University of Perpetual Help System GMA Campus

San Gabriel GMA, Cavite, Philippines, 4117

(02)519-4100 • (046)460-4086 •
www. gma. uphsl.edu.ph

PERFORMANCE CHECKLIST IN PREPARATION OF IV/

DISCONTINUING AN INTRAVENOUS INFUSION

Name: _______________________________ Date: ___________________

Yr. & Sec: ___________________________ Group #_______________

PERFORMANCE CHECKLIST IN PREPARATION OF IV 2 1 0 Remarks

1. Verify IV order against the physician order.

2. Assemble equipment needed:
 IV infusion set
 IV fluids
 IV pole
 IV tag/label
 Basin
3. Perform hand hygiene.
4. Remove the administration set/tubing from the package
and straightened it out.
5. Slide the tubing clamp along the tubing until it is just
below the drip chamber to facilitate its access.
6. Close the clamp.
7. Leave the ends of the tubing covered with the plastic
caps until the infusion is started.
8. Remove the protective cover from the entry site of the
IV bag or bottle
9. Remove the cap from the spike, and insert the spike
into the insertion site of the bag or bottle.
10. Hang the IV bottle on the IV stand
11. Adjust the IV stand so that the container is suspended
about 1 m (3feet) above the client’s head.
12. Partially fill the drip chamber with solution.
Squeeze the chamber gently until it is half full of
solution.
13. 13. Prime the tubing. Remove the protective cap at
the end of the tubing, and hold the tubing over a
basin/container. Maintain the sterility of the end of the
tubing and the cap.
14. Release/ open the clamp, and allow the fluid to flow
through the tubing until all air bubbles are removed
and the entire length of the tubing is primed (filled)
with IV solution. Tap the tubing with your finger if
necessary, to help the bubbles move.
15. Close the clamp and recap end tubing, maintaining the
sterility of set up
16. Label IV bottle with date and time started. (Follow
agency practice)
• Apply medication label to the solution container, if
medication was added

DISCONTINUING AN INTRAVENOUS INFUSION 2 1 0 Remarks

1. Determine: Physician’s order to discontinue IV.
2. Assemble Equipment:
• Clean gloves
• Dry or antiseptic-soaked swabs (according to agency
policy)
• Small sterile dressing and micropore tape
 University of Perpetual Help System GMA Campus
San Gabriel GMA, Cavite, Philippines, 4117
(02)519-4100 • (046)460-4086 •
www. gma. uphsl.edu.ph

3. Introdce yourself and verify the client’s identity

4. Explain the procedure and how the client can
cooperate
5. Provide for client privacy
6. Close the roller clamp of the administration set/tubing.
7. Loosen the tape at the venipuncture site while holding
the needle firmly and applying and applying counter
traction to the skin.
8. Put on clean gloves, and hold sterile gauze above the
venipunture site
9. Withdraw the needle or IV catheter by pulling it out
along the line of the vein.
10. Immediately apply firm pressure to the site, using
sterile
11. gauze, for 2-3 minutes.
12. Examine the catheter removed from the client.
13. Check the catheter to make sure it is intact. Report a
broken catheter.
14. If the broken piece can be palpated, apply a tourniquet
above the insertion site
15. If the broken piece can be palpated, apply a tourniquet
above the insertion site
16. Cover the venipuncture site using a sterile dressing.
17. Discard the used supplies properly.
18. Document all relevant information. Record the amount
of fluid infused on the intake and output record on the
cart and the time and date the IV infusion was
discontinued.

CI’s signature _______________________________________

PERFORMANCE GRADING SYSTEM

GRADE CRITERIA
2  Performs procedure correctly, in sequence.
1  Performs procedure incorrectly, not in proper sequence
0  Did not perform procedure

Computation:
1. Grade each step of the procedure.
2. Sum up the grade.
3. Get the perfect score by multiplying, 3 with the no. of steps in the procedure.
4. To get the percentage, divide the total grade to the perfect score, multiply by 60 then add 40.
Legend:
90 and above Excellent
85-89 Very Satisfactory
80-84 Satisfactory
75-79 Fair
74 and below Needs Improvement
University of Perpetual Help System GMA Campus
San Gabriel GMA, Cavite, Philippines, 4117
(02)519-4100 • (046)460-4086 •
www. gma. uphsl.edu.ph