University of Saint Anthony

(Dr. Santiago G. Ortega Memorial)

Iriga City

HEALTH CARE EDUCATION

PERFORMANCE CHECKLIST

SETTING UP/CHANGING/DISCONTINUING I.V. INFUSION

Name: ________________________________Course/Year: ________ Score: _________

Clinical Instructor:________________________ Signature of Clinical Instructor:_________
Legend: 4 – Action is correct, complete and performed in
proper order and time
3 – Action is correct, complete, but not in order and
performed action slowly or very fast
2 – Action is incorrect or incomplete and performed
action very slowly or very fast
1 – Action is not performed but mentioned
0 – Did not perform the procedure

Grading: Knowledge – 35%

Skills – 35%
Attitude – 30%

PROCEDURE 4 3 2 1 COMMENTS
A. SETTING UP
1. Verify doctor’s order and make I.V. Label.

2. Explain procedure to patient and/or significant

others and assess patient’s vein; choose appropriate
vein; location, size, condition, secure consent if
necessary.
3. Wash hands and maintains asepsis throughout
the preparation and during the therapy.
4. Prepare necessary materials for procedure ( I.V.
tray with IV solution, administration set, IV canula,
forceps soaked in aseptic solution, cotton balls with
alcohol, plaster, tourniquet, gloves, splint and IV
hook.
5. Check the sterility and integrity of the Iv solution,
IV set, and others device.
6. Place IV label on IVF bottle ( patient’s name,
room number, solution, drug incorporation, bottle
sequence and duration).
7. Open the seal of the IV solution and disinfect
port with cotton balls with alcohol
8. Open administration set aseptically (IVset) and
close the IV clamp.
9. Spike the container aseptically.
10. Full drip chamber to the at least half prime the
tubing aseptically.
11. Remove air bubbles if any and put back the
cover of the distal end the IV tubing (get ready for
IV insertion.
II. CHANGING AN IV INFUSION
1. Verify doctor’s order in the Doctor’s sheet and IV
sheet, counter check IV label, IV card bottle
number or bottle sequence, type, amount, additives
( if any), durationor infusion.
2. Explain procedure to patient’s and assess IV site
for redness. Plain swelling, pain etc.
3. Wash hand before and after procedure
4. Prepare necessary (IV solution, IV label,
Disinfectant, kidney, basin, IV tray.
5. Check sterility of IV solution
6. Calibrate new IV bottle according to duration of
infusion.
7. Open and disinfect rubber port IV solution for
follow.
8. Close the IV clamp of kink tubing and spike the
container aseptically.
9. Regulate the flow rate on duration of infusion.
Remove air ( if any ).
10. Discard all waste material according to hospital
policy.
11. Document accordingly and endorse to incoming
shift.
III. DISCONTINUING AN IV INFUSION
1. Verify written doctor’s order to discontinue IV
including IV medicines.
2. Assess and inform the patient of the order
3. Prepare necessary material: IV tray of injection
tray, cotton balls with alcohol, plaster, pick up
forceps in antiseptic solution, kidney basin.
4. Wash hands before and after procedure.
5. Close IV Clamp of the IV tubing.
6. Moisten adhesive tapes around IV catheter with
cotton balls, alcohol, remove plaster gently
7. Use pick up forceps to get cotton ball with
alcohol and without applying pressure remove
needle of IV cannula then pressure after and tape
or place dressing if indicated.
8. Inspect IV Catheter for Completeness.
9. Discard all waste material including the IV
cannula according to hospital policy
10. Reassure patient
11. Document of Discontinuance, status of insertion
site integrity of IV catheter and endorse to incoming
shift.
12. Perform procedure in a relaxed manner.
13. Accepts correction and shows, willingness to
improve performance.
14. Observes professional decorum in carrying out
the procedures.
15. Saves times and effort in performing the
procedure.

______________________________ _____________________________

Student’s Signature CI’s Name and Signature