OLIVAREZ COLLEGE

Dr. A. Santos Avenue, San Dionisio, Parañaque City

PACUCOA Accredited
COLLEGE OF HEALTH SCIENCES EDUCATION
NURSING DEPARTMENT
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Student Name: ___________________________________________ Score: _________________________

Level and Group No.: ______________________________________ Date: ________________________
Directions: Evaluate each step/task by putting (✔) under the proper heading. A numerical number may also be assigned &a minimum passing level determined.
Rate the students from 2 - 0, where:
(2) Performed Correctly Students performed the step according to the standard procedure or guidelines
(1) Attempted Not CorrectlyStudents unable to perform the steps/task according to procedure or guidelines
(0) Not Done Students did not do the step/task
(NO) Not Observed (NO) Evaluator unable to observe the step/task for various reasons like interruptions/inattentiveness,.

Checklist on SETTING UP IV ( IV Cannulation )

STEPS Performed Performed Not Done Not

Correctly but not (0) Observed
(2) Correctly (NO)
Done
(1)

1. Verify doctor’s orders

2. Gather & prepare materials needed.

● Sterile disposable gloves.
● Appropriate size "over-the-needle" IV catheter (typically 25 - 18 gauge)
● Bag of IV fluid. / Heplock
● Non-latex tourniquet.
● Sterile bandage or dressing
● Gauze
● Alcohol wipes
● Medical tape
3. Greet the client, Introduce yourself & explain the procedure .

4. Perform handwashing

5. Ensure privacy and good lighting. Position the patient correctly for the
procedure.
6. Don clean gloves.

7. IV Site preparation, locate a suitable vein, using a tourniquet on the

patient's arm.
8. Clean the patient's skin with the alcohol wipe, re-check the vein.

9. Insertion of catheter into vein, Use the non – dominant hand to pull the
skin taut below the entry site.
10. Hold the over – the – needle catheter at a 15 - to 30 – degree angle
with bevel up,insert the needle at an angle of 10-25 degrees for a superficial
vein or 30-45 degrees for a deeper one
11. Advance the cannula until you have entered a vein and blood enters the
base.
12. Release the tourniquet, apply pressure and remove the needle.

13. Initiate the infusion or place the heplock

 14. Tape and secure the catheter

15. Dress and label the venipuncture site a according to

agency policy
16. Documents the relevant data, including assessments

Computation for student rating:

Raw score X 60 + 40
Perfect score
Student’s Signature and Date: _____________________________
Signature of Clinical Instructor and Date: ______________________

Remarks:
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