Intravenous Therapy Performance Evaluation Tool

INTRAVENOUS THERAPY
PERFORMANCE EVALUATION TOOL
Name of Student: ______________________________________________________________________

Year/Clinical Group: __________________________ School Year: _____________ Term: ____________
Inclusive Dates of Clinical Rotation: ________________________________________________________
Legend: 4 Competent (student performs consistently in an effective & efficient manner)

3 Progress Accepted (performance is usually acceptable and effective but not always)
2 Needs Improvement (progress in performance is too slow to judge satisfactory: task
performance is not done properly for majority of the time)
1 Progress Unacceptable (no progress in performance, and/ or performance is
consistently ineffective and inefficient)
PROCEDURE: SETTING-UP IV
PROCEDURAL STEPS SCORE REMARKS

4 3 2 1
1. Verify written prescription.
2. Observe the 10 Rs when preparing and
administering IVF.
3. Explain procedure to reassure patient and/or
significant other, secure consent if necessary.
4. Assess patient vein; choose appropriate site,
location, size/condition.
5. Prepare necessary materials 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 IV, plaster, tourniquet, gloves,
splint, and IV hook) sterile 2X2 gauze or transparent
dressing.
6. Check the sterility and integrity of the IV solution,
IV set and other devices.
7. Place IV label on IVF bottle duly signed by RN who
prepared it (patient’s name, room no., solution, time
and date).
8. Do hand hygiene before and after the procedure.
9. Open IV administration set aseptically and close
the roller lamp and spike the infusate container
aseptically following the infection control measures.
10. Fill the drip chamber to at least half and prime it
with IV fluid aseptically.
11. Expel air bubbles if any and put back the cover to
the distal end of the set (get ready for IV insertion).
TOTAL
CLINICAL INSTRUCTOR:__________________________________________
CONFORME: STUDENTS NAME AND SIGNATURE ____________________________________

INTRAVENOUS THERAPY
Name of Student: ______________________________________________________________________


PROCEDURE: INSERTING IV CANNULA UTILIZING DUMMY ARM

4 3 2 1
1. Verify the written prescription for IV therapy;
check prepared IVF and other things needed.
2. Explain procedure to reassure the patient and
significant others and observe the 10 Rs.
4. Choose a site for IV.
5. Apply tourniquet 2-6 inches above injection site
depending on condition of the patient.
6. Check for the radial pulse below the tourniquet.
7. Disinfect the insertion site with an alcohol swab.
8. Using the appropriate IV cannula, pierce skin with
the correct technique.
9. Upon backflow visualization, continue inserting the
catheter into the vein.
10. Position the IV catheter parallel to the skin.
11. Hold stylet stationary and slowly advance the
catheter until the hub is 1mm to the puncture site.
12. Slip sterile gauze under the hub. Release the
tourniquet; remove the stylet while applying digital
pressure over the catheter with one finger about 1-2
inches from the tip of the inserted catheter.
13. Connect the infusion tubing of the prepared IVF
aseptically to the IV catheter.
14. Open the clamp and regulate the flow rate.
15. Reassure patient.
16. Anchor needle firmly in place.
17. Tape a small loop of IV tubing for additional
anchoring. Apply splint, if needed.
18. Calibrate the IVF bottle and regulate flow of
infusion according to prescribed duration.
19. Label on IV tape near the IV site to indicate the
date of insertion, type and gauge of IV catheter and
countersign.
20. Label with plaster on the tubing to indicate the
date when to change the IV tubing.
21. Observe the patient and report any untoward
effect.
22. Discard sharps and waste according to Health Care
Waste Management (DOH/DENR).
23. Document in the patient’s chart and endorse the

incoming shift.
TOTAL
CONFORME: STUDENTS NAME AND SIGNATURE _____________________________________

INTRAVENOUS THERAPY
Name of Student: ______________________________________________________________________


PROCEDURE: IV MEDICATION PUSH THROUGH THE IV PORT

4 3 2 1
1. Verify medication card against the written doctor’s
prescription.
2. Observe the 10 Rs when preparing and
administering medication.
3. Explain the procedure to reassure the patient and
significant others (the name of medicine and
action/interaction of medication) before
administration.
4. Do hand hygiene before and after procedure (use
gloves especially for chemotherapeutic and other
vesicant drugs).
5. Check patency and other reaction signs of swelling,
redness, phlebitis, etc... If any of these are evident, do
not give the drug.
6. Check for skin test result of drug for IV push, drug
to drug, drug IV fluid incompatibility, dosage
(computation).
7. Prepare necessary materials for the procedure
such as: right drug, right diluents needed, IV injection
tray, syringes with needles, alcohol etc.
8. Disinfect injection port of the diluents, vial or
ampule as may be appropriate.
9. Aspirate right amount of diluents 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
according to the manufacturer's recommendation.
12. Using the same syringe, aspirate 1-2 cc of IVF to
flush the medicine given.
13. Regulate rate of IV fluid infusion as prescribed (if
needed.)
14. Reassure the patient and observe for signs and
symptoms of adverse drug reaction.
15. Discard sharps and other waste according to
health care waste management (DOH/DENR).
16. Document the procedure done on the patient’s
chart.
TOTAL

INTRAVENOUS THERAPY
Name of Student: ______________________________________________________________________


PROCEDURE: CHANGING AN IV SOLUTION

4 3 2 1
1. Verify Doctors prescription, countercheck IV label,
IV tag, infusate/solution sequence, type amount,
additives (if any), and duration of infusion.
2. Observe the 10 Rs.
3. Explain procedure to reassure the patient and
significant others and assess the IV site for redness,
swelling, pain, etc.
4. Change IV tubing and cannula within 72 hours
after IV insertion or upon the discretion of the
attending physician.
5. Wash hands before the procedure.
6. Prepare necessary materials; place on an IV tray.
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 connect the IV tubing into the solution
bottle.
11. close the roller clamp.
12. Regulate the flow rate according to the prescribed
infusion rate. Expel air bubbles, if evident.
13. Reiterate assurance to the patient and significant
others.
14. Discard all waste materials according to health
Care Waste Management (DOH/DENR)
15. Document and endorse accordingly.
TOTAL

INTRAVENOUS THERAPY
Name of Student: ______________________________________________________________________


PROCEDURE: DISCONTINUING AN IV INFUSION

4 3 2 1
1. Verify written doctor’s order to discontinue IV
including IV medications.
2. Observe the 10 Rs.
3. Assess and inform the patient of the
discontinuation of IV infusion.
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 and band aid.
5. Wash hands before and after the procedure.
6. Close the roller clamp of the IV administration set.
7. Moisten adhesive tape around the IV catheter with
cotton ball with alcohol; remove plaster gently.
8. Use pick-up forceps to get a 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. Reassure patient.
12. Discard all waste materials including the IV
cannula according to Health Care Waste Management
(DOH/DENR).
13. Document time of discontinuance, status of
insertion site and integrity of IV catheter and endorse
accordingly.
TOTAL

INTRAVENOUS THERAPY
Name of Student: ______________________________________________________________________


PROCEDURE: ONE-ON-ONE IV INSERTION

4 3 2 1
1. Verify the written prescription for IV therapy;
check prepared IVF and other things needed.
2. Explain the procedure to reassure the patient and
significant others and observe the 10Rs.
4. Apply a tourniquet 5 to 12 cm. (2-6 in) above the
injection site depending on the condition of the
patient.
5. Check the radial pulse below the tourniquet.
6. Using the appropriate Iv cannula, pierce skin with
the correct technique.
7. Upon backflow visualization, continue inserting the
catheter into the vein.
8. Position the IV catheter parallel to the skin. Hold
stylet stationary and slowly advance the catheter until
the hub is 1mm to the puncture site.
9. Slip a sterile gauze under the hub. Release the
tourniquet; remove the stylet while applying digital
pressure over the catheter with one finger about 1-2
inches from the tip of the inserted catheter.
10. Discard all waste materials according to health
care waste management.
insertion site and integrity of IV catheter and
endorsed accordingly.
TOTAL

INTRAVENOUS THERAPY
Name of Student: ______________________________________________________________________


PROCEDURE: BLOOD TRANSFUSION

4 3 2 1
1. Verify the doctor's written prescription and make a
treatment card according to hospital policy.
2. Observe 10 Rs when preparing and administering
any blood or blood components.
3. Explain the procedure/rationale for giving blood
transfusion to reassure the patient and significant
others and secure consent. Get patient histories
regarding previous transfusion.
4. Explain the importance and benefits of voluntary
blood donation (RA 7719-National Blood Service Act
of 1994)
5. Request prescribed blood/blood components from
blood bank to include blood typing and X-matching
and blood result of transmissible disease.
6. Use a safe and clean container to get the
prescribed blood product from the hospital blood
bank and keep it at room temperature.
7. Assess the patient's condition. The doctor and the
nurse should counter check the compatible blood and
blood product to be transfused against the
X-matching sheet noting ABO grouping and RH, serial
no. Of each blood unit, an expiry date with the blood
bag label and other laboratory blood exams as
required before transfusion (Hgb and Hct).
8. Get the baseline vital signs BP, RR, and
temperature before transfusion. Refer to the doctor
accordingly.
9. Give a pre-med 30 minutes before transfusion as
prescribed.
10. Prepare equipment needed for BT (IV injection
tray, compatible BT set, IV catheter G16 to 19 and/or
as appropriate, plaster, tourniquet, blood, blood
components to be transfused, Plain NSS 500CC, IV set,
needle gauge 16 to 18 (only if needed), IV hook,
gloves, sterile 2X2 gauze or transparent dressing, etc.
12. If main IVF with dextrose 5% initiate an IV line
with appropriate IV catheter G18 to 19 and/or as
appropriate, with plain NSS on another site, anchor
catheter properly and regulate IV drops.
13. Open compatible blood set aseptically and close
roller clamp. Spike blood bag carefully; fill the drip
chamber at least half full; prime tubing and remove
air bubbles (if any). Use needle G16 to 19 and/or as
appropriate for adults or G22 to 24 for pedia (if blood
is given through the Y injection port.
14. Disinfect the Y injection port of IV tubing (plain
NSS) and insert the needle from BT administration set
and secure with adhesive tape.
15. Close roller clamp of IV fluid of Plain NSS or
regulate to KVO while transfusion is going on.
16. Transfuse the blood via the injection port and
regulate at 10-15 gtts/min. Initially for 15 minutes and
then at the prescribed rate (usually based on the
patient’s condition).
17. Monitor the patient within the first 5-10 minutes
of transfusion and refer immediately to the physician
for any adverse reaction.
18. Observe/assess patients on an on-going basis for
any untoward signs and symptoms such as flushed
skin, chills, elevated body temperature, itchiness,
urticaria and dyspnea. If any of these symptoms
occur, stop the transfusion, open the IV line with Plain
NSS and regulate accordingly, and report to the
doctor immediately.
19. Swirl the bag gently from time to time to mix the
solid with the plasma, One BT set should be used for
1-2 units of blood.
20. When blood is consumed, close the roller clamp
of BT, and disconnect from IV lines then regulate the
IVF of Plain NSS as prescribed..
21. Continue to observe and monitor patient post
transfusion, for delayed reaction could still occur.
22. Recheck Hgb and Hct, bleeding time, serial
platelet count within specified hours as prescribed
and/or per institutions policy.
23. Discard blood bags and BT sets and sharps
according to Health Care Waste Management
(DOH/DENR).
24. fill-out adverse reaction sheets as per institutional
policy and return the blood bag and whole set to the
blood bank or laboratory for examination.
25. Remind the Doctor about the administration of
Calcium Gluconate if a patient has several blood
transfusions (3-5 more units of blood).
insertion site and integrity of IV catheter and endorse
accordingly.
TOTAL
PERIOPERATIVE NURSING
Name of Student: ______________________________________________________________________


PROCEDURE: SURGICAL HAND SCRUB

4 3 2 1
A. PREPARATION
1. Approaches scrubs sink in proper OR attire.
2. Recognizes proper time limit for procedure.
3. Sets water timer and wets arms and hands.
4. If a soap dispenser is available, pre-lathers with
soap.
5. Open the sponge and discard the wrapper.
B. SCRUBBING PROCEDURE
1. Follows prescribed method for surgical scrub
technique.
2. Keep your hands and arms at the correct level.
3. Keep the front of the scrub suit dry to avoid
“splash back”.
4. Avoids going over pre-scrubbed areas.
5. Does not touch unsterile areas while scrubbing.
6. Avoids unnecessary talking or moving away
from the sink during scrub.
7. Rinses hands and arms while avoiding raising
hands or arms above shoulder level.
8. Approaches the door to the OR room correctly.
9. If contaminated, starts from beginning of
Procedure.
TOTAL

Name of Student: ______________________________________________________________________


consistently ineffective and inefficient).
PROCEDURE: HAND DRYING AND DONNING STERILE GOWN

4 3 2 1
A. HAND DRYING
1. Holds arms away from the body, no higher
than shoulders.
2. Approaches the table and picks up a sterile
towel by the nearest corner.
3. Allow the towel to unfold lengthwise.
4. Place one hand on the towel, using one half of
the towel.
5. Begins to dry from fingers to elbow, bending at
waist to avoid contact with clothing.
6. Transfer the towel to the other hand and
repeat the drying procedure.
7. Discard towel when finished.
B. APPLYING STERILE GOWN
1. Grasp gown at neckline and steps away from
the table.
2. Allows gown to unfold with inside facing
wearer.
3. Place arms in armholes, being careful not to
contact unsterile surfaces with slaves.
4. extends arms horizontally at shoulder level and
pushes hands into sleeves up to the cuff seam.
5. Extend fingers to the tip of the cuff, but not
beyond.
6. Avoids contamination during procedure.
Note: Nonsterile person will assist
TOTAL
Name of Student: ______________________________________________________________________


PROCEDURE: REMOVING SOILED GOWN AND GLOVES

4 3 2 1
1. Gown and gloves are removed, contaminant to
contaminant and clean to clean.
A. REMOVING GOWN
1. With one hand grasps the opposite shoulder of
the gown.
2. Pulls down and inward, taking care outside of
the gown does not touch scrub attire.
3. Repeat step 1 for the other shoulder.
4. Disposes of gown in appropriate receptacle,
touching inside only.
B. REMOVING GLOVES
1. Removes first glove using glove to glove
technique.
2. Removes other gloves using skin-to-skin
technique.
3. Disposes of gloves (touching inside of gloves
only in appropriate receptacle.
4. Performs general hand washing after leaving
the procedure room.
TOTAL
Name of Student: ______________________________________________________________________


PROCEDURE: APPLICATION OF STERILE GLOVES-CLOSED AND OPEN METHODS

4 3 2 1
A. CLOSED GLOVED METHOD
1. Recognizes proper usage of this method.
2. Open glove pocket using mitten-hands (gown
covering hands).
3. Lifts glove out of package and places glove
thumb-to-thumb and palm-to-palm with fingers
pointing towards elbow.
4. Grasp cuff of glove and gown with mitten-hand
and extends glove cuff over gown cuff and hand.
5. Extends individual fingers into correct slots.
6. Repeat the same procedure on the other hand.
7. Adjust gloves; wipe off with a damp towel.
B. OPEN GLOVE METHOD
1. Recognizes proper usage for this method.
2. Open the glove packet using outside flaps.
3. Grasps the cuff of one glove and slides the
glove over hand.
4. Adjust fingers into proper slots.
5. Release cuff.
6. Using a gloved hand, lifts the second glove off
the package using finger-to-finger touch.
7. Slides glove over ungloved hand.
8. Avoid touching gloved fingers with ungloved
hands.
9. Adjust gloves.
10. Avoids contact of gloved hands with Non
Sterile items or persons.
TOTAL
Name of Student: ______________________________________________________________________

PROCEDURE: DRYING, GOWNING AND GLOVING ANOTHER TEAM MEMBER

4 3 2 1
A. PRESENTATION OF TOWEL
1. Opens towel, laying it across the hand of the
team member.
2. Avoid contacts with Non Sterile areas.
B. GOWNING PROCEDURE
1. Unfolds gown in proper manner.
2. Present gown to the wearer with inside of
gown facing wearer.
3. Protects sterile hands while presenting the
gown.
4. Adjust sleeves of gown.
5. Avoids contact with Non Sterile hands while
gowning.
C. GLOVING PROCEDURE
1. Open gloves, announce hand to be gloved first.
2. Presents gloves so that the thumb is facing the
wearer and the sterile hand is protected.
3. Applies resistance while the glove is being
applied.
4. Gloves other hand, pulling cuff away to ease
insertion.
5. Offers a damp towel to wipe off gloves.
6. Avoids contamination of self during procedure.
TOTAL

Name of Student: ______________________________________________________________________


PROCEDURE: CHANGING CONTAMINATED GLOVE(S) DURING A PROCEDURE

4 3 2 1
A. SELF
1. Holds contaminated gloves away from the
field.
2. Maintains cuff at wrist while glove is removed
by Non sterile person.
3. Uses open glove technique when reapplying
sterile replacement gloves.
4. Wipe the glove off with a damp towel.
5. Returns to the sterile field when the task is
complete.
B. TEAM MEMBER
1. Asks Nonsterile person to remove soiled
glove(s).
2. Present glove to team member, with the
thumb facing the wearer.
3. Supplies resistance during gloving.
4. Offers a damp towel to wipe off new glove(s).
5. Avoids contamination with self and sterile
fields during removal and reapplication.
TOTAL

Intravenous Therapy Performance Evaluation Tool

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INTRAVENOUS THERAPY

PERFORMANCE EVALUATION TOOL

Name of Student: ______________________________________________________________________

Legend: 4 Competent (student performs consistently in an effective & efficient manner)

PROCEDURAL STEPS SCORE REMARKS

CONFORME: STUDENTS NAME AND SIGNATURE ____________________________________

Name of Student: ______________________________________________________________________

Legend: 4 Competent (student performs consistently in an effective & efficient manner)

PROCEDURE: INSERTING IV CANNULA UTILIZING DUMMY ARM

PROCEDURAL STEPS SCORE REMARKS

23. Document in the patient’s chart and endorse the

CONFORME: STUDENTS NAME AND SIGNATURE _____________________________________

Name of Student: ______________________________________________________________________

Legend: 4 Competent (student performs consistently in an effective & efficient manner)

PROCEDURE: IV MEDICATION PUSH THROUGH THE IV PORT

PROCEDURAL STEPS SCORE REMARKS

CONFORME: STUDENTS NAME AND SIGNATURE _____________________________________

Name of Student: ______________________________________________________________________

Legend: 4 Competent (student performs consistently in an effective & efficient manner)

PROCEDURE: CHANGING AN IV SOLUTION

PROCEDURAL STEPS SCORE REMARKS

CONFORME: STUDENTS NAME AND SIGNATURE _____________________________________

Name of Student: ______________________________________________________________________

Legend: 4 Competent (student performs consistently in an effective & efficient manner)

PROCEDURE: DISCONTINUING AN IV INFUSION

PROCEDURAL STEPS SCORE REMARKS

CONFORME: STUDENTS NAME AND SIGNATURE _____________________________________

Name of Student: ______________________________________________________________________

Legend: 4 Competent (student performs consistently in an effective & efficient manner)

PROCEDURE: ONE-ON-ONE IV INSERTION

PROCEDURAL STEPS SCORE REMARKS

CONFORME: STUDENTS NAME AND SIGNATURE _____________________________________

Name of Student: ______________________________________________________________________

Legend: 4 Competent (student performs consistently in an effective & efficient manner)

PROCEDURE: BLOOD TRANSFUSION

PROCEDURAL STEPS SCORE REMARKS

CONFORME: STUDENTS NAME AND SIGNATURE _____________________________________

Name of Student: ______________________________________________________________________

Legend: 4 Competent (student performs consistently in an effective & efficient manner)

PROCEDURE: SURGICAL HAND SCRUB

PROCEDURAL STEPS SCORE REMARKS

CONFORME: STUDENTS NAME AND SIGNATURE _____________________________________

Name of Student: ______________________________________________________________________

Legend: 4 Competent (student performs consistently in an effective & efficient manner)

PROCEDURE: HAND DRYING AND DONNING STERILE GOWN

PROCEDURAL STEPS SCORE REMARKS

CONFORME: STUDENTS NAME AND SIGNATURE _____________________________________

Name of Student: ______________________________________________________________________

Legend: 4 Competent (student performs consistently in an effective & efficient manner)

PROCEDURE: REMOVING SOILED GOWN AND GLOVES

PROCEDURAL STEPS SCORE REMARKS

CONFORME: STUDENTS NAME AND SIGNATURE _____________________________________

Name of Student: ______________________________________________________________________

Legend: 4 Competent (student performs consistently in an effective & efficient manner)

PROCEDURE: APPLICATION OF STERILE GLOVES-CLOSED AND OPEN METHODS

PROCEDURAL STEPS SCORE REMARKS

CONFORME: STUDENTS NAME AND SIGNATURE _____________________________________

Legend: 4 Competent (student performs consistently in an effective & efficient manner)

PROCEDURE: DRYING, GOWNING AND GLOVING ANOTHER TEAM MEMBER

PROCEDURAL STEPS SCORE REMARKS

CONFORME: STUDENTS NAME AND SIGNATURE _____________________________________

Name of Student: ______________________________________________________________________

Legend: 4 Competent (student performs consistently in an effective & efficient manner)