REPUBLIC OF THE PHILIPPINES

JOSE RIZAL MEMORIAL STATE UNIVERSITY

The Premier University in Zamboanga del Norte
GOV. GUADING ADAZA ST., STA. CRUZ, DAPITAN CITY, ZAMBOANGA DEL NORTE
College of Nursing and Allied Health Sciences
NCM 107
SKILLS CHECKLIST
NAME: _____________________________________ SCORE: _____________________
INSTRUCTOR: ________________________________ DATE: ______________________
(1 point)SATISFACTORY
( 2 points)EXCLELLENT

( 0 point)NEEDS PRACTICE

IV PRIMING (Preparation of IV Fluids) Comments

____ ____ ____ 1. Verify Physician’s order for IV Therapy.

____ ____ ____ 2. Gather necessary equipment.
____ ____ ____ 3. Perform Hand hygiene.
4. Remove outer wrap of IV Bottle (as necessary); check
the fluid contents (type of fluid; expiration date)
____ ____ ____
5. Open Administration set and uncoil; maintain sterility
____ ____ ____ of Bag spike and needle end.
6. Slide the roller clamp along the tubing (2-5cm) or 1-
____ ____ ____ 2inches until it is just below the drip chamber.
____ ____ ____ 7. Close roller clamp or flow regulator.
8. Remove protective cap from IV bottle. If using an IV
bottle with a rubber stopper, remove the metal disc
____ ____ ____ and swab protective stopper with disinfectant.
9. Remove the cap from the Bag spike Insert spike into
rubber stopper of IV container with a quick twist and
____ ____ ____ maintain sterility.
10. Hang fluid container on IV pole. (1 m or 3 ft.) Above
____ ____ ____ the pt head.
____ ____ ____ 11. Squeeze drip chamber once or twice until half full.
12. Prime the tubing by removing protective cap of the
needle end and hold the tubing over a cup or basin.
(Note: Maintain sterility) Open roller clamp or
regulator slowly, and let fluid flow through the tubing
____ ____ ____ until all the bubbles are removed.
13. Close roller clamp and replace the tubing cap,
____ ____ ____ maintaining sterile technique.
14. Label the solution container, applying the label upside
down on the container, include the following
information: patient’s name, dosage and absorption
time, drip rate, the date, the time the container is
____ ____ ____ hung, and the container number.
15. Discard used supplies appropriately and perform
____ ____ ____ Hand hygiene.
REPUBLIC OF THE PHILIPPINES
JOSE RIZAL MEMORIAL STATE UNIVERSITY
The Premier University in Zamboanga del Norte
GOV. GUADING ADAZA ST., STA. CRUZ, DAPITAN CITY, ZAMBOANGA DEL NORTE
College of Nursing and Allied Health Sciences
NCM 107
SKILLS CHECKLIST with RATIONALE
NAME: _____________________________________ SCORE: _____________________
INSTRUCTOR: ________________________________ DATE: ______________________

IV PRIMING (Preparation of IV Fluids) RATIONALE

1. Verify Physician’s order for IV Therapy.
2. Gather necessary equipment.
3. Perform Hand hygiene.
4. Remove outer wrap of IV Bottle (as
necessary); check the fluid contents (type of
fluid; expiration date; color; clarity)
5. Open Administration set and uncoil;
maintain sterility of Bag spike and needle end.
6. Slide the roller clamp along the tubing (2-
5cm) or 1-2inches until it is just below the drip
chamber.
7. Close roller clamp or flow regulator.
8. Remove protective cap from IV bottle. If
using an IV bottle with a rubber stopper,
remove the metal disc and swab protective
stopper with disinfectant.
9. Remove the cap from the Bag spike Insert
spike into rubber stopper of IV container with
a quick twist and maintain sterility.
10. Hang fluid container on IV pole. (1 m or
3 ft.) Above the patient’s head.
11. Squeeze drip chamber once or twice
until half full.
12. Prime the tubing by removing
protective cap of the needle end and hold the
tubing over a cup or basin. (Note: Maintain
sterility) Open roller clamp or regulator slowly,
and let fluid flow through the tubing until all
the bubbles are removed.
13. Close roller clamp and replace the
tubing cap, maintaining sterile technique.
14. Label the solution container, applying
the label upside down on the container,
include the following information: patient’s
name, dosage and absorption time, drip rate,
the date, the time the container is hung, and
the container number.
15. Discard used supplies appropriately and
perform Hand hygiene.
A physician’s order is needed to initiate therapy.
Order should include type of infusion, route,
dosage of administration, volume to be infused,
rate, and duration.
To facilitate efficiency.
Prevents spread of microorganisms.
To reduce risk of error and to assess the sterility of
IV fluids.
Prevents microorganisms from entering the
infusion equipment.
Close proximity of the clamp allows easier access
in regulating the flow rate.
Prevents accidental spillage of IV fluids.
Allows sterile tubing entry into the solution.
Allows sterile tubing entry into the solution and
prevents contamination of spike and IV bottle.
This height enables gravity to overcome venous
pressure and facilitate flow of the solution into the
vein.
The drip chamber creates a suction effect and
partially fills with solution to prevent air from
moving down the tubing.
Slowly filling the tube decreases turbulence and
inhibits bubble formation.
Closing clamp prevents accidental loss of fluid.
To reduce risk of error and help monitor the exact
amount of fluid volume needed by the patient.
To prevent spread of microorganisms.

Resources:

1. Berman, Audrey. Et al. (2016) KOZIER & ERB’S FUNDAMENTALSOF NURSING, 10 th Edition

2. Rhoads, Jacqueline. Meeker, Bonnie Juve (2008) DAVIS’S GUIDE TO CLINICAL NURSING SKILLS

SKILLS CHECKLIST
NAME: _____________________________________ SCORE: _____________________
REPUBLIC OF THE PHILIPPINES
JOSE RIZAL MEMORIAL STATE UNIVERSITY
The Premier University in Zamboanga del Norte
GOV. GUADING ADAZA ST., STA. CRUZ, DAPITAN CITY, ZAMBOANGA DEL NORTE
College of Nursing and Allied Health Sciences
NCM 107
INSTRUCTOR: ________________________________ DATE: ______________________

(1 point)SATISFACTORY
( 2 points)EXCLELLENT

( 0 point)NEEDS PRACTICE
IV TERMINATION Comments

1. Prior to performing the procedure, introduce self and

verify the client’s identity using agency protocol. Explain
____ ____ ____ the procedure.
____ ____ ____ 2. Gather necessary equipment.
____ ____ ____ 3. Perform Hand hygiene and apply clean gloves.
____ ____ ____ 4. Close the roller clamp.
5. Remove the tapes at the venepuncture site while
____ ____ ____ holding the cannula firmly.
6. Place sterile gauze pad over the venepuncture site,
(Note: Touch the upper portion of the gauze pad and
maintain sterility on the upper portion) and with the
other hand, withdraw the catheter needle by pulling
straight back away from the puncture site.
____ ____ ____
7. Immediately apply firm pressure to the site, using
____ ____ ____ sterile gauze, for 2 to 3 minutes.
8. Cover the venepuncture site with a new sterile dressing
____ ____ ____ and tape.
9. Remove gloves, discard supplies appropriately and
____ ____ ____ perform hand hygiene.
10. Read the amount remaining in the IV solution
____ ____ ____ container.
11. Apply a black-out label over the existing IV solution
label prior to discarding the IV solution into a biohazard
____ ____ ____ container.
____ ____ ____ 12. Document all relevant information.

SKILLS CHECKLIST with RATIONALE

NAME: _____________________________________ SCORE: _____________________
REPUBLIC OF THE PHILIPPINES
JOSE RIZAL MEMORIAL STATE UNIVERSITY
The Premier University in Zamboanga del Norte
GOV. GUADING ADAZA ST., STA. CRUZ, DAPITAN CITY, ZAMBOANGA DEL NORTE
College of Nursing and Allied Health Sciences
INSTRUCTOR: ________________________________
IV TERMINATION
1. Prior to performing the procedure,
introduce self and verify the client’s identity
using agency protocol. Explain the
procedure.
2. Gather necessary equipment.
3. Perform Hand hygiene and apply clean
gloves.
4. Close the roller clamp.
5. Remove the tapes at the venepuncture site
while holding the cannula firmly.
6. Place sterile gauze pad over the
venepuncture site, (Note: Touch the upper
portion of the gauze pad and maintain
sterility on the upper portion) and with the
other hand, withdraw the catheter needle
by pulling straight back away from the
puncture site.
7. Immediately apply firm pressure to the site,
using sterile gauze, for 2 to 3 minutes.
8. Cover the venepuncture site with a new
sterile dressing and tape.
9. Remove gloves, discard supplies
appropriately and perform hand hygiene.
10. Read the amount remaining in the IV
solution container.
11. Apply a black-out label over the existing IV
solution label prior to discarding the IV
solution into a biohazard container.
12. Document all relevant information.
Resources:
1. Berman, Audrey. Et al. (2016) KOZIER & ERB’S FUNDAMENTALSOF NURSING, 10 th Edition
2. Rhoads, Jacqueline. Meeker, Bonnie Juve (2008) DAVIS’S GUIDE TO CLINICAL NURSING SKILLS
NCM 107
DATE: ______________________
RATIONALE
Allays patient anxiety.
To facilitate efficiency.
Prevents spread of microorganisms.
Clamping the tubing prevents the fluid from
flowing out of the needle onto the client or bed.
Movement of the catheter can injure the vein and
cause discomfort to the client.
Pulling it out in line with the vein avoids injury to
the vein. Avoid pressing down on the sterile gauze
pad while removing the catheter.
Pressure helps stop the bleeding and prevents
hematoma formation.
The dressing continues the pressure and covers
the open area in the skin, preventing infection.
To prevent spread of microorganisms.
For documentation purposes.
The existing IV label contains client information.
The black-out label conceals client information
and ensures client confidentiality.
Record the amount of fluid infused on the intake
and output record and in the record, according to
agency policy. Include the container number, type
of solution used, time of discontinuing the
infusion, and the client’s response.