Catanduanes State University

College of Health Sciences

DEPARTMENT OF NURSING
Virac, Catanduanes

NCM 109 RLE – Care of Mother and Child, at Risk and with Problems (Acute and
Chronic)

Name ____________________________Block _____ Group_____ Date ________

PERFORMANCE CHECKLIST – BRUSHING AND FLOSSING THE TEETH

DIRECTIONS:Mark each step of the procedure following the rubric below denoting the
skill performance of the student. Total the scores and look for the equivalent grade on
the transmutation table. The Remark section is for suggestions that will help improve the
skills of students.

(3) – Skill performed with mastery using the recommended technique.

(2) – Skill performed using the recommended technique but without mastery.
(1) – Skill performed using some but not all of the recommended technique.
(0) – Skill not performed or missed.

SCORE
STEPS 3 2 1 0 REMARKS
1. Verify written doctor’s order. Ensures correct procedure to
correct patient solution.
2. Observe ten (10) Rs when preparing and administering IVF.
Ensures correct procedure to correct patient with correct
solution.
3. Explain procedure to reassure patient and/or significant other,
secure consent if necessary. To allay patient’s anxiety and
foster his/her cooperation.
4. . Assess patient’s vein; choose appropriate site, location,
size/condition. The selection of an appropriate site decreases
discomfort and possible damage to patient’ s body tissue.
5. Prepare necessary materials for procedure: IV solution
prescribed, Infusion set, IV cannula, Micropore or IV dressing,
disposable gloves, IV stand, IV tray, kidney basin. Having
equipment available saves time and facilitates accurate skill
performance.

6. Check the sterility and integrity of the IV solution, IV set and

other devices. To prevent administration of expired or
unsterile solution to patient.

7. Place IV label on IVF bottle duly signed by RN who prepared it

(patient’s name, room no., solution, time and date). Indicate
the medication if added to the solution and include time. Tape
label on the container. This provides correct solution with
prescribed medication. Time tapping permits immediate
evaluation of IV infusion ac-cording to schedule.

8. Do hand hygiene before and after the procedure. To prevent

spread of infection.

9. Open IV administration set aseptically and close the roller

clamp and spike the infusate container aseptically following
the infection control measures. This punctures the seal in the
IV bag maintaining the sterility.
10. Fill drip chamber to at least half and prime it with IV fluid
aseptically. Suction effects cause to move fluids into drip
chamber and prevents air entrance in the tubing.

11. Expel air bubbles if any and put back the cover to the
distal end of the IV set. This removes air from tubing that can
in larger amounts act as air embolus.

INITIATING IV LINE

1. Check doctor’s order, identify the client and secure

consent. IV insertion can’ t be performed without doctor’s
order. Proper identification ensures that the procedure is
done to the right client. Initiating IV therapy through IV
insertion is an invasive procedure that needs client
consent.

2. Wash hands and prepare all equipment at bed-side such

as IV tubing, IV cannula, tourniquet, alcoholized cotton,
plaster, markers, receptacle, clean gloves. Ensures
asepsis and a smooth flow of procedure.

3. Explain procedure and answer client’s question and

worries. Decreases fears and anxiety.

4. Select the IV site. Choose distal veins so that once

damaged, the proximal part of the vein can still be used.
Avoid areas that bends to prevent infiltration. Use non
dominant hand for freedom of movement. Avoid extremity
with low sensation or poor integrity.

5. Ask client to rest arm of selected vein. Makes the veins

more visible.

6. Put on gloves. Maintains asepsis. Cleanse insertion site

from starting in the middle of the site going outward.
Reduces transmission of microorganism. Be sure to leave
the area dry before insertion.

7. Cleanse insertion site from starting in the middle of the

site going outward. Reduces transmission of
microorganism. Be sure to leave the area dry before
insertion.

8. Apply tourniquet 5-6 inches above the selected site.

Engorges the vein for easier IV insertion.

9. Anchor vein by placing thumb over vein and stretching the

skin against the direction of insertion. Stabilizes the vein
and aids in IV insertion.

10. Insert the stylet catheter, with bevel up at 20 to30-degree

angle. (During IV insertion on elderly clients use a 5-
15degree angle because their veins are more superficial.)
Prevent damage to the posterior wall of the vein.

11. Check for blood backflow. Pressure from tourniquet

causes quick backflow of blood into the catheter.

12. Loosen stylet and advance catheter into the vein until hub
 rests on the IV site. Ensures proper placement of
catheter.
Note: Do not reinsert stylet after loosening to prevent
puncture to the catheter.

13. Hold thumb over the vein above catheter tip and release
tourniquet. Prevents blood leaking and reestablishes
venous blood flow.

14. Quickly release pressure over the vein and connect

needle adapter of the IV set to the hub of the catheter.
Prompt connection reduces blood loss or leakage.

15. Begin infusion at slow rate or KVO or per institution policy.

Keeps vein open and ensures patency of IV.

16. Tape over the hub of the catheter. Place trans-parent

dressing over the site. Secure catheter in place and
controls bleeding and infection.

17. Secure tubing in loop fashion. Prevent tubing

dislodgement.

18. Remove gloves and do aftercare. Prevents transmission

of microorganisms.

19. Label the site with date and time of insertion and the size
and gauge of catheter. Serves as guide for next dressing
change. It is recommended to change IV site every 3
days to avoid infection and other IV complication.

20. DOCUMENTATION: Make sure to document the following

after procedure:
1. Date and time of IV insertion
2. Size and gauge of catheter
3. Client’s untoward reaction to the procedure.
4. Type of fluid infused and prescribed rate
5. Additives, i.e. contrast amount and type

Total
Equivalent Grade

___________________ _______________________________
Student’s Signature Name & Signature of Clinical Instructor