College of Allied Health Sciences

Nursing Department
Rizal Street, Iloilo City

CHECKLIST ON INTRAVENOUS INSERTION

Name of Student: ___________________________________

Section: __________________________________________
Clinical Instructor: ______________________________________ Overall Rating

PERFORMANCE EVALUATION CHECKLIST

PERFORMED UNABLE
PERFORMED
WITH TO
PROCEDURE INDEPENDENTLY
ASSISTANCE PERFORM
REMARKS
5-4 3-2 1-0
ASSESSMENT
1. Check physician’s written order for the
type, amount and rate of IV fluid.
2. Assess the client’s previous experience with
IV therapy and arm placement preference.
3. Assess the client’s vein, location, size and
condition of the vein.
PLANNING
4. Wash hands.
5. Prepare necessary articles/equipment for
initiation of IV
IMPLEMENTATION
6. Identify the client and explain the
procedure.
7. Assist the client to a comfortable position.
8. Open the sterile packages using
aseptic technique.
9. Check and open the seal of IV solution
using the Rights of drug administration then
open the seal.
10. Open the infusion set, push spike into the
bottle port.
11. Fill drip chamber to at least half and
prime the tubing aseptically.
12. Wear gloves.
13. Select the vein for IV placement, apply
tourniquet 2-6 inches above the
selected insertion site.
14. Clean the vein area using cotton ball
soaked with alcohol beginning at the
vein and circling outwards in a 2-inch
diameter
15. Encourage the client to take a slow,
deep breath.
16. Hold skin taut with one hand while the
other hand holds the appropriate IV
cannula/catheter; pierce skin with
needle positioned on 15-30 degrees
angle.
17. Lower the needle until it almost
flushes with vein.
18. Push needle into the vein about ¼
inches after the blood is noted.
19. Slip sterile gauze under the hub.
Release the tourniquet; remove the stylet
while applying digital pressure over the
catheter with applying digital pressure over the
catheter with one finger about ½ inches from
the tip of inserted catheter.
 PERFORMED UNABLE
PERFORMED
WITH TO
PROCEDURE INDEPENDENTLY
ASSISTANCE PERFORM
REMARKS
5-4 3-2 1-0
IMPLEMENTATION
20. Connect the infusion tubing to the IV
catheter.
21. Open roller clamp slowly to allow fluid
to flow freely for few seconds.
22. Anchor the needle firmly in place with
the use of transparent tape directly on
the puncture site.
23. Tape a small loop of IV tubing for
additional anchoring. Apply splint or
arm board if needed.
24. Regulate IV flow manually or set infusion
device at appropriate rate.
25. Write on the IV label the date, time of IV
insertion and its regulation.
26. Place patient back into comfortable
position.
27. Dispose of used needles in appropriate
sharp’s container.
28. Remove gloves and wash hands.
EVALUATION
29. Observe the client every hour to determine
if the fluid is infusing accurately.
30. Evaluate the client for any discomfort
or pain on the IV site.
DOCUMENTATION
31. Record the type of fluid, flow rate, date
and time the infusion was started.
32. Record the client’s response to IV fluid.

CONFORME: ________________________ ___________________________

STUDENT’S SIGNATURE CLINICAL INSTRUCTOR