Far Eastern University

Institute of Nursing

STUDENT PERFORMANCE EVALUATION TOOL

INTRAVENOUS THERAPY

Name:_____________________________ Sec/Group No:________________ Date:________________

Area:______________________________ Faculty:__________________ Concept:___________________

DIRECTION: Rate the learner based on the competencies listed below

KEY:
3 – Very Good Performed with minimum guidance and supervision
2 – Satisfactory Performed with frequent guidance and supervision
1 – Needs Improvement Requires close guidance and supervision
0 – Poor Did not exhibit expected behavior even under close guidance and supervision
CRITERIA 0 1 2 3
A. ATTENDANCE AND ATTITUDE
1. Report on time and attend to activities punctually
2. Display proper grooming and wears complete uniform
3. Behaves appropriately towards teachers, classmates and
clients
4. Accepts constructive criticism
B. PROCEDURE
B. I SETTING UP
a. Check doctor’s order and made IV label
b. Prepare necessary equipment
c. Introduce yourself and verify the client’s identity
d. Explain procedure
e. Assess client’s vein
f. Check the solution and set for sterility
g. Place IV level on IVF bottle
h. Perform hand hygiene and observe other appropriate
infection control through out the procedure
i. Provide for client privacy
j. Place the client in a appropriate position
k. Maintain sterility of IV solution container while opening
port
l. Disinfect rubber port with cotton ball with alcohol
m. Open administration set aseptically ( venoset ) and close
the roller clamp
n. Spike the container without contaminating port
o. Hang the IV bottle using the IV stand or hook
p. Fill drip chamber to at least half
q. Prime the tubing while maintaining sterility of the end of
tubing ( use kidney basin )
r. Remove all air from tubing ( get ready for IV insertion )
B. II CHANGING AN IV INFUSION
a. Check doctor’s order in the doctor’s orders sheet and IV
sheet; counter check IV label, IVcord, bottle number or
bottle sequence, type, amount, addictives ( if any ) duration
of infusion
b. Assess the presence of fluid infiltration, bleeding, phlebitis
blockages in the IV system
c. Check the appearance of the dressing, date and the time of
the previous dressing change
d. Prepare necessary materials
e. Obtain the correct solution container and check sterility of
IV solution
f. Correct solution, correct client, correct additives ( if any )
and correct doses and label it
g. Bring necessary materials at the best side
h. Introduce yourself and verify the client identity. explain to
the client what you are going to do
i. Perform hand hygiene and observe other appropriate
infection control procedures
j. Provide for client’s privacy
k. Disinfect rubber port of new IV solution prior to inserting
spike of the previous administration set when changing IV
solution bottle
l. Close roller clamp or kink tubing of administration set when
changing IV solution bottle
m. Spike the container without contaminating port
n. Regulate the flow rate based on duration of infusion
o. Remove bubbles ( if any )
p. Document in client’s IV sheet and kardex
B. III DISCONTINUING AN IV INFUSION
a. Verify written doctor’s order to discontinue IV
b. Prepare necessary materials
c. Wash hand before and after procedure
d. Verify the client’s identity and explain the procedure
e. Provide for client privacy
f. Clamp tubing, loosen the type at the venipuncture site
g. Put on clean gloves, and hold sterile gauze above the
venipuncture site
h. Withdraw the needle or catheter by pulling it out along the
line of the vein
i. Immediately apply firm pressure to the site, using sterile
gauze, for 2-3 minutes
j. Cover the venipuncture site apply the sterile dressing
k. Discard the IV solution container properly and discard the
used supplies appropriately
l. Record the amount of fluid infused on the intake and output
record and on the client

TOTAL SCORE =

_________________________________ __________________________________
Signature of Student Signature of Faculty