St.

Paul University Philippines

Tuguegarao City, Cagayan 3500

School of Nursing and Allied Health Sciences

COLLEGE OF NURSING
Bachelor of Science Nursing 4

IVT CHECKLIST
NAME: _______________________________________________ SECTION:________________________

PROCEDURE IV: INSERTING IV

STEPS 5 4 3 2 1

1. Verify written order for IV therapy, check

prepared IVF and other things needed (Procedure I-A
Setting up IV Infusion)
2. Explain procedure to patient / SO
3. Observe “10 Rights” of medication administration
4. Wash hands before and after procedure
5. Choose site for IV
6. Apply tourniquet 2-6 inches above injection site
depending on condition of patient
7. Check for radial pulse below tourniquet
8. Put on clean gloves

Note: CDC Universal precaution: Always wear gloves when

doing any venipuncture

9. Clean venipuncture site with effective topical

antiseptic according to hospital policy or cotton balls
soaked with alcohol in circular motion and allow to
dry (no touch technique)
10. Using the appropriate IV cannula, pierce skin with
needle positioned on a 15-30 degree angle
11. Once blood appears in the lumen of the needle
catheter, reduce the angle of the catheter almost
parallel to skin and advance the needle ¼ inch more
into the vein.
12. Holding the needle steady in its position, advance
the catheter until the hub is at the venipuncture site.
13. Slip a piece of sterile gauze under the hub
14. Release the tourniquet, remove the stylet while
applying digital pressure over the catheter and
stabilizing hub with the thumb or index finger of
your non-dominant hand
15. Connect the infusion tubing of the IVF prepared in
Procedure I-A setting, as aseptically to the IV
catheter.
 STEPS 5 4 3 2 1
16. Open the clamp slowly and start the infusion
17. Anchor cannula in place with the use of:
a. Transparent tape (tegaderm) or sterile dressing
over the venipuncture site.
b. Tape (using any appropriate anchoring style)

Note: Never place unsterile tape directly on IV insertion site,

instead place a small piece of sterile OS then secure with
adhesive tape.

18. Tape a small loop of IV tubing for additional

anchoring, apply splint if necessary.
19. Calibrate the IVF bottle and regulate flow of infusion
according to prescribed duration
20. Label on IV tape near the IV site to indicate the date
of insertion, type and gauge of IV catheter and
countersign
21. Label with plaster on IV tubing to indicate the date
when to change IV tubing
22. Observe and report any untoward effect
23. Discard all used devices according to hospital policy
24. Document in the patient’s chart accordingly

TOTAL SCORE: ________________

Direction: Rate the student’s performance utilizing the scale given below:
5 – Demonstrates procedure independently and competently, relates theoretical concepts to practice
4 – Demonstrates procedures independently, most features demonstrated and related to theoretical
concepts
3 – Adequate performance, some features demonstrated and explained
2 – Needs more supervision on procedures, lacks theoretical concepts
1 – Poor demonstration of procedure, actions unrelated to theoretical knowledge

Formula for Getting the Grade Percentage:

Grade Percentage = Raw Score X 50 + 50

Perfect Score