OLIVAREZ COLLEGE

Dr. A. Santos Avenue, San Dionisio, Parañaque City

PACUCOA Accredited
COLLEGE OF HEALTH SCIENCES EDUCATION
NURSING DEPARTMENT
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Student Name: ___________________________________________ Score: _________________________

Level and Group No.: ______________________________________ Date: ________________________

Directions: Evaluate each step/task by putting (✔) under the proper heading. A numerical number may also be assigned &a minimum passing level determined.
Rate the students from 2 - 0, where:
(2) Performed Correctly Students performed the step according to the standard procedure or guidelines
(1) Attempted Not CorrectlyStudents unable to perform the steps/task according to procedure or guidelines
(0) Not Done Students did not do the step/task
(NO) Not Observed (NO) Evaluator unable to observe the step/task for various reasons like interruptions/inattentiveness,.

Checklist on CHANGING AN IV SOLUTION

Perform
Perform ed but
Not
ed not Not
STEPS Correctl Correctl Done
Observe
d
y y Done (0)
(NO)
(2) (1)

1. Verify doctor’s prescription in doctor’s order sheet; countercheck IV label, Iv tag,

infusate/solution sequence, type, amount, additives (if any), and duration of
infusion
2. Observe 10Rs.

3. Greet the client, Introduce yourself & explain the procedure

4. Assess IV site for redness, swelling, pain, etc. Change IV tubing and cannula within 72
hours after IV insertion or upon the discretion of the attending medical doctor.
5.Prepare the necessary materials; place on an I.V. tray

6. Check sterility and integrity of IV solution and place IV label on the IV bottle.
7. Calibrate / calculate the new IV bottle according to duration of infusion as per
prescription/ according to doctor’s order.
8. Open and connect the I.V. tubing into the solution bottle

9. Close the roller clamp.

10 . Regulate the flow rate according to the prescribed infusion rate. Expel air bubbles, if
evident.
11. Discard all waste materials according to Health Care Waste Management
(DOH/DENR)
12. Document and endorse accordingly. ( IVF Sheet & patient’s kardex )

Computation for student rating:

Raw score X 60 + 40
Perfect score
Student’s Signature and Date: _____________________________
Signature of Clinical Instructor and Date: _____________________________
Remarks:
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