TRINITY UNIVERSITY OF ASIA

ST. Luke’s College of Nursing

Return Demonstration Checklist
MEDICATION PREPARATION

Name _________________________________ Date_______ Total Score:_____

Section: _________________________________
DONE NEEDS NOT REMARKS
CARE ACTIONS (2) IMPROVEMT DONE (0)
(1)
1. Checks Doctor’s Orders and MAR for accuracy and
completeness; clarifies any unclear orders.
2. Reviews pertinent information related to the
medications: labs, last time medication was given,
and medication information: generic name, brand
name, dose, route, time, class, action, purpose,
side effects, contraindications, and nursing
considerations.
3. Assesses patient's medical and medication history
and history of allergies
4. Does assessment for contraindications.
5. Assesses patient symptoms or condition for
which medication was prescribed
6. Performs hand hygiene.
7. Gathers needed supplies: correctly sized syringes
and needles appropriate for medication, diluent (if
required), aspirating/filter needles, tape or patient
label for each syringe, sharps container, alcohol
wipes and MAR
8. Selects correct drug, compared label with MAR
9. Checks expiration date and physical condition of
the drug and performs any necessary calculations.

PREPARING MEDICATIONS FROM AMPULES

10. Taps the top of the ampule or swirls with the
fingers until fluid moves from neck of ampule
11. Places gauze pad around the neck of the ampule
12. Snaps/breaks the neck of ampule properly
13. Prepares the syringe and uses a filter needle
14. Holds the ampule properly and draws the
medications from the ampule avoiding the needle
to touch the rim of the ampule
15. Keeps the needle tip under the surface of the
liquid, tips the ampule if needed
16. Did not expel air if air bubbles were aspirated
17. Expels air bubbles outside the ampule as
necessary
18. Uses the sink to dispose excess fluid & rechecks
the level in the syringe
19. Replaces the filter needle with the correct needle
size for injection
20. Labels the syringe
PREPARING MEDICATIONS FROM VIALS
21. Removes cap cover of the unused vial, wipes
surface with alcohol wipes & allows to dry
22. Picks up the syringe and places an aspirating
needle
23. Draws amount of air into the syringe equal to the
volume of medication to be aspirated
24. Inserts the needle through the center of rubber
seal
25. Injects the air into the vial holding plunger firmly
26. Inverts the vial, ensures proper hold on the syringe
and plunger to counteract the pressure
27. Keeps tip of the needle below fluid level
28. Allows the air pressure to fill syringe with
medication and pulls back on the plunger if
necessary
29. Removes the needle from the vial
30. Removes air bubbles as necessary
31. Rechecks the volume in the syringe
32. Replaces the aspirating needle with the correct
needle size for injection
33. Labels the syringe & vial as necessary (if
multi-dose)
PREPARING MEDICATIONS FROM POWDERED VIALS
34. Removes cap covering the vials of the medication
& the diluent & swabs with alcohol & allows to dry
35. Picks up the syringe and places an aspirating
needle
36. Draws the amount of air equal to the volume of
diluent required
37. Inserts the needle into the diluent vial & injects air
& inverts vial & withdraws the amount of diluent
required
38. Withdraws the needle & inserts in the vial with
powdered medication & injects diluent
39. Removes needle and mixes the medication
40. Mixes thoroughly by rolling & not shaking
41. Determines appropriate dose after reconstitution
42. Draws the appropriate amount of medication into
the syringe without adding additional air
43. Follows steps # 26 to 33

MIXING INSULINS
44. Verifies dosage required & calculate as necessary
& have it counterchecked by another nurse
45. Rolls bottle to resuspend insulin preparation as
necessary
46. Wipes off the tops of the insulins to be mixed with
alcohol swab
47. Verifies insulin doses required
48. Picks up the insulin syringe & aspirates air equal to
amount needed for Insulin A (cloudy one)
49. Inserts the needle in Insulin A & injects the air
50. Removes needle from vial of Insulin A without
aspirating medication
51. Aspirates air equal to amount of medication
needed from Insulin B (clear)
52. Inserts needle into Insulin B vial & injects air &
withdraws the required dose of Insulin B
53. Ensures amount withdrawn from Insulin B
54. Inserts needle into vial of Insulin A & withdraws
the correct amount without injecting air anymore
55. Inverts vial as necessary keeping the tip of the
needle submerged in the medications
56. Withdraws the needle and checks fluid level of the
mixed insulin in the syringe
57. Keeps the needle sheath or recaps the needle
58. Labels appropriately

AFTER CARE
59. Disposes all used supplies
60. Disposes used needles, ampules & vials in the
Sharps Collector
61. Cleans the work area & performs hand hygiene
62. Checks all prepared syringes and ensures their
integrity.

Ma. Cristina T. Reyes, RN, MAN

Instructor’s Signature / Date

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