Republic of the Philippines

Western Mindanao State University

College Of Nursing
GRADUATE STUDIES IN NURSING PROGRAM
Zamboanga City

NAME: _________________________________________
YEAR & SECTION: ________________________________

Evaluation checklist on
INTRAVENOUS THERAPY
INSTRUCTIONS: Please check () on the space provided to assure whether the
participants is able to perform the procedure correctly or whether it is incorrectly done.

STEPS CD ID REMARKS

A – 1. Assessment
1. Verify prescription for IV therapy, check solution label, and
identify patient.
2. Observe the 13 Rights in administering medications.
3. Explain procedure to reassure patient and/or significant
others.
4. Secure informed consent.
5. Assess patient’s vein. Choose appropriate site, location, size
and condition.
A – 2. Preparing Equipment
6. Prepare necessary materials for the procedure.
 Sterile Gloves
 Sterile 2x2 gauze or transparent dressing
 IV Pole
 IV Solution
 Administration Set
 IV Cannula
 Sterile Forceps
 Cotton Balls with Alcohol/ Alcohol Swab/ Povidone
Iodine Swab
 Plaster / Hypoallergenic Adhesive
 Tourniquet
 Protective Pad
 7. Check the sterility and integrity of the IV solution, IV Set and
other devices.
8. Label the IV bottle duly signed by the nurse who prepared
the IV:
• Patient’s Name
• Room number / Bed number
• Solution
• Time and date started
• Time and date to consume
9. Do hand hygiene before and after the procedure.
10. The equipment should not be opened until in the patient’s
room and patient education, assessment of vein and
appropriate positioning has been attended
10.1. Open IV administration set aseptically, close the roller
clamp, and spike the infusate container following the
infection control measure.
10.2. Fill drip chamber to at least half and prime it with IV
fluid aseptically; expel air bubbles if any and cover the
distal end of the IV set.
A – 3. Positioning the Patient

11. If possible use the non-dominant arm

12. Raise bed prior to procedure (to comfortable working height
and position for patient; adjust lighting).
13. Place the arm in a supported comfortable position.
14. Use a tourniquet to find vein but release it while you are
getting equipment ready
15. Place protective pad on bed under patient’s arm.

16. Have IV trolley close by

B – 1. Preparing IV Site
17. Warm veins by
17.1. Rubbing
17.2. Washing client’s hands under warm water
17.3. Apply warmed towel
17.4. If limb is warm ask the patient to gently clench and
unclench their hand
17.5. Or gently rub up and down the vein
18. The tourniquet is applied 5 – 12cm (2 – 6 inches) above
insertion site and should not be left on for more than 2-3
minutes.
19. Apply the Palpate for a pulse distal to the tourniquet.
 20. Don sterile gloves, and clean site with appropriate solution
using a circular outward movement.
21. Prepare site according to hospital policy.

B – 2. Inserting the Cannula

22. With hand not holding the venous access device, steady
patient's arm and use finger or thumb to pull skin taut over
vessel.
23. Ensure needle has bevel side up and insert at approximately
5–25° angle, depending on the depth of the vein, pierce skin
to reach but not penetrate vein.
24. Decrease angle of needle further until nearly parallel with
skin, then enter vein either directly above or from the side
in one quick motion.
25. If backflow of blood is visible (you will see a flashback of
blood in the chamber once you have pierced the vein),
straighten angle and position the cannula parallel to the
skin.
26. Hold stylet stationary and slowly advance the cannula a few
more millimeters (until the hub is 1mm to the puncture site)
27. And then flatten the cannula, stabilize the device and
advance the cannula until at skin level.
28. Slip sterile gauze under the hub. Remove the stylet and
apply pressure just beyond the catheter tip.
29. Gently stabilize the cannula hub. Anchor needle firmly in
place with tape.
30. Release the tourniquet while applying digital pressure over
the IV site.
31. Attach the extension line

C. Dressing
32. Apply dressing and secure cannula according to hospital
policy and procedure.
32.1. A transparent sterile occlusive dressing is the
optimal dressing to use.
32.2. Before applying dressing, ensure site is clean of
blood and moisture
32.3. Check with patient re allergies to dressings
33. Flush cannula with 5-10ml 0.9% sodium chloride to ensure
patency
D. Intravenous Fluid Administration
34. Connect the infusion tubing of the prepared IV Fluid
aseptically to the IV catheter.
35. Open the roller clamp. Regulate the fluid as prescribed by
the physician.
 36. Reassure the patient.
37. Tape a small loop of IV tubing for additional anchoring splint
if necessary.
38. Calibrate the IV fluid bottle and regulate flow of infusion
according to physician’s order.
39. Label on IV tape near the IV site to indicate the date of
insertion type and gauge of IV catheter and countersign.
40. Label the IV tubing to indicate the date when to change the
tubing.
41. Observe patient and report any untoward effects.
42. Dispose of sharps and waste. Discard sharps and waste
according to Health Care Waste Management.
E. Documentation
43. Document in patient notes
43.1. Date and time insertion (therapy initiated).
type of vascular access device (Site of insertion-vein
and arm/hand)
43.2. Type and gauge of cannula
43.3. Date and time of insertion
43.4. Type and amount of IV solution (additives and
dosages; flow rate)
43.5. Reason for IV therapy
43.6. Patient response to procedure
43.7. Name and title of the health care provider who
inserted the catheter.

TOTAL SCORE:

42 – 43 = 1.0
40 – 41 = 1.25
37 – 39 = 1.5
34 – 36 = 1.75
31 – 33 = 2.0 TOTAL SCORE: ______________
29 – 30 = 2.20 STUDENT’S SIGNATURE: ______________
26 – 28 = 2.5
23 – 25 = 2.75 CLINICAL INSTRUCTOR’S SIGNATURE: ______________
20 – 22 = 3.0
17 – 19 = 3.25
DATE: ______________
14 – 16 = 3.5 ROTATION: ______________
11 – 13 = 3.75
8 – 10 = 3.5
5–7 = 3.75
4 below = 4.0