SETTING UP AN IV SET EXCELENT SATISFACTORY NEEDS

(3 points) (2 points) PRACTICE

Republic of the Philippines Page 1 (1 point)
PALAWAN STATE UNIVERSITY
College of Nursing and Health Sciences 1. Verify written prescription.
Ensures correct procedure to correct patient with correct
solution.
NCM 106 SKILLS LABORATORY 2. Observe ten (10) Rs when preparing and administering
IVF.Ensures correct procedure to correct patient with
PERFORMANCE CHECKLIST
correct solution.
IV THERAPY
3. Explain procedure to reassure patient and/or signifi-
NAME:__________________________________________SCORE:_______________ cant other, secure consent if necessary.To allay patient’s
BSN 4 DATE:________________ anxiety and foster his/her cooperation.

DIRECTIONS: GIVEN ACTUAL OR MODEL CLIENT, EVALUATE THE STUDENT’S 4. Assess patient’s vein; choose appropriate site, location,
PERFORMANCE ACCORDING TO THE FOLLOWING CRITERIA: size/condition.The selection of an appropriate site de-
creases discomfort and possible damage to patient’s body
tissue.
QUALITATIVE NUMERICAL DEFINITION
DESCRIPTION DESCRIPTION 5. Prepare necessary materials for procedure:
IV solution prescribed, Infusion set, IV cannula, Mi-
cropore or IV dressing, disposable gloves, IV stand, IV
Excellent 3 points Safe, accurate performance accord- tray, kidney basin.Having equipment available saves time
ing to accepted standards; affect is and facilitates accurate skill performance.
appropriate, the student is profi-
cient, coordinated, confident; occa- 6. Check the sterility and integrity of the IV solution, IV
sional expenditure of excess energy set and other devices.To prevent administration of ex-
is noted; task is completed within pired or unsterile solution to patient.
reasonable time period; no sup- 7. Place IV label on IVF bottle duly signed by RN who
porting cues are needed. prepared it (patient’s name, room no., solution, time and
Satisfactory 2 points Safe, accurate performance accord- date). Indicate the medication if added to the solution
ing to accepted standards; the de- and include time-tape label on the container.This pro-
sired outcome is obtained most of vides correct solution with prescribed medication. Time
the time; affect is approariate most tapping permits immediate evaluation of IV infusion ac-
of the time; skilful in parts of the cording to schedule.
behaviour; the student is inefficient
and uncoordinated; student ex- 8. Do hand hygiene before and after the procedure.To
pends excess energy to accomplish prevent spread of infection.
the task; task is completed within a
9. Open IV administration set aseptically and close the
delayed time period; frequent ver-
roller clamp and spike the infusate container aseptically
bal and occasional physical di-
following the infection control measures.This punctures
rective cues are needed in addition
the seal in the IV bag maintaining the sterility.
to supportive cues.
Needs Practice 1 point Unsafe, unable to demonstrate
behaviour; student lacks confi- 10. Fill drip chamber to at least half and prime it with IV
dence, coordination, efficiency, fluid aseptically.Suction effects cause to move fluids into
continuous, verbal and physical drip chamber and prevents air entrance in the tubing.
cues are needed.
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

Health Care Waste Management (DOH/
DENR).To prevent spread of microorganisms.
14. Document and endorse accordingly.This pro-
CHANGING AN IV SOLUTION EXCELENT SATISFAC- NEEDS vides communication among the health care
(3 points) TORY PRACTICE
(1 point)
team.
(2 points)
SUB-TOTAL SCORE
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 Comments:___________________________________________________________________
to correct patient with correct solution. ____________________________________________________________________________
____________________________________________________________________________
2. Observe 10 Rs.To prevent error in administration.
3. Explain procedure to reassure the patient and Noted by: Evaluated by:
significant others and assess IV site for redness, ______________________________ ________________________________
swelling, pain etc.To check complications of IV (Sign over printed name of Student) (Sign over printed name of Instructor)
therapy and assess for patient’s need for further in-
structions. 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 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-
7. Moisten adhesive tapes around the IV out doctor’s order. Proper identification ensures that
catheter with cotton ball with alcohol; re- the procedure is done to the right client. Initiating IV
move plaster gently.This loosens the adhe- therapy through IV insertion is an invasive procedure
sion of the tape to the skin. that needs client consent
2. Wash hands and prepare all equipment at bed-
8. Place a dry cotton ball over the puncture side such as IV tubing, IV cannula, tourniquet, alco-
site without applying pressure and remove holized cotton, plaster, markers, receptacle, clean
the needle or IV catheter. Immediately ap- gloves. Ensures asepsis and a smooth flow of proce-
ply slight pressure and ask patient to apply dure.
pressure for at least 2 minutes.To avoid bleed-
ing from the site. Normal coagulation time is 2-5 3. Explain procedure and answer client’s question
minutes. and worries. Decreases fears and anxiety.
9. Inspect IV catheter for completeness.To
prevent injury to the patient. 4. Select the IV site.Choose distal veins so that once
damaged, the proximal part of the vein can still be
10. Place dressing over the venipuncture used. Avoid areas that bends to prevent infiltration.
site. Use non dominant hand for freedom of movement.
Avoid extremity with low sensation or poor integrity.
11. Reassure patient.
5. Ask client to rest arm of selected vein. Makes the
12. Discard all waste materials including the veins more visible.
IV cannula according to Health Care Waste
6. Put on gloves. Maintains asepsis.
Management (DOH/DENR).
13. Document time of discontinuance, status 7. Cleanse insertion site from starting in the middle
of insertion site and integrity of IV catheter of the site going outward. Reduces transmission of
and endorse accordingly. microorganism. Be sure to leave the area dry before
SUBTOTAL insertion.
8. Apply tourniquet 5-6 inches above the selected
site. Engorges the vein for easier IV insertion.

Comments:___________________________________________________________________ 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
Noted by: Evaluated by:
30-degree angle.
______________________________ _______________________________
(During IV insertion on elderly clients use a 5-15
(Sign over printed name of Student) (Sign over printed name of Instructor)
degree angle because their veins are more superfi-
cial.) Prevent damage to the posterior wall of the
Date:_________________________ Date:__________________________
vein.
 Comments:___________________________________________________________________
INITIATING IV LINE EXCELENT SATISFAC- NEEDS ____________________________________________________________________________
(3 points) TORY PRACTICE Page 4
(1 point) ____________________________________________________________________________
(2 points)

11. Check for blood backflow. Pressure from tourni- Noted by: Evaluated by:
quet causes quick backflow of blood into the cathe- ______________________________ ________________________________
ter. (Sign over printed name of Student) (Sign over printed name of Instructor)

12. Loosen stylet and advance catheter into the Date:_________________________ Date:___________________________
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. PREPARING MEDICATIONS FROM AMPULES EXCELENT SATISFAC- NEEDS
(3 points) TORY PRACTICE
13. Hold thumb over the vein above catheter tip (2 points) (1 point)
and release tourniquet. Prevents blood leaking and
reestablishes venous blood flow. 1. Verify the medication order in the Doctor’s or-
der sheet. Follow the three checks for correct med-
14. Quickly release pressure over the vein and con- ication and dose. Read the label on the medication
nect needle adapter of the IV set to the hub of the (1) when it is taken from the medication cart, (2)
catheter. Prompt connection reduces blood loss or before withdrawing the medication, and (3) after
leakage. withdrawing the medication. • Calculate medica-
15. Begin infusion at slow rate or KVO or per insti- tion dosage accurately. • Confirm that the route is
tution policy. Keeps vein open and ensures paten- correct.
cy of IV . 2. Organize the equipment.
16. Tape over the hub of the catheter. Place trans- Equipment: Ampule, File (if ampule is not scored)
parent dressing over the site. Secure catheter in and small gauze square or plastic ampule opener •
place and controls bleeding and infection. Antiseptic swabs ,syringe ,needle for administering
the medication
17. Secure tubing in loop fashion. Prevent tubing
dislodgement. 3.Perform hand hygiene and observe other appro-
priate infection prevention procedures.
18. Remove gloves and do aftercare. Prevents
transmission of microorganisms. 4. Prepare the medication ampule for drug with-
drawal. Flick the upper stem of the ampule several
19. Label the site with date and time of insertion times with a fingernail. This will bring all medica-
and the size and gauge of catheter. Serves as guide tion down to the main portion of the ampule. .
for next dressing change. It is recommended to
change IV site every 3 days to avoid infection and 5. • Use an ampule opener or place a piece of ster-
other IV complications. ile gauze or alcohol wipe between your thumb and
the ampule neck or around the ampule neck, and
DOCUMENTATION: Make sure to document the break off the top by bending it toward you to en-
following after procedure: sure the ampule is broken away from yourself and
away from others. The sterile gauze
1. Date and time of IV insertion protects the fingers from the broken glass, and any
2. Size and gauge of catheter glass fragments will spray away from the nurse.

3. Client’s untoward reaction to the procedure. OR Place the antiseptic wipe packet over the
4. Type of fluid infused and prescribed rate top of the ampule before breaking off the top. This
method ensures that all glass fragments fall into the
5. Additives, i.e. contrast amount and type. packet and reduces the risk of cuts. • Dispose of the
top of the ampule in the sharps container.
SUB-TOTAL SCORE
 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:
puffiness or swelling. This indicates infiltra-
______________________________ ________________________________
tion into tissue, which would require removal
(Sign over printed name of Student) (Sign over printed name of Instructor)
of the IV catheter.
Date:_________________________ Date:___________________________  Inject the medication slowly at the recom-
mended rate of infusion. Use a watch or digi-
EXCELENT SATISFAC- NEEDS tal to time the injection.
ADMINISTERING INTRAVENOUS MEDICATIONS
(3 points) TORY PRACTICE
USING IV PUSH (1 point)  Clean the injection port of the lock. . Attach
(2 points)
the second saline syringe, and inject 1 mL of
1. Verify the medication order in the Doctor’s order saline.
sheet.  The saline injection flushes the medication
through the catheter and prepares the lock for
2. Organize the equipment.
heparin if this medication is used. Heparin is
Equipment: Client’s chart, prescribed medication
incompatible with many medications. f heparin
Sterile syringe (3 to 5 mL) , Sterile needles, #21 to #25
is to be used, insert the heparin syringe and
gauge, Antiseptic swabs , Clean gloves, watch wit
inject the heparin slowly into the lock.
second hand, kidney tray, IV tray, Vial of normal
saline to flush the IV catheter or vial of heparin flush 8.2 Administer the medication by IV push.
solution or both depending on agency practice. These IV Lock with Needleless System
maintain the patency of the IV lock. Saline is common-  Clean the injection port of the lock.
ly used for peripheral locks.  Insert syringe containing normal saline into
3.Perform hand hygiene and wear clean gloves. the injection port. •
 Flush the lock with 1 mL of sterile saline. This
4. Provide for client privacy. clears the lock of blood.
 Remove the syringe.
5. Prepare the client. Explain the purpose of the medica-
tion and how it will help, using language that the client  Insert the syringe containing the medication
can understand. into the port and inject the medication slowly.
 Withdraw the syringe. • Repeat injection of 1
6. Prepare the medication. If necessary, withdraw mL of saline.
from an ampoule or a vial.
8.3 Administer the medication by IV push.
7. Clean the injection port with the antiseptic swab. Existing Line
 Clean the port closest to the client with an
8. 1 Administer the medication by IV push.
antiseptic swab.
IV Lock with Needle
 Stop the IV flow by closing the clamp or
 Insert the needle of the syringe containing nor- pinching the tubing above the injection port.
mal saline through the injection port of an IV
lock and aspirate for blood.
 Connect the syringe to the IV system.
 In some situations, blood will not return even A. NEEDLE SYSTEM:
though the lock is patent. Flush the lock by in-  Hold the port steady.
jecting 1 mL of saline slowly. This removes blood  Insert the needle of the syringe that contains
and heparin (if present) from the needle and the the medication through the center of the port. This
lock. • 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:___________________________