PROCEDURE CHECKLIST

Chapter 38, Skill 38-02: Administering IV Piggyback Medication

Check () Yes or No

PROCEDURE STEPS Yes No COMMENTS

1. Reviews the physician’s orders and the medication
administration record (MAR) for the correct patient,
medication, dose, route, and time.
2. Reviews a drug book for actions, required
assessments, correct dosage, route, side effects, expected
results, and the period of time over which the medication
may be safely administered IV. Checks for compatibility
with IV fluids.
3. Assesses the patient’s allergies.
For IVPB With Continual IV Primary Line:
4. Assesses patency of IV line and assesses IV site.
5. Obtains appropriate equipment and supplies: IV
medication bag, tubing, access device, alcohol wipes, NS
flush syringe, and gloves. Assesses packages for intactness
and expiration dates. Performs first two safety checks.
6. Washes hands and prepares IVPB for administration:
Spikes bag and clears tubing without contamination.
7. Calculates drip rate for IVPB correctly.
8. Follows the “Initial Implementation Steps.”
9. Washes hands again and assesses IV site. Performs
third safety check.
10. Hangs IVPB on pole or pump. If pump, hangs bags at
same height. If gravity flow, hangs primary solution bag
lower than IVPB solution bag.
11. Prepares IPPB tubing for attachment. Locates highest
Y-injection port on primary tubing and cleanses with
alcohol wipe.
12. Connects IVPB tubing to primary line using Luer-
Lok adaptor or blunt-tipped adaptor.
13. If using an IV pump, programs settings for the IVPB:
“secondary volume to be infused” and “secondary rate of
infusion.” If using gravity flow, sets drip rate correctly
according to previous calculations.
14. After IVPB is infused, washes hands, dons clean
gloves, and correctly disconnects IVPB tubing from the
injection port. Wipes port with alcohol wipe.
15. Documents appropriate information about IV site
assessment, effectiveness of medication, and any problems
with the infusion.
For IVPB Into prn Lock Without Continuous Infusion:

Copyright © 2015, F. A. Davis Company

4. Obtains appropriate equipment and supplies: IV
medication bag, primary IV tubing, two normal saline
(NS) flushes, alcohol wipes, and examination gloves.
5. Calculates IV drip rate for gravity flow. Inspects
packages for intactness and expiration dates. Performs
first two safety checks.
6. Washes hands and prepares IVPB for administration:
Spikes bag and clears tubing without contamination.
7. Calculates drip rate for IV piggyback correctly.
8. Follows the “Initial Implementation Steps.”
9. Washes hands again and assesses IV site. Performs
third safety check.
10. Hangs IVPB on IV pole and dons clean gloves.
11. Cleans injection port on prn lok with alcohol wipe
and attaches prepared flush (with air removed). Opens
slide clamp on PRN lock.
12. Checks for blood return by aspirating, then injects NS
slowly over 1 minute while observing for swelling at the
site.
13. Discards flush syringe and clean injection site with
alcohol wipe. Connect IVPB tubing to the Luer-Lok end
of the injection port maintaining sterile technique.
14. Set the flow rate according to previous calculations,
and assess IV site. Monitor rate and site throughout
infusion.
15. When the IVPB is infused, washes hands and dons
gloves. Correctly disconnects IVPB tubing from injection
port. Wipes port with alcohol wipe.
16. Attaches prepared flush (with air removed) and checks
for blood return by aspirating. Then injects NS slowly
over 1 minute while observing for swelling at the site.
17. Closes the slide clamp on the PRN lock. Removes
gloves and wash hands.
18. Follows the “Ending Steps.”
19. Documents appropriate information about IV site
assessment, effectiveness of medication, and any problems
with the infusion.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

Copyright © 2015, F. A. Davis Company