with correct dose.
8. Add desired IVF diluent into volumetric chamber by
opening the sliding clamp from the bottle than close the
clamp.
9. Disinfect rubber injection port of the volumetric chamber
and incorporate the drug. Mix gently.
10. Open the clamp of the airway at the volumetric
chamber.
11. Regulate flow rate of IVF infusion accordingly.
12. Place IV label on volumetric chamber indicating drug
incorporated and flow rate.
13. Reassure/ monitor patient when incorporated medicine
is consumed, clamp airway of V. C. add IVF & regulate
flow rate of main IVF as prescribe.
14. Discard waste according to Health Care Waste
Management (DOH/DENR)
15. Document in patient’s chart of the drug administered &
patient condition.
16. Document in patient’s chart IVF sheets and kardex (of
changes in IV rate/ time due)
III. D. IV PUSH through the HEPARIN-LOCK
DEVICE
1. Check medication card against the written doctor’s
prescription
2. Observe ten Rs when preparing and administering
medications.
3. Explain procedure to patient (medicine and action) and
check IV site. Verify for skin test of the drug before IV
incorporation
4. Do hand hygiene before and after procedure (use
gloves especially for chemo drugs)
5. Gather equipment to include / but not limited to IV tray,
heparin solution, normal saline diluent or Isotonic
solution, 2.5 cc syringes 3 pieces, Tuberculin/ TB
syringe 1 pc.
6. Prepared medication to administered e.g., antibiotic,
and draw it up into a syringe.
7. Fill a tuberculin syringe with Heparin solution. N.B.
Heparin is usually prepared with 0.1 cc Normal; Saline
or Isotonic solution.
8. Fill the 2.5 cc syringe with isotonic solution or normal
saline 1 cc each.
9. If using Hep. Loc device with 3 way stop cock with luer–
lock rotate the stop cock so that the line going to the
patient is closed (this will prevent backflow of blood)
10. Remove the cover of the injection port aseptically and
keep the sterility of the cover.
11. Open the IV line, inject medication into vein, timing the
flow rate according to doctor’s prescription or drug
manufacturer’s instructions.
12. Close the IV line & remove saline syringe and insert
medication syringe into port.
13. Open the IV line & inject medication into the vein, timing
the flow rate according to doctor’s prescription or drug
manufacturer’s instructions.
14. Observe patient for any adverse reactions & do nursing
interventions.
15. Close the IV line & remove medication syringe
16. Insert the saline syringe, open the line & flush catheter
tubing b/ IV cannula to flush the line.
17. Close and remove saline syringe
18. Close the IV line, remove syringe and return the cover
of the injection port aseptically.
19. Document in the patient chart and kardex.
20. Discard waste according to Health Care Waste
Management. (DOH/DENR)
Note: Normal saline can take the place of Heparin. Studies
have shown the efficacy of NSS. Heparin solution can be
used if normal saline or isotonic solution is not available.
