Bicol University Tabaco Campus

NURSING DEPARTMENT
Tabaco City

RLE EVALUATION SHEET

(SKILLS LABORATORY)

Intravenous Therapy

Name: __________________________________ Rating: __________________

Group No.: ______________________________ Date: ___________________

Legend:

5 – Excellent – Carries out the procedures efficiently, systematically and

independently.
4 – Very Satisfactory – Carries out the procedures efficiently and systematically but
requires minimal guidance and supervision.
3 – Satisfactory – Carries out the procedures efficiently and systematically but
requires moderate guidance and supervision.
2 – Fair – Carries out the procedures efficiently and systematically but requires close
guidance and supervision.
1 – Needs Improvement – Carries out the procedure inefficiently and
unsystematically and requires close guidance and supervision.

Intravenous Theraphy
Equipment:
a. Sterile Gloves
b. Sterile 2x2 gauze or transparent dressing
c. IV Pole
d. IV Solution
e. Administration Set
f. IV Cannula
g. Sterile Forceps
h. Cotton Balls with Alcohol/ Alcohol Swab/ Povidone Iodine Swab
i. Plaster / Hypoallergenic Adhesive
j. Tourniquet
k. Protective Pad

Assessment
5 4 3 2 1 Comments

1. Verify prescription for IV therapy, check solution label,

and identify patient.

2. Observe the 13 Rights in administering medications.

3. Explain procedure to reassure patient and/or significant

 others.

4. Secure informed consent.

5. Assess patient’s vein. Choose appropriate site, location,

size and condition.

Performance
5 4 3 2 1 Comments

6. Label the IV bottle duly signed by the nurse who

prepared the IV:
• Patient’s Name
• Room number / Bed number
• Solution
• Time and date started
• Time and date to consume

7. The equipment should not be opened until in the

patient’s room and patient education, assessment of
vein and appropriate positioning has been attended
10.1. Open IV administration set aseptically, close the
roller clamp, and spike the infusate container
following the infection control measure.
10.2. Fill drip chamber to at least half and prime it with

IV fluid aseptically; expel air bubbles if any and

cover the distal end of the IV set.

8. Prior to performing the procedure, introduce self and

verify the client’s identity using agency protocol. Explain
to the client what you are going to do,why it is
necessary.

9. Perform hand hygiene and observe other appropriate

infection prevention procedures.

10. Provide for client privacy.

Positioning the Client

5 4 3 2 1 Comments

11. If possible use the non-dominant arm

If possible use the non-dominant arm

12. Raise bed prior to procedure (to comfortable working

height and position for patient; adjust lighting).

13. Place the arm in a supported comfortable position.

14. Use a tourniquet to find vein but release it while you

are getting equipment ready
 15. Place protective pad on bed under patient’s arm.

16. Have IV trolley close by

Preparing the Venipuncture (IV) Site

5 4 3 2 1 Comments

17. Warm veins by

a. Rubbing
b. Washing client’s hands under warm water
c. Apply warmed towel
d. If limb is warm ask the patient to gently clench
and unclench their hand
e. Or gently rub up and down the vein

18. The tourniquet is applied 5 – 12cm (2 – 6 inches) above

insertion site and should not be left on for more than
2-3 minutes.

19. Apply the Palpate for a pulse distal to the tourniquet.

20. Don sterile gloves, and clean site with appropriate

solution using a circular outward movement.

21. Prepare site according to hospital policy.

Inserting the Cannula

5 4 3 2 1 Comments

22. With hand not holding the venous access device,

steady patient's arm and use finger or thumb to pull
skin taut over vessel.

23. Ensure needle has bevel side up and insert at

approximately 5–25° angle, depending on the depth of
the vein, pierce skin to reach but not penetrate vein.

24. Decrease angle of needle further until nearly parallel

with skin, then enter vein either directly above or
from the side in one quick motion.

25. If backflow of blood is visible (you will see a flashback

of blood in the chamber once you have pierced the
vein), straighten angle and position the cannula
parallel to the skin.

26. Hold stylet stationary and slowly advance the cannula

a few more millimeters (until the hub is 1mm to the
puncture site)
27. And then flatten the cannula, stabilize the device and
advance the cannula until at skin level.

28. Slip sterile gauze under the hub. Remove the stylet
and apply pressure just beyond the catheter tip.

29. Gently stabilize the cannula hub. Anchor needle firmly

in place with tape.

30. Release the tourniquet while applying digital pressure

over the IV site.

31. Attach the extension line

Dressing 5 4 3 2 1 Comments

32. Apply dressing and secure cannula according to

hospital policy and procedure.
a. A transparent sterile occlusive dressing is the
optimal dressing to use.
b. Before applying dressing, ensure site is clean of
blood and moisture
c. Check with patient re allergies to dressings

33. Flush cannula with 5-10ml 0.9% sodium chloride to

ensure patency

Intravenous Fluid Administration

5 4 3 2 1 Comments

34. Connect the infusion tubing of the prepared IV Fluid

aseptically to the IV catheter.

35. Open the roller clamp. Regulate the fluid as

prescribed by the physician.

36. Reassure the patient.

37. Tape a small loop of IV tubing for additional

anchoring splint if necessary.

38. Calibrate the IV fluid bottle and regulate flow of

infusion according to physician’s order.

39. Label on IV tape near the IV site to indicate the date

of insertion type and gauge of IV catheter and
countersign.

40. Label the IV tubing to indicate the date when to

 change the tubing.

41. Observe patient and report any untoward effects.

42. Dispose of sharps and waste. Discard sharps and

waste according to Health Care Waste Management.

Documentation
5 4 3 2 1 Comments

43. Document in patient notes

a. Date and time insertion (therapy initiated).
type of vascular access device (Site of insertion-vein
and arm/hand)
b. Type and gauge of cannula
c. Date and time of insertion
d. Type and amount of IV solution (additives and
dosages; flow rate)
e. Reason for IV therapy
f. Patient response to procedure
g. Name and title of the health care provider who
inserted the catheter.

Supervised by:

____________________________________________
ROMAN J-LOU B. CORDOVILLA, MAN, RN, RM, EMT-B
Assistant Professor II