Republic of the Philippines

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Villa Lucida Campus, Tarlac City Philippines 2300
Tel.no.: (045) 982-6062 Fax: (045) 982-0110 website: www.tsu.edu.ph
Awarded Level 3 Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines Inc
(AACCUP)

Performance Evaluation Checklist

INTRAVENOUS THERAPY

Name of Student: _______________________________________

Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ___First Semester ____Second Semester ___ Summer
Inclusive Dates of Clinical Rotation: ________________
Instructor: _____________________________________

Description:
Intravenous Therapy is the insertion of a needle or catheter/cannula into a vein, based on physicians
written prescription. The needle or catheter/cannula is attached to a sterile tubing and/or a fluid
container to provide medication and fluids.

Indications:
1. To maintain hydration and/or correct dehydration in patients unable to tolerate sufficient volumes
of oral fluids/medications.
2. Parenteral nutrition.
3. Administration of drugs.
4. Transfusion of blood or blood components.

Descriptive Interpretation for Actual Score:

2 - Very Good
1 - Good
0 - Not Performed

PROCEDURES: A. SETTING UP AN IV INFUSION, B. INSERTING IV CATHETER/CANNULA

C. CHANGING AN IV SOLUTION, D. DISCONTINUING AN IV SOLUTION

SCORE
PROCEDURES 2 1 0
Assessment:
• Vital signs for baseline data
• Skin turgor
• Allergy to tape or iodine
• Bleeding tendencies
• Disease or injury to extremities
• Status of veins to determine appropriate venipuncture site
Consider:
• How long the patient is likely to have the IV
• What kinds of fluids will be infused
• What medications the patient will be receiving
Assemble equipment and supplies:
• Infusion set (IV tubing, syringe with needle, IV fluids)
• Container of sterile parenteral solution
• IV pole
• Adhesive or nonallergenic tape
• Clean gloves
• Tourniquet
• Antiseptic swabs
• Antiseptic solution, such as povidone-iodine (optional)
• Intravenous catheter/needle
• Sterile gauze dressing or transparent occlusive dressing or tegaderm
• Arm splint, if required
• Towel or pad,
• Electronic infusion device or Pump
A. SETTING UP AN IV INFUSION
1 Verify written prescription and make IV label
2 Observe ten (10) Rs when preparing and administering IVF.
3 Explain procedure to reassure patient and/or significant others. Secure
consent if necessary.
4 Assess patient’s vein; choose appropriate site location, size/condition.
5 Do hand hygiene before and after the procedure.
6 Prepare necessary materials for procedure
7 Check the sterility and integrity of the IV solution, IV set and other devices.
8 Place IV label on IVF bottle.
9 Open the seal of the IV bottle aseptically and disinfect rubber port with
cotton balls with alcohol.
10 Open IV administration set aseptically and closed the roller clamp and spike the infusate
container aseptically.
11 Fill drip chamber to at least half and prime it with IVF aseptically
12 Expel air bubbles if any and put back the cover to the distal end of the IV set
B. INSERTING IV CATHETER/CANNULA
1 Explain procedure to reassure the patient and significant others and observe the 12 R’s.
2 Do hand hygiene before and after the procedure,
3 Choose site for IV.
4 Apply tourniquet 5-12 cm. (2-6 in) above injection site depending on condition of patient.
5 Check the radial pulse below tourniquet.
 6 Prepare site with effective topical antiseptic according to hospital policy or cotton balls with
alcohol in circular motion and allow 30 seconds to dry. (no touch technique).
7 Note: CDC Universal Precaution: Always wear gloves when doing any venipuncture.
8 Using the appropriate cannula, pierce skin with needle positioned on a 15-30 degree angle.

9 Upon flashback visualization decrease the angle, advance the catheter and stylet (1/4 inch)
into the vein, check if tip of catheter can be rotated freely inside the vein.
10 Position the IV catheter parallel to the skin. Hold stylet stationary and slowly advance the
catheter until the hub is 1 mm to the puncture site.
11 Slip the sterile gauze under the hub. Release the tourniquet, remove the stylet while
applying digital pressure over the catheter with one finger about 1-2 inch from the tip of the
inserted catheter.
12 Connect the infusion tubing of the prepared IVF aseptically to the IV catheter.
13 Open the clamp, regulate the flow rate. Reassure patient.
14 Anchor needle firmly in place with the use of:
a. Transparent tape/dressing directly on the puncture site Ex. Tegaderm
b. Tape (using any appropriate anchoring style)
Note: never place unsterile tape directly on IV insertion site, instead place a small piece of
sterile OS and then secure it with adhesive tape.
15 Tape a small loop of IV tubing for additional anchoring; apply splint (if needed).
16 Calibrate IV bottle and regulate flow of infusion according to prescribed duration.
17 Label on IV tape near the IV site to indicate date of insertion, type and gauge of IV catheter
and countersign.
Label with plaster on the IV tubing to indicate the date when to change the IV tubing.
18 Observe patient and report any untoward effect.
Discard sharps and waste according to Health Care waste management (DOH, DENR)
20 Document in the patient’s chart and endorse to incoming shift.
C. CHANGING AN IV SOLUTION
Verify doctor’s prescription in doctor’s order sheet; countercheck IV label, IV card, infusate
1 sequence, type, amount, additives (if any), duration of infusion.
2 Observe the ten (10) Rs.
3 Explain the procedure to reassure the patient and significant others
4 Assess IV site for redness, swelling, pain, etc.
5 Change IV tubing and cannula if 48-72 hrs.has lapsed after IV insertion.
6 Wash hands before and after the procedure.
7 Prepare necessary materials; place on an IV tray.
8 Check sterility and integrity of IV solution.
9 Place IV label on the IV bottle.
10 Calibrate new IV bottle according to duration of infusion as prescribed
11 Open and disinfect rubber port of IV solution to follow.
12 Close the roller clamp and spike the cont ainer aseptically.
13 Regulate the flow based on the prescribed infusion rate.
14 Discard all waste materials according to Health Care Waste
Management (DOH/DENR)
15 Document and endorse accordingly.
D. DISCONTINUING AN IV INFUSION
1 Verify doctor’s prescription to discontinue IV including IV medications.
2 Observe the ten (10) Rs.
3 Assess and inform the client of the discontinuation of IV infusion.
4 Prepare necessary materials, an IV or injection tray.
5 Wash hands before and after the procedure.
6 Close the roller clamp of the administration set.
7 Moisten the adhesive tapes around the IV catheter with cotton balls with
alcohol and remove the plaster gently.
Remove needle/IV catheter and immediately apply pressure over the
8 venipuncture site.
9 Inspect IV catheter for completeness.
10 Place dressing over the venipuncture site.
11 Discard all waste materials.
12 Document time of discontinuance, status of insertion site and integrity
of IV catheter and endorse accordingly.
TOTAL SCORE:
Transmuted Grade:

Evaluated by:

________________________________
Signature over Printed Name
Clinical Instructor

________________________________
Signature over Printed Name
Student
 Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Villa Lucida Campus, Tarlac City Philippines 2300
Tel.no.: (045) 982-6062 Fax: (045) 982-0110 website: www.tsu.edu.ph
Awarded Level 3 Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines Inc
(AACCUP)

Performance Evaluation Checklist

BLOOD TRANFUSION

Name of Student: _______________________________________

Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ___First Semester ____Second Semester ___ Summer
Inclusive Dates of Clinical Rotation: ________________
Instructor: _____________________________________

Description:
Blood transfusion is a procedure in which whole blood or blood components are put into a patient’s
bloodstream through an intravenous line.

Indications/Purposes:
1. Surgery
2. Injury
3. Disease (Anemia)
4. Bleeding disorders

Descriptive Interpretation for Actual Score:

2 - Very Good
1 - Good
0 - Not Performed

SCORE
PROCEDURES 2 1 0
1 Verify doctor’s prescription and make a treatment card according to hospital policy.
2 Observe the 10 Rs when preparing and administering any blood and blood components.
3 Explain the procedure/rationale for giving blood transfusion to reassure patient and significant
others and secure consent, Get patient’s history regarding previous transfusion.
Note: Explain the importance of the benefits on Voluntary Blood Donation (RA 7718)- National
Blood Service Act of 1994).
4 Request prescribed blood/blood components from blood bank to include blood typing and
cross-matching and blood result of transmissible disease.
5 Using a clean lined tray, get compatible blood from hospital bank.
6 Wrap blood bag with clean towel and keep it at a room temperature.
7 Have a doctor and a nurse assess a patient’s condition. Countercheck the compatible blood to
 be transfused against the x-matching sheet noting ABO grouping and RH, serial number of
each blood unit and expiry date with the blood bag label and other laboratory examination as
required before transfusion (Hgb, Hct).
8 Get the baseline vital signs before transfusion. Refer to M.D. accordingly.
9 Give pre-med 30 minutes before transfusion as prescribed.
10 Do hand hygiene before and after the procedure.
11 Prepare equipment needed for BT.
12 If main IVF is with dextrose 5% initiate an IV line catheter with appropriate IV catheter with
Plain NSS on the 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 18 or
19 for side drip (for adults) or of 22 for pedia ( if blood is given through the Y injection port, the
gauge of needle is disregarded).
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 and regulate to KVO while transfusion is going on.
16 Transfuse the blood via the injection port and regulate at 10-15 gtts initially for 15 minutes and
then at the prescribed rate. (usually based on patient’s condition)
17 Observe patients for 10-15 minutes for any immediate reaction.
18 Observe patient on an on-going basis for any untoward signs and symptoms such as flushed
skin, chills, elevated temperature, itchiness, urticaria and dyspnea. If any of these symptoms
occurs stop the transfusion, open the roller clamp of an IV line with Plain NSS, and report to
doctor immediately.
19 Swirl the bag hourly to mix the solid with the plasma. One BT set should be used for 1-2 units
of blood only.
20 When blood is consumed, close the roller clamp of BT and disconnect from IV lines the
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 the Hgb, Hct, bleeding time, serial platelet count within specified hours as prescribed.
23 Discard blood bag and BT set and sharps according to Health Care Management
(DOH/DENR)
24 Document the procedure, pertinent observations and nursing interventions and endorse
accordingly.
25 Remind the doctor about the administration of Calcium Gluconate if patent had several units of
blood transfusion ( 3-6 or more units of blood).
TOTAL SCORE:
Transmuted Grade:

Evaluated by:
___________________________
Signature over Printed Name
Clinical Instructor
_______________________________
Signature over Printed Name
Student