SAN PEDRO COLLEGE

Davao City

PERFORMANCE CHECKLIST
STARTING an INTRAVENOUS INFUSION

Name: Grade:
Year & Sec.: Date:

Legend: 5 – Excellent; 4 – Very good; 3 – Good; 2 – Fair; 1 – Poor

Rating

PROCEDURE 5 4 3 2 1

1. Checks the written medical order.

2. Washes hands.

3. Assembles needed equipment.

4. Closes the roller clamp in the tubing.

5. Removes the protective covering of the IV bag / bottle

and tubing without contamination.
6. Incorporates additives aseptically as needed.

7. Connects the tubing to the IV bag/bottle.

8. Partially fills the drip chamber.

9. Opens the clamps and flushes air from the tubing (primes
the tubing).
10. Calls the doctor/nurse and brings preparation to bedside.

11. Identifies the patient. Explain the procedure to the client.

12. Hangs the fluid container on the IV stand.

13. Assists the patient to a low Fowler’s position.

14. Assists the physician/nurse in the insertion of IV fluid.

15. Releases the torniquet.

16. Opens the roller clamp to allow slow but gradual infusion
of solution.
17. Notes that solution continues to drip and site does not
become swollen.
18. Secures tubing with strips of plaster.

19. Adjusts the flow rate as prescribed.

 20. Restrains the arm with an armboard as necessary.

21. Positions patient comfortably.

22. Attaches the completed IVF label

23. Does after care of equipment.

24. Washes hands.

25. Records the appropriate information on patient’s chart.

26. Maintains body mechanics throughout the performance of

the procedures.
27. Manifests neatness in the performed procedure.

28. Receptive to criticisms.

29. Observes courtesy.

30. Shows calmness while performing the procedure.

31. Uses correct English.

32. Shows mastery of the procedure.

Remarks:

Criteria: I Knowledge (quiz) 30%

II Performance 70%
100%

Student’s Signature Over Printed Name Date

Instructor’s Signature Over Printed Name Date