Davao Doctors College, Inc. Gen. Malvar St.

, Davao City Nursing Program

DAVAO DOCTORS COLLEGE, INC

Nursing Program
PERFORMANCE EVALUATION CHECKLIST
INTRAMUSCULAR ADMINISTRATION

NAME: SECTION: RATING:

DATE: GROUP:
Directions: Each student is to be rated on performance in the return demonstration. Careful evaluation to be taken to compare the
performed by the student nurse with those expected from the full performance of that assignment. Keeping the guidelines in mind
Performance Evaluation Tool. Then determine an overall rating, giving weight to various performance categories as appropriate t
assignment. Please indicate check remarks as done or not done and comment/s in the "remarks" if necessary in the space. Ove
considered with the following standard definition.

PREPARING MEDICATION FROM AN AMPULE DONE

At the preparation area, read the medication label, compare it with the eMAR (or medication ticket)
10
then scan the barcode of the drug.

Check the ampule. Make certain that all of the drug is in the body of the ampule and not in the stem or
11
neck. Check the neck if it is scored or not. Use a file to grate the ampule's neck for easier opening.

12 Wipe the neck of the ampule with cotton soaked in 70% alcohol.
Use a small gauze pad or dry cotton ball to hold the ampule when breaking it open or use an ampule
13
opener if available.
Snap neck of the ampule quickly and firmly away from hands. Discard the sharps in the sharps'
14
container.

Use syringe with an aspirating needle to draw the drug from the ampule either by holding the ampule
15 upside down, then withdraw the drug or setting the ampule on a flat surface, then withdraw the drug.
Do not allow needle tip or shaft to touch the rim of the ampule. Do not inject air into the ampule.

Recap the syringe using fish-hook method. Change the aspirating needle with an injecting needle. Set
16 aside and secure the empty ampule and aspirating needle at one side of the medication tray. Do not
dispose empty ampule for the meantime.
With bevel facing up in line with syringe calibration, push the plunger to fill the needle with the
17
medication until there is a drop of medication formed at the tip of the needle.
Arrange equipment on the medication tray. Recheck medication label and compare it once again with
18
eMAR or medication ticket.
INTRAMUSCULAR INJECTION
Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol.
19
Inform the client and the family of the procedure.
Compare names of medication with medication tickets at client's bedside. If using the Emar, scan the
20 client's barcode to verify the administration of medication. Pick up the due medication and compare
the labels with barcode on the drug and eMAR.
Educate the client and client's family of the medication to be given, its purpose, route of
21
administration, intended effect and possible side effects.

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 Davao Doctors College, Inc. Gen. Malvar St., Davao City Nursing Program

Provide for client privacy. Position the client appropriately. Obtain assistance for an uncooperative
22
client if necessary.
Apply clean gloves. Select for an appropriate site (rotate sites according to schedule) and cleanse the
23 skin at the site using a firm circular motion starting at the center and widening the circle outward to
about 5cm (2in). Disinfect the area twice. Allow the area to dry thoroughly.
Hold a dry cotton ball or an alcohol swab between the third and fourth fingers of your nondominant
24 hand in readiness for needle withdrawal, or position the swab on the client’s skin above the site.

25 Grasp the area of the injection site and hold in cushion fashion or Z-track if necessary.
Remove needle cap and hold the syringe between the thumb and index finger of the dominant hand.
26 Hold the syringe as if holding a dart. Inject the needle quickly in a smooth, steady motion at a 90˚
angle.
After all of the medication was injected, wait for another 10 seconds then withdraw the needle while
27 applying an alcohol swab or dry cotton ball. Do not massage the site. Recap the syringe using fish-
hook method.
28 Assist the patient into a comfortable position. Flip down medication ticket if not using eMAR.
Do aftercare. Remove gloves. Dispose used items in appropriate waste receptacle. Return other
29
equipment to its proper place especially the MAR machine.
30 Perform hand hygiene.
31 Document each medication given.

32 Return to the client when the medication is expected to take effect (usually 30 minutes) and note any
adverse effects or side effects
OTHERS
33 Maintains body mechanics throughout the performance.
34 Observes neatness and orderliness while performing the assessment.
35 Receptive to criticisms and observes courtesy. Shows calmness and maintains composure while
performingproper
36 Exercises the procedure.
and fluent use of English language
37 Shows mastery of the procedure.

Comments:

26
Student's Comment(s):

Student's Signature
Clinical Instructor's Comment(s):

elc/bbn/lhd 3.4.17 Page 2 of

 Davao Doctors College, Inc. Gen. Malvar St., Davao City Nursing Program

DAVAO DOCTORS COLLEGE, INC

Nursing Program
PERFORMANCE EVALUATION CHECKLIST
INTRADERMAL ADMINISTRATION

NAME: SECTION: RATING:

DATE: GROUP:
Directions: Each student is to be rated on performance in the return demonstration. Careful evaluation to be taken to
compare the jobs and tasks actually performed by the student nurse with those expected from the full performance
of that assignment. Keeping the guidelines in mind, please complete the Performance Evaluation Tool. Then
determine an overall rating, giving weight to various performance categories as appropriate to the particular
assignment. Please indicate check remarks as done or not done and comment/s in the "remarks" if necessary in
the space. Overall rating must be considered with the following standard definition.
PREPARING DONE NOT DONE REMARKS
Using a FOR SKINsyringe
tuberculin TESTING
with an aspirating needle, withdraw 0.9cc of
1 sterile water. Then, withdraw 0.1cc of the medication. Ensure that there
are no bubbles inside the syringe when aspirating.
With bevel facing up in line with syringe calibration, push the plunger to fill
2 the needle with the medication until there is a drop of medication formed
at the tipthe
Change of the needle.needle
aspirating Recapwith
the needle usingneedle
the injecting the fish-hook method.
of the tuberculin
syringe and label accordingly. Secure the aspirating needle. Assemble all
3
other equipment to be used in the medication tray.
INTRADERMAL ADMINISTRATION
Prior to performing (SKIN
the procedure, TESTING)
introduce self and verify the client’s
identity using agency protocol. Inform the client and the family of the
4
procedure.
Compare names of medication on lables with medication tickets at client's
5 bedside. If using the Emar, scan the client's barcode. Pick up the due
medication and compare the labels with barcode on the drug and eMAR.
6 Educate the client and family about skin test and other considerations.
7 Provide for client privacy. Position the client appropriately.
Apply clean gloves as per agency policy or if necessary. Select for an
appropriate skin site and cleanse the skin at the site using a firm circular
8
motion starting at the center and widening the circle outward. Allow the
area to dry thoroughly.
9 With the nondominant hand, pull the skin at the site until it is taut.
Grasp the syringe in your dominant hand, close to the hub, holding it
10 between thumb and forefinger. Hold the needle almost parallel to the skin
surface (less than 15 degrees), with the bevel of the needle up.
Insert the tip of the needle far enough to place the bevel through the
11 epidermis into the dermis. The outline of the bevel should be visible under
the skin surface.
Stabilize the syringe and needle by holding the hub of the syringe with the
12
thumb of your non-dominant hand.
Inject 0.1cc of the medication carefully and slowly so that it produces a
13
small wheal on the skin.

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 Davao Doctors College, Inc. Gen. Malvar St., Davao City Nursing Program

Withdraw the needle quickly at the same angle at which it was inserted.
14 Activate the needle safety device or recap the syringe using the fish-hook
method.

15 Pat dry the area using a dry cotton ball. Using a black or blue ballpen,
trace the wheal.
Instruct the client not to touch or massage tha area. The wheal will be
16
checked 30 minutes after.
17 Assist client to a comfortable position.
18 Do aftercare. Dispose single-use items properly and perform hand
hygiene. the testing medication given, the injection time, due time for
Document
19
assessment and the site at which the medication was injected.
After 30 minutes, together with the resident physician, check if the
20
injection site.
Document if the client had a positive or negative skin test result. Follow
21
agency protocol on labeling of allergies.
OTHERS
22 Maintains body mechanics throughout the performance.
23 Observes neatness and orderliness while performing the assessment.
24 Receptive to criticisms and observes courtesy. Shows calmness and
25 maintains
Exercises composure while performing
proper and fluent the language
use of English procedure.
26 Shows mastery of the procedure.
TOTAL
Comments:

=
26
Student's Comment(s):

Student's Signature
Clinical Instructor's Comment(s):

CI's Name and Signature

kms/amo 2023

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