Republic of the Philippines

CAVITE STATE UNIVERSITY

Don Severino de las Alas Campus
Indang, Cavite
(046) 415-0010 / (046) 415-0011
www.cvsu.edu.ph
cvsu.op206@gmail.com

COLLEGE OF NURSING

MEDICAL AND SURGICAL NURSING –

NURS 13 RELATED LEARNING
EXPERIENCES

Name: _________________________________________ Date: _______________

Year and Section: _________ Group No. ___________

Competency Performance Checklist

IV FLUID THERAPY

Very Needs
Good Fair
PROCEDURE good Improvement
(3) (2)
(4) (1)
1. Verify the prescription for IV Therapy, checked
prepared IVF and other things needed.

2. Explain procedure to re assure the patient and

significant others and observed the R’s.
3.Do hand hygiene before and after the
procedure
4.Choose site for IV

5. Apply tourniquet 5 to 12cm (2-6 inch) above

injection site depending on condition of patient.

6. Check for radial pulse below tourniquet

7. Prepare site with effective topical antiseptic

according to hospital policy or cotton balls with alcohol
in circular motion and allow 30 seconds to dry. (No
touch technique)
Note: CDC Universal precaution: Always wear gloves
when doing any venipuncture.

8. Using the appropriate IV cannula, pierce skin with

needle positioned on a 15-30 degree angle.
9. Upon flashback visualization decrease the angle,
advance the catheter and stylet (1/4 inch) into the
vein, check if tip of catheter can be rotated freely
inside the vein.
10. Position the IV catheter parallel to the skin. Hold
stylet stationary and slowly advance the catheter until
the hub is 1 mm to the puncture site.
11. Slip a sterile gauze under the hub. Release the
tourniquet remove the stylet while applying digital
pressure over the catheter with one finger about 1-2
inch from the tip of the inserted catheter.
12. Connect the infusion tubing of the prepared IVF
aseptically to the IV catheter.
13. Open the clamp, regulate the flow rate,
Reassure patient.
14.  Anchor needle firmly in place with the use of:
a. Transparent tape/dressing directly on the puncture
site.
b. Tape (using any appropriate anchoring style)
c. Band aid
Note: Never place unsterile tape directly on IV
insertion site, instead place a small piece of sterile OS
& then secure it with adhesive tape,
15.  Tape a small loop of IV tubing for additional
anchoring, apply splint (if needed).
16. Calibrate the IVF bottle & regular flow of infusion
according to prescribed duration
17. Label on IV tape near the IV site to indicate the
date of insertion, type and gauge of IV catheter and
countersign.
18. Label with plaster on the IV tubing to indicate the
date when to change the IV tubing.
19. Observe patient and report and untoward
effect.
20. Document in the patient's chart and endorse to
incoming shift.
21. Discard sharps and waste according to Health Care
Waste Management (DOH/DENR).

Perfect Score:84
Passing Score:60 Total Score:

Remarks:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

_______________________ ______________________
Student Name and Signature Clinical Instructor Signature