No.

Ruangan :
No. Urut Absen :
FR-FK-20-06/RO

FACULTY OF MEDICINE UNIVERSITAS TARUMANAGARA

CLINICAL SKILL

STUDENT’S NAME :
PASS / FAIL
STUDENT’S NIM :
STUDENT’S SIGNATURE :

INSTALLING VENOUS ACCESS CLINICAL SKILL CHECK

LIST
Score
No. Checklist Points
0 1 2
1 Prepares instruments and materials needed to gain a venous access:
− Sterile gloves, 1 pair
− Infusion line (mico or macro drip)
− Infusion stand
− Parenteral fluids according to the patient’s fluid treatment plan
− Venous catheter
− Alcohol Swab
− Torniquet
− Under-pad
− Kidney basin
− Adhesive tape
− Sterile gauze
− Stopwatch
− Antiseptic Solution
2 Does a verification of the patient’s fluid treatment plan
3 Releases all hand accessories, do a proper hand wash
4 Greets patient as a therapeutic approach, explain the procedure and its purpose
and acquire a consent
Procedure
5 Prepares the infusion line, clamp the line
6* Disinfects the puncture site of the infusion bottle
7 Punctures the infusion bottle correctly with the infusion line, hangs on the
infusion stand
8 Fills the reservoir until half
9* Opens the clamp to let the air flow out of the infusion line
10 Positions the extremity and decides the vein to be punctured
11 Puts an under-pad beneath the extremity
12 Washes hands and wear gloves
13 Applies a tourniquet 5-10 cm proximal to the puncture site
14* Disinfects skin with alcohol swab, once only, circularly starting from the
middle.
15 Holds the iv catheter with a 30 degrees angulation, puncturing the vein with the
bevel of the needle facing up
16 Confirms entry of the iv catheter into the vein (blood flows through the
catheter), pull back the needle ± 0.5 cm
17 Inserts the iv catheter slowly while pulling back the needle
18 Releases the tourniquet
19* Connects the iv catheter with the infusion line, lets the fluid flow
20 Fixates the iv catheter between fingers, cleans the under-pad and patient’s
extremity from any blood
21 Does a disinfection at the puncture site with betadine and gauze
22 Fixates iv catheter AND infusion line
23 Checks flow of fluid in accordance with fluid therapy plan
24 Tidies up the instruments, greets the patient
25 Washes hands
TOTAL

Checklist points with * is a must, failure to do so will be considered as a fail

Note:
0 : not done
1 : done imperfectly
2 : done perfectly

SCORE : _______ X 100 =

50

Block Coordinator Examiner

(Alya Dwiana, dr., M.Sc.) (......................................)