Far Eastern University

Institute of Health Sciences and Nursing

STUDENT PERFORMANCE EVALUATION TOOL

CENTRAL LINE CARE, CVP MEASUREMENT & BLOOD SAMPLING ON A CENTRAL LINE

Name: Date: _______

Sec/Group No: __

DIRECTION: Rate the learner based on the competencies listed below

KEY:
2 – Acceptable Demonstrates expected procedure correctly.
1 – Moderately Acceptable Demonstrates expected procedure with errors.
0 – Unacceptable Missed procedure or procedure done but entirely incorrect

RATING REMARKS
A. PREPARATION
1. Introduce yourself to the patient 0 1 2
2. Verify the client’s identity. 0 1 2
3. Perform hand hygiene. 0 1 2
4. Assemble equipment 0 1 2
5. Explain the procedure to the client. 0 1 2
6. Provide for client privacy. 0 1 2
B. PERFORMING CENTRAL LINE CARE

1. Don PPE including mask and clean gloves. 0 1 2

2. Position patient supine with head turned away from 0 1 2

dressing site (as appropriate).
3. Inspect insertion and suture site for redness, 0 1 2
inflammation, tenderness or drainage.
4. Remove existing dressing. 0 1 2
5. Remove the soiled clean gloves 0 1 2

6. Perform hand hygiene

7. Don Sterile gloves 0 1 2
7. Cleanse entire area where dressing is placed using 0 1 2
Chlorhexidine solutions in a cross hatch motion (back
and forth) with light friction in two different directions for
a total of 30 seconds.
8. Let dry for 2-3 minutes, do not fan dry 0 1 2
8. Apply transparent semi-permeable dressing over the dry 0 1 2
insertion site.
9. Avoid stretching the transparent dressing by smoothing 0 1 2
from center out to edge molding around catheter lumens.
10. Document the procedure 0 1 2

C. BLOOD SAMPLING ON A CENTRAL LINE

1. Perform hand hygiene 0 1 2

2. Don PPE (sterile gloves, mask and eye shield) 0 1 2

3. Disconnect infusion if in place maintaining asepsis 0 1 2

4. Cleanse needleless access adapter vigorously with an 0 1 2
alcohol/chlorhexidine swab using 15 second scrub.
5. Allow hub to air dry. 0 1 2
6. Attach 10 ml syringe 0 1 2
7. Aspirate until flashback of blood appears in the central 0 1 2
catheter
8. Continue aspirating until at least 10 ml of blood is 0 1 2
collected
9. Discard the aspirated blood 0 1 2
 10. Cleanse needleless access adapter vigorously with 0 1 2
alcohol/chlorhexidine swab using 15 second scrub (let
dry).
11. Allow hub to air dry 0 1 2
12. Attach greater than or equal to 10ml of syringe 0 1 2
13. Aspirate needed amount of blood specimen 0 1 2
14. Transfer blood to appropriate specimen container 0 1 2
15. Cleanse needleless access adapter vigorously with 0 1 2
alcohol swab using 15 second scrub (let dry).
16. Attach greater than or equal to 10 mL pre-filled N/S 0 1 2
syringe.
17. Flush with 10 mL using a vigorous push-pause 0 1 2
technique.
18. Perform Hand Hygiene 0 1 2
19. Discard used PPE and equipment 0 1 2
20. Document the procedure 0 1 2

D. MEASURING CVP

1. Position the head of the bed flat or up to 60 degree 0 1 2

angle
2. Position the zero point of the manometer at the level of
the right atrium at the fourth intercostal space, mid-
anterior- posterior diameter of the chest wall.
3. Turn the stop cock so that the IV solution flows into the 0 1 2
manometer
4. Open the IV fluid bag and slowly fill the manometer with
fluid to about 20-25cm level.
5. Turn off the flow from the fluid bag 0 1 2
6. Open the stopcock from the manometer to the patient.
7. Observe fluctuation of liquid in the manometer. 0 1 2

8. Record the level at which the solution stabilizes or stop 0 1 2

moving downward.
9. Turn the stop cock again to allow IV solution to flow from 0 1 2
the solution bottle into the client’s vein.
10. Document findings 0 1 2

TOTAL SCORE =

Signature of Student Signature of Faculty