Republic of the Philippines

ISABELA STATE UNIVERSITY

COLLEGE OF NURSING
Echague, Isabela

PERFORMANCE EVALUATION CHECKLIST

NAME: ____________________________________________ Date: ___________________

YEAR AND GROUP: ____________________ RATING: ________________
STARTING AN INTRAVENOUS INFUSION
PROCEDURE 0 1 2 REMARKS
State the Purposes:
 To supply fluid when clients are unable to take in an adequate volume
of fluids by mouth
 To provide salts needed to maintain electrolyte balance
 To provide glucose (dextrose), the main fuel for metabolism
 To provide water-soluble vitamins and medications
 To establish a lifeline for rapidly needed medications
1. Verify the written prescription of the doctor

2. Observe the twelve (12) Rights of medication administration.

3. Introduce yourself, verify the clients identity, and explain procedure to

reassure patient and/or significant other.

4. Prepare necessary materials:

 IV fluid bottle
 IV infusion set
 IV cannula
 Alcohol swab/ wet cotton
 Micropore

5. Secure consent from the patient of guardian.

6. Choose appropriate site, location, size and condition of the vein.
7. Check the integrity of the IV solution, IV set and other devices.
8. Place IV label on IVF bottle.
9. Do hand hygiene.

10. Open IV administration set aseptically

11. Close the roller clamp
12. Spike the infusate container aseptically following the infection control
measures.
13. Fill drip chamber to at least half and prime it with IV fluid aseptically.

14. Expel air bubbles if any and put back the cover to the distal end of the
IV set.
15. Do after care.
16. Observe proper hygiene.
17. Document and assess the patient

________________________________
Name and Signature of Clinical Instructor