Student: ___________________________

Instructor: __________________________

Instructor Signature: __________________ Date: ________________

ASSISTING INTRAVENOUS (IV) THERAPY

INSERTING IV CANNULA UTILIZING DUMMY ARM
PERFORMANCE CHECKLIST

STEPS S U NP REMARKS

E. INSERTING IV CANNULA UTILIZING

DUMMY ARM
Prepare complete IV tray with IV infusions; Dummy
Arm and other safety devices.

1. Verify the written prescription for IV therapy.

2. Check Dummy Arm prepare IVF and other things

needed.

3. Explain procedure to reassure the patient and

significant others and observe the 12Rs in
administering medication.

4. Do hand hygiene before the procedure.

5. Wear gloves when only during venipuncture.

6. Choose appropriate site, location, size and

condition of the vein.

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

injection site.

8. Check for radial pulse below tourniquet.

9. Prepare site with effective topical antiseptic

according to hospital policy (No touch technique).

10. Use the appropriate IV cannula utilizing the

correct technique.

11. Insert catheter progressively until backflow is

visualized.
12. Position the IV catheter parallel to the skin.

13. Hold stylet stationary and slowly advance the

catheter until the hub is 1mm to the puncture site.

14. Slip a sterile gauze under the hub.

 STEPS S U NP Remarks

15. Release the tourniquet, remove the stylet while

applying digital pressure over the catheter with
one finger about 1-2 inches from the tip of
inserted catheter.

Note: Do not reinsert stylet once pulled out to prevent

breakage of catheter that may cause embolism.

16. Connect the infusion tubing of the prepared IVF

aseptically to the IV catheter.

17. Open the clamp and regulate the flow rate.

Reassure patient.

18. Secure and apply the taping technique.

19. Tape a small loop of IV tubing for additional

anchoring. Apply splint, if needed.

20. Calibrate the IVF bottle and regulate flow of

infusion.

21. Label on IV tape near the IV site to indicate the

date of insertion, type and gauge of IV catheter
and countersign.

22. Label with plaster on the IV tubing to indicate the

date when to change the IV tubing.

23. Observe patient and report any untoward effect.

24. Discard sharps and waste according to Health

Care Waste Management (DOH/DENR).

25. Do hand hygiene after the procedure.

26. Document in the patient’s chart and endorse to

incoming shift.

As adapted from the :

Nursing Standards on Intravenous Practice, 10th edition

Association of Nursing Services Administrators of the Philippines ,Inc. (ANSAP)

vvb /11/2014