OUR LADY OF FATIMA UNIVERSITY

College of Nursing – Valenzuela

Bachelor of Science in
PROGRAM STUDENT NAME
Nursing
YEAR AND SECTION
COURSE NCMA 219 INSTRUCTOR
DATE

PROCEDURE : SETTING UP INTRAVENOUS LINE

EXPECTED OUTCOME : The student should be able to set up an Intravenous line
correctly
ASSESSMENT TASK : Return Demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
1. Verify the doctor’s Verified the Verified the doctor’s Verified the Failed to verify the
order and make an doctor’s order order and made an doctor’s order and doctor’s order and
IV label and made an IV IV label with made an IV label did not make an IV
label minimal error incorrectly label

2. Observe the 10 R’s Observed the 10 Observed at least 8 Observed at least 6 Observed less than
when preparing rights in rights rights 4 rights
and administering preparing and
IV fluid administering IV
fluid

3. Explain the Explained the Explained the Explained the Failed to explain the
procedure to procedure to the procedure but lacks procedure but in procedure
reassure patient client and details an unclear manner
and or significant significant others
others, secure clearly and
consent if completely with
necessary approval

4. Handwashing Observed Hand washing was Hand washing was Hand washing was
principle of done with minimal done with maximal not done
medical hand error error
washing

5. Prepare the Gathered the Gathered the Gathered materials Failed to gathered
necessary materials materials with little with more time all the materials
materials for the needed time preparation preparation needed
procedure completely

6. Check for the Demonstrated Demonstrated the Demonstrated the Failed to perform
sterility and the procedures procedure with little procedure with the procedure
integrity of the with ease errors some errors
solution, IV set and
other materials
needed

7. Place the IV label Performed the Performed but Performed with Failed to perform
 on the IV bottle procedure needs minimal slight difficulty, the procedure
duly signed by the accurately with supervision needs supervision
nurse who evident ease most of the time
prepared it without
supervision

8. Open and prepare Performed the Performed but Performed with Failed to perform
the infusion set. procedure needs minimal slight difficulty, the procedure
Remove the tubing accurately with supervision needs supervision
from the container, evident ease most of the time
and straighten it without
out. Slide the roller supervision
clamp along the
tubing until it is
below the drip
chamber to
facilitate its access
and close the
clamp.

9. Open the seal of Performed the Performed but Performed with Failed to perform
the IV infusion procedure needs minimal slight difficulty, the procedure
bottle aseptically accurately with supervision needs supervision
and disinfect evident ease most of the time
rubber port. Spike without
to infusate supervision
container
aseptically.

10. Fill in the drip Performed the Performed but Performed with Failed to perform
chamber half full procedure needs minimal slight difficulty, the procedure
and prime the tube accurately with supervision needs supervision
by releasing the evident ease most of the time
clamp and let the without
fluid run through supervision
the tubing until all
the bubbles are
removed.

11. Expel the air Performed the Performed but Performed with Failed to perform
bubbles if any and procedure needs minimal slight difficulty, the procedure
put back the cover accurately with supervision needs supervision
to the distal end of evident ease most of the time
IV set. Get ready without
for IV insertion supervision

12. Identify type of Identified type of Slight difficulty in Have difficulty in Failed to identify
infusion pump infusion pump identifying the type identifying the the type of infusion
used of infusion pump type of infusion pump used.
used pump used
13. Identify type of IV Identified the Slight difficulty in Have difficulty in Failed to identify
infusion set type of IV identifying the type identifying the the type and
compatible with infusion set of infusion set type of infusion set compatibility of the
the pump needed compatible with compatibility of the compatible with infusion set with the
the pump pump needed the pump needed pump needed
needed
14. Adjust the level of Adjusted the Slight difficulty in Have difficulty Failed to adjust the
 the pump to at level of the adjusting the level adjusting the level level of the pump to
least 20” below the pump to at least of the pump to at of the pump to at at least 20” below
source container or 20” below the least 20” below the least 20” below the the source
IV bag source container source container or source container container or IV bag
or IV bag IV bag or IV bag
15. Open the pump Performed the Performed but Performed with Failed to perform
door procedure needs minimal slight difficulty, the procedure
accurately with supervision needs supervision
evident ease most of the time
without
supervision
16. Adjust the Adjusted the Slight difficulty in Have difficulty in Failed to adjust the
appropriate appropriate adjusting the adjusting the appropriate
regulation using regulation using appropriate appropriate regulation using the
the pump interface the pump regulation using the regulation using pump interface
interface pump interface the pump interface
17. Hook the IV line to Performed the Performed but Performed with Failed to perform
the patient procedure needs minimal slight difficulty, the procedure
accurately with supervision needs supervision
evident ease most of the time
without
supervision
18. Open the roller Performed the Performed but Performed with Failed to perform
clamp procedure needs minimal slight difficulty, the procedure
accurately with supervision needs supervision
evident ease most of the time
without
supervision
19. Push the start Performed the Performed but Performed with Failed to perform
button to start procedure needs minimal slight difficulty, the procedure
infusion accurately with supervision needs supervision
evident ease most of the time
without
supervision
20. Monitor the client Performed the Performed but Performed with Failed to perform
procedure needs minimal slight difficulty, the procedure
accurately with supervision needs supervision
evident ease most of the time
without
supervision
21. Wash hands and Washed hands Washed hands and Washed hands but Washed hands but
documentation and documented some of the details most of the details documentation was
the information of procedure were of the procedure not done.
about the not documented. were not
procedure documented
properly and
completely.

OVERALL SCORE: _________________

Target raw score: 47 out of 63. If raw score is less than 47, repeat the demonstration.

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FACULTY SIGNATURE OVER PRINTED NAME