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 DISCONTINUING AN IV INFUSION

Performed
Performed but not Not
STEPS Correctly Correctly
Not Done
Observed
Done (0)
(2) (1) (NO)

1. Verify written doctor’s order to discontinue IV.

2. Observe 10 Rs.
3. Prepare the necessary materials; IV tray or injection tray with sterile
cotton balls with alcohol, plaster, pick-up forceps in antiseptic
solution, kidney basin and band-aid.
4. Greet the client & assess and inform the patient of the discontinuation
of IV infusion.
5. Perform handwashing.
6. Ensure privacy and good lighting. Position the patient correctly for the
procedure.
7. Don clean gloves.

8. Close the roller clamp of the IV administration set

9. Moisten adhesive tapes around the IV catheter with cotton ball with
alcohol; remove plaster gently.
10. Use pick-up forceps to get cotton ball with alcohol and without applying
pressure, remove needle or IV catheter then immediately apply
pressure over the venipuncture site.
11. Inspect IV catheter for completeness.

12. Place dressing over the venipuncture site. Reassure patient

13. Discard all waste materials including the IV cannula according to Health
Care Waste Management (DOH/DENR)
14. Document time of discontinuance, status of insertion site and integrity
of IV catheter and endorse accordingly. ( IVF sheet / patient
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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