PERFORMANCE CHECKLIST LEVEL II

ADMINISTERING OPHTHALMIC INSTILLATIONS

Definition:
 Instills medications in mucous membranes of eye for various therapeutic effects.

Materials Needed:
 Medication
 Medication card
 Sterile gloves (optional)

Procedures Done Not Remarks

done
ASSESSMENT
1. Verify the physician's order for the name of the drug,
preparation, and strength.
PLANNING
1. Identify the patient, explain the procedure to the client and
discuss how they can cooperate.
2. Ensure proper lighting to facilitate ease in administration
IMPLEMENTATION
1. Compare the medication sheet, card, and actual medicine.
2. Check for the expiration date.
3. Don gloves if indicated.
4. Assist the individual in a comfortable position.
5. Prepare the correct dose, discard the first bead of the
ointment.
6. Expose the lower conjunctival sac by placing the thumb or
fingers of your non-dominant hand on the client’s
cheekbone just below the eye and gently drawing down the
skin on the cheek.
7. Holding the tube above the conjunctival sac, squeeze an
ample amount of ointment from the tube into the lower
conjunctival sac from the inner canthus of the eye in an
outward motion.
8. Close the eyelids but not squeezing them shut. Closing the
eye spreads the medication over the eyeball.
9. Remove gloves. Wash hands.
EVALUATION
1. Evaluate using the following criteria:
 PERFORMANCE CHECKLIST LEVEL II
 6 rights followed
 Correct site used
 Effectiveness of medication assessed
 Any side effect promptly identified
DOCUMENTATION
1. Record pertinent data in terms of:
 Medication dosage
 Route of administration
 Time of administration
 Signature

____________________________ _______________________________ ____________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature
 PERFORMANCE CHECKLIST LEVEL II
ADMINISTERING ORAL MEDICATION

Definition:
 Delivers medication for absorption through the alimentary tract. The oral route is the
safe and most convenient and relatively economical way of administering solid or liquid
form of drug preparation by mouth.
Materials Needed:
 Prescribed Medication  Towel
 Medication card  Medicine dropper
 Medicine cup (calibrated)  Sterile gloves (optional)

Procedures Done Not Remarks

done
ASSESSMENT
1. Verify the physician's order of medication, check for
the medication listed on the medicine card against
the physician’s order sheet and standing order
sheet/
2. Check the client’s chart for allergies.
3. Know the actions, special nursing considerations,
safe-dose ranges, purpose of administration, and
adverse effects of medications to be administered.
PLANNING
1. Wash your hands
2. Prepare medications for one client at a time.
3. Ensure proper lighting to facilitate ease in
administration
IMPLEMENTATION
 Select the proper medication from the drawer or
stock and compare it with the kardex. Check
expiration dates and perform calculations.
 For unit-dose packaged medications, place capsule
or tablet directly in a disposable cup. Do not open
the package until at bedside.
 For medications in a stock container, pour the
necessary number into the bottle cap and then place
the tablets in a medication cup.
 For liquid medications, remove the cap and place it
upside down. Hold bottle with the label against the
palm. Place medication cup on a flat surface at eye
 PERFORMANCE CHECKLIST LEVEL II

level. Pour the desired amount of liquid and read

the amount of medication at the bottom of the
meniscus.
 Recheck each medication for one client has been
prepared; recheck once again with the medication
order before taking them to the client.
 Transport medications to the client’s bedside carefully
and keep the medications in sight at all times.
 See that the client receives medications at the correct
time.
 Identify the client carefully. There are three correct
ways to do this:
o Check the name of the client’s identification
band.
o Ask the client his or her name.
o Verify the client’s identification with a staff
member who knows the client.
 Assist the client to an upright or lateral position..
 Administer medications:
o Offer water or other permitted fluids with pills,
capsules, tablets, and some liquid medications.
o Ask the client’s preference regarding
medications to be taken by hand or in cup and
one at a time or all at once.
o If the capsule or tablet falls to the floor, it must
be discarded and a new one administered.
 Record any fluid intake and output measurement as
ordered.
 Remain with the client until each medication is
swallowed
 Wash your hands.
EVALUATION
1. Evaluate using the following criteria:
o 10 rights followed
o Correct site used
o Effectiveness of medication assessed
o Any side effect promptly identified
DOCUMENTATION
1. Record pertinent data in terms of:

4|P age
 PERFORMANCE CHECKLIST LEVEL II

o Medication dosage
o Route of administration
o Time of administration
o Signature

____________________________ _______________________________ ____________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

5|P age
 PERFORMANCE CHECKLIST LEVEL II

VIAL PREPARATION AND ADMINISTERING INTRADERMAL INJECTIONS

Definition:
 The procedure of dissolving powdered medication from a vial and withdrawing the
dissolved medication using a syringe
Materials Needed:
• Prescribed Medication in a vial
• 1 cc syringe
• Cotton balls wet (70% alcohol) and dry
• Medication card
• Medicine tray
• Sterile gloves
• Black ink pen

Procedure Done Not Remarks

Done
ASSESSMENT
1. Review the physician’s order and medication
record for medication to be given.
2. Assess site if the patient has had other intradermal
injections
3. Assess need for assistance
PLANNING
1. Determine materials needed
2. Wash your hands.
3. Gather materials needed
IMPLEMENTATION
1. Verify the right drug to be administered by:
o Read the name of the medication from the
record
o Check the label on the medication before
picking it up
o Recheck the label before calculating and
preparing the dose
2. Vial Preparation
o Remove the metal or plastic cap on the vial that
protects the rubber stopper.
o Swab the rubber top of the vial using cotton
6|P age
 PERFORMANCE CHECKLIST LEVEL II

balls with alcohol.

o Remove the cap from the needle by pulling it
straight off.
o Inject the amount of air equal to the volume of
the medication you will withdraw then remove
the syringe.
o Pick up the vial with your non-dominant hand
and hold the vial upside down at eye level,
ensuring that the needle tip is below the fluid
level. Pull the plunger down to draw the
necessary amount of medication, and then
withdraw the syringe once the correct dose is
withdrawn.
o If any air bubbles accumulate in the syringe,
tap the syringe's barrel to move the air bubbles
on top of the syringe, then push the plunger to
expel the air.
o If a multi-dose vial is being used, label the vial
with the date and time it is opened and store
the vial containing the remaining medication
according to agency policy.
3. Intradermal Injection
o Clean the area around the injection site with an
alcohol swab in a firm, circular motion while
moving outward from the injection site and
allow the antiseptic to dry.
o Hold the syringe with your dominant hand
between your thumb and forefinger. Remove
the needle cap with the non-dominant hand,
pulling it straight off.
o Place a dry cotton ball between the fingers of
your non-dominant hand.
o Still, with your non-dominant hand, pull the
skin at the site until it is taut. If using the
forearm's ventral surface, place your non-
dominant hand at the dorsal forearm and pull
it to tighten the ventral skin.
o Stabilize hand and inject the needle, bevel side
up at an angle of 10º and no higher than 15º

7|P age
 PERFORMANCE CHECKLIST LEVEL II

parallel to the site. Making sure that the entire

lumen of the needle is inside the thin layer of
the dermis.
o Slowly inject the medication while watching for
a small wheal or blister to appear.
o Withdraw the needle at the same angle it was
inserted and wipe excess medication around
the area using the cotton placed on your non-
dominant hand. Never massage the area
o Encircle the site directly over the borders with
a black marking pen and assess the site for a
reaction at the appropriate time (30 minutes
after administering medication).
4. Do not recap the used needle. Discard the needle
and syringe in the appropriate receptacle.
5. Remove gloves and dispose of them properly.
6. Assist the client in a position of comfort.
7. Wash your hands.
EVALUATION
1. Evaluate using the following criteria:
o 10 rights followed
o Correct site used
o Effectiveness of medication assessed
o Any side effect promptly identified
DOCUMENTATION
1. Record pertinent data in terms of:
o Medication dosage
o Route of administration
o Time of administration
o Signature

____________________________ _______________________________ ______________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

8|P age
 PERFORMANCE CHECKLIST LEVEL II

AMPULE PREPARATION AND ADMINISTRATION OF SUBCUTANEOUS INJECTIONS

Definition:
 The procedure of dissolving powdered medication from an ampule and withdrawing
the dissolved medication using a syringe
Materials Needed:
• Prescribed Medication in an ampule
• 1 cc syringe
• Cotton balls wet (70% alcohol) and dry
• Medication card
• Medicine tray
• Sterile gloves

Procedure Done Not Remarks

Done
ASSESSMENT
1. Review the physician’s order and medication
record for medication to be given.
2. Assess site if the patient has had other intradermal
injections
3. Assess need for assistance
PLANNING
1. Determine materials needed
2. Wash your hands.
3. Gather materials needed
IMPLEMENTATION
1. Verify the right drug to be administered by:
o Read the name of the medication from the
record
o Check the label on the medication before
picking it up
o Recheck the label before calculating and
preparing the dose
2. Ampule Preparation
o Tap the stem of ampule or twist your wrist
quickly while holding the ampule vertically.
o Put a gauze pad around the neck of the
ampule. Snap back to break off the top of the
ampoule along the pre-scored line at its neck.

9|P age
 PERFORMANCE CHECKLIST LEVEL II

Make sure to keep yourself safe from

accidental cuts or injuries.
o Discard the head part of the ampule into
proper waste receptacle.
o Remove the cap from the needle by pulling it
straight off. Hold the ampule by your non-
dominant hand and insert the needle into the
ampule, being careful not to touch the rim.
Insert the needle's tip into the ampule bevel up
and bring ampule and needle at eye level.
o Aspirate the calculated dosage of the
medication plus a small amount more.
o Do not inject any air bubble towards the
ampule. If any air bubbles accumulate in the
syringe, withdraw the needle, tap the syringe's
barrel, and expel the air.
3. Subcutaneous Injection
o Carry medication and materials along the
bedside
o Identify the patient and explain the procedure.
o Don sterile gloves.
o Locate the site of choice according to the
directions given. Ensure that the area is not
tender and is free of lumps and nodules.
o Clean the area around the injection site with an
alcohol swab in a firm, circular motion while
moving outward from the injection site and
allow the antiseptic to dry.
o Hold the syringe with your dominant hand
between your thumb and forefinger like in
writing. Remove the needle cap with the non-
dominant hand, pulling it straight off.
o Place a dry cotton ball between the fingers of
your non-dominant hand.
o Pinch the area surrounding the injection site
with your non-dominant hand. Inject the
needle at an angle of 45º-90º depending on the
amount and turgor of the tissue and length of
the needle.
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 PERFORMANCE CHECKLIST LEVEL II

o After the needle is in place, release the tissue

and immediately move your non-dominant
hand to steady the lower end of the syringe.
Slide your dominant hand to the end of the
plunger.
o Inject the solution slowly by applying an even
push pressure to the plunger.
o Withdraw the needle quickly at the same angle
at which it was inserted. Do not massage the
area, instead apply cotton very gently at the
insertion site.
4. Do not recap the used needle. Discard the needle
and syringe in the appropriate receptacle.
2. Remove gloves and dispose properly.
3. Assist the client to a position of comfort.
4. Wash your hands.
EVALUATION
1. Evaluate using the following criteria:
o 10 rights followed
o Correct site used
o Effectiveness of medication assessed
o Any side effect promptly identified
DOCUMENTATION
1. Record pertinent data in terms of:
o Medication dosage
o Route of administration
o Time of administration
o Signature

____________________________ _______________________________ __________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

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 PERFORMANCE CHECKLIST LEVEL II

PERFORMING INFANTS’ BATH

Materials Needed:
 Washbasin or bathtub
 Water should feel warm to touch
 Washcloths
 Dry towel or bath blanket
 Hypoallergenic soap
 Clean clothes
 Cotton Balls

Procedures Done Not Remarks

done
ASSESSMENT
1. Determine infants’ temperature
PLANNING
1. Wash your hands.
2. Gather materials needed
IMPLEMENTATION
1. Place towel, laid out in diamond fashion, on a tabletop next
to a basin.
2. Remove all clothing except shirt and diaper.
3. Wipe the eyes using a cotton ball moistened with water,
starting from the inner to the outer canthus. Use a new
cotton ball for each eye.
4. Dip washcloth. Make a mitt and wash the face, ears, and
neck. Dry all areas thoroughly.
5. Hold infant on one arm (football hold) over the tub and wet
hair.
6. Soap your own hands and lather to hair and scalp using a
gentle circular motion—splash water against the head to
rinse off.
7. Place the infant on the towel and dry the head using the
corners of the towel.
8. Undress the infant. Wet upper extremities, front, back,
buttocks, and legs using a washcloth. Apply soap and lather.
9. Pick up the infant and slowly lower him into the bathtub to

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 PERFORMANCE CHECKLIST LEVEL II

rinse off.
10. Support the baby while lifting him from the tub, by placing
your hand and arm around the infant, cradling his head and
neck in your elbow. Grasp his thigh with the other hand.
11. Dry infant’s body gently but thoroughly.
12. For a female infant, separate labia and with a cotton ball
moistened with soap and water, cleanse downward one on
each side. Use a new piece of cotton ball on each side.
13. For a male infant, retract the foreskin and gently cleanse the
penis with a cotton ball moistened with soap and water.
14. Re-dress infant and hold an infant for a while following the
bath procedure.
EVALUATION
1. Evaluate using the following area :
 Observed for the overall skin condition
 Observed for the signs of hypothermia
 Re-checked temperature
 Kept thermoregulated
DOCUMENTATION
1. Document any pertinent observations or according to the
hospital’s policy.

____________________________ _______________________________ -------------------------

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

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 PERFORMANCE CHECKLIST LEVEL II

INFANT ORO-NASOPHARYNGEAL SUCTIONING

Definition:
 A method of aspirating mucus or other secretions and or fluids from the nose, mouth
and pharynx using a suction catheter attached to a suction apparatus.
Materials Needed:
 Suction machine
 Sterile saline
 Suction catheter/sterile suction kit
 Sterile gloves

Procedures Done Not Remarks

done
ASSESSMENT
1. Note for physician’s order
2. Assess the rate and depth of the infant’s respirations, breath
sounds, and chest movements. Check pulse rate, skin color,
mouth, and nose for secretions
PLANNING
1. Wash your hands.
2. Gather necessary equipment
IMPLEMENTATION
1. Open the sterile suction package
2. Set up cup or container and pour sterile water or saline for
lubrication
3. Attach connector tubing to suction equipment
4. Turn on the suction mechanism and test by placing a thumb
over the end of the tube
5. Place the infant on a bassinette under droplight. Place in a
Trendelenburg position with head turned to his side
6. Put on gloves
7. Pick up the catheter with the dominant hand, and using the
non-dominant hand, attach connector end to suction tubing.
8. Test equipment by suctioning water through tubing and
catheter
9. Insert catheter sideways to the infant’s mouth and apply
suction by covering the suction port for no more than 10
seconds.
10. Withdraw the catheter in a circular motion
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 PERFORMANCE CHECKLIST LEVEL II

11. Flush the catheter with sterile water or NSS to remove

secretions.
12. Repeat the steps 9 to 11 until mouth is clear.
13. Insert catheter to the infant’s nose, one nostril at a time and
apply suction by covering the suction port no more than 10
seconds.
14. Withdraw the catheter in a circular motion
15. Flush the catheter with sterile water or NSS to remove
secretions.
16. Repeat the steps 13 to 15 until each nostril is clear.
17. Turn off suction and listen to the infant’s breath sounds.
Repeat if needed.
18. Remove gloves and discard them.
19. Place infant on his side.
20. Wash hands.
EVALUATION
2. Evaluate using the following criteria
 Breath sounds clear
 Mouth and nose free of secretions
DOCUMENTATION
1. Document any pertinent observations or according to the
hospital’s policy.

____________________________ _______________________________ _________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

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 PERFORMANCE CHECKLIST LEVEL II

INFANT CARDIO – PULMONARY RESUSCITATION (1 RESCUER)

Definition:
 Cardiopulmonary resuscitation (CPR) is the basic life-saving skill used in the event of
cardiac, respiratory, or cardiopulmonary arrest to maintain tissue oxygenation by
providing external cardiac compression and/or artificial respiration. CPR is initiated
when an infant is found without or develops absence of a pulse or respiration or both.
Materials Needed:
 Hard surface
 Gloves
 Bag-valve mask
 Oral airway
 Emergency resuscitation cart
 Documentation forms

Procedures Done Not Remarks

done
ASSESSMENT
1. Make sure the scene is safe for you and the infant
2. Place the infant on a flat surface
3. Tap the victim’s foot and check for the infant’s response
4. If there is no response, shout for help and begin steps of
CPR
IMPLEMENTATION
1. Open the airway using Head-tilt Chin Lift Maneuver:
 Place one hand on the infant’s forehead and push with
your palm to tilt the head back.
 Place the fingers of the other hand under the bony part
of the lower jaw near the chin
 Lift the jaw to bring the chin forward. The head is in a
neutral or sniffing position.
2. Check the infant’s breathing (for at least 5 seconds and no
more than 10 seconds):
 Place your ear near the infant’s mouth and nose.
 While observing the infant’s chest:
 Look for the chest to rise and fall
 Listen for air escaping during exhalation
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 PERFORMANCE CHECKLIST LEVEL II

 Feel for the flow of air against your cheek

3. If no breathing, give 2 breaths:

USING MOUTH TO MOUTH AND NOSE:

 Maintain an open airway following procedure 1.
 Place your mouth over the infant’s mouth and nose to
create an airtight seal.
 Blow into the infant’s nose and mouth (pausing to inhale
between breaths) to make the chest rise with each breath.
 If the chest does not rise, repeat step 1 to re-open the
airway and try to give an effective breath that will make
the chest rise.
USING A BAG-VALVE MASK (1 ventilation about every 3
seconds).
 Position the mask over the infant’s mouth and nose.
 Seal the mask over the nose, around the mouth, and
above the chin area and open the airway using the EC
Clamp Technique – With your non-dominant hand, use
the three fingers to lift the jaw (they form the “E” while
the thumb and the index finger hold the mask to the face
(making a “C”).
 Using the dominant hand, squeeze the bag slowly until
the chest rises. Give 1 ventilation about every 3 seconds.
The chest should fall before the subsequent ventilation is
given.
 After delivering 2 effective ventilations, follow
procedure 4 to check the pulse.

4. After delivering 2 effective breaths, take at least 5 seconds

and no more than 10 seconds to check for a pulse:
 Place 2 to 3 fingers on the inside of the upper arm,
between the infant’s elbow and shoulder
 Press the index and middle fingers gently on the inside
of the upper arm for at least 5 seconds and no more than
10 seconds when attempting to feel the brachial pulse.
5. If no pulse, or if the heart rate is less than 60 beats per
minute with signs of poor perfusion, perform cycles of
compressions and ventilation (30 compressions: 2 breaths
ratio):
 Place the infant on a firm, flat surface
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 PERFORMANCE CHECKLIST LEVEL II

 Move or remove clothing from the infant’s chest

 Draw an imaginary line between the nipples. Place 2
fingers on the breastbone just below this line. This will
allow you to compress on the lower half of the
breastbone. Do not press on the xiphoid process
 To give chest compressions, press the infant’s breastbone
down about 1/3 to ½ the depth of the chest
 After each compression, completely release the pressure
on the breast bone and allow the chest to recoil or re-
expand completely
 Smoothly deliver compressions for 30 times
 Then repeat procedure number 3 for 2 breaths (Mouth to
mouth and nose or 2 ventilations (Bag-Valve Mask).
6. After the 5 cycles activate the emergency response system.
Then return to the infant and provide CPR.

____________________________ _______________________________ ______________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

18 | P a g e
 PERFORMANCE CHECKLIST LEVEL II

STARTING AN INTRAVENOUS INFUSION

Definition:
 Provides route for administration of fluids, medication, blood or nutrients
Materials Needed:
 Solution
 IV cannula or steel-winged needle
 Administration set
 IV pole
 Tourniquet
 Aseptic swab
 Tape
 Bandage scissors
 Dressing material
 Arm board

Procedures Done Not Remarks

done
ASSESSMENT
1. Review physician’s order
PLANNING
1. Wash your hands
2. Choose appropriate equipment
3. Set up IV fluid tubing
4. Take equipment to bedside
IMPLEMENTATION
1. Identify patient and explain the procedure
2. Wash your hands
3. Select a position of comfort for yourself
4. Put on gloves.
5. Locate vein. Apply tourniquet 5 to 12 cm. (2-6 inches) above
the injection site
6. Prepare site with effective topical antiseptic according to
hospital policy or cotton balls with alcohol on circular
motion and allow 30 seconds to dry.
7. Using the IV Cannula:
 Pierce the skin with the needle, positioned on 15-30
degree angle, upon flashback visualization, decrease
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the angle, and advance the catheter and stylet into

the vein.
 Position the IV catheter parallel to the skin. Hold
stationary and slowly advance the catheter off of the
stylet until the hub meets the puncture site.
 Release the tourniquet, remove the stylet while
applying digital pressure over the catheter with one
finger about ½ inch from the tip of the inserted
catheter
Using the Steel-winged needle
 Pierce the skin with the needle’s bevel up, position it
on a 5-10 degree angle
 With the steel-winged needle parallel on the skin,
enter the vein directly and advance the needle ¼ inch
after successful venipuncture. Check for backflow.
 Release tourniquet
8. Attach the infusion tubing and open the roller clamp
enough to allow the fluid to drip.
9. Slip a sterile gauze pad under the catheter hub.
10. Anchor needle firmly in place with tape.
11. Place a transparent tape/dressing directly over the puncture
site.
12. Regulate the flow of infusion according to the physician’s
order.
13. Label the IV fluid bottle
EVALUATION
1. Evaluate, using the following criteria:
 Right patient, right solution, right time, right
amount, right rate.
 IV secure
 Patient’s comfort
DOCUMENTATION
1. Document IV insertion on appropriate chart form.

____________________________ _______________________________ ______________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

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 PERFORMANCE CHECKLIST LEVEL II

MONITORING AND MAINTAINING AN INFUSION

Definition:
 An important responsibility is to monitor an IV infusion so that the flow of the correct
solution is maintained at the correct rate

Materials Needed:
 Watch with a second hand

Procedures Done Not Remarks

done
ASSESSMENT
1. Identify whether the patient has IV fluid running.
2. Examine IV record for accuracy and completeness as to:
 Number of IV infusing
 Ordered contents of the fluid container
 Time the IV was hung
 Time the IV is to be completed
3. Review information about IV infusing if not familiar with.
4. Identify patient
5. Explain that you are monitoring the IV infusion
6. Check IV container
 Date and time
 Correct solution infusing
 The number of IV container is correct
 The fluid level in the container and designated time
of completion
7. Inspect drip chamber
 Filled to an appropriate level
 Dripping
 Rate is correct
8. Check tubing for kinks or obstruction
9. Examine IV site for phlebitis or infiltration
 Skin color and temperature
 Pain
 Swelling
10. If arm board is in use, remove, examine for skin irritation
and circulation impairment and replace
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11. Identify specific problem present

PLANNING
1. Plan an appropriate course of action on the IV problem
noted
IMPLEMENTATION
1. Carry out action planned
EVALUATION
1. Evaluate using the following criteria:
 Any problem identified and corrected
 Correct IV infusion running at the correct rate
DOCUMENTATION
1. On the flowsheet, note that the correct IV is running, the rate
and the appearance of the site
2. If the problems identified were corrected, note on nurse’s
notes or flow sheet.

____________________________ _______________________________ ________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

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 PERFORMANCE CHECKLIST LEVEL II

CHANGING FLUID CONTAINER

Definition:
 When only a small amount of fluid is left in the neck of the intravenous container and
fluid still remains in the drip chamber, intravenous containers are changed, and usually
tubing is also changed at the same time.
 Decreases opportunity for growth of microorganisms by removing possible medium for
infection

Materials Needed:
 Correct fluid
 Appropriate infusion set
 Cotton balls with alcohol
 Dressing materials if needed
 A syringe with a needle for flushing
 Plaster

Procedures Done Not Remarks

done
ASSESSMENT
1. Review physician’s order for the type of fluid and infusion
rate
2. Check date of last tubing and dressing
PLANNING
1. Determine equipment you will need
2. Wash your hands
3. Select the correct fluid container
4. Gather materials needed
IMPLEMENTATION
1. Explain the procedure
2. Check the patient’s identity, IV site, and solution to be
changed
3. Close the roller clamp or kink tubing of the administration
set and remove the fluid container from the stand.
4. Remove tubing from the empty container and insert tubing
to the new container while observing the aseptic technique.
5. Hang the new IV fluid to the pole

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6. Regulate the flow rate based on the duration of infusion.

Remove air bubbles if any
7. Change the IV Solution slip
EVALUATION
1. Evaluate using the following criteria:
 Tubing and fluid container changed with no
contamination
 Correct IV infusion running at correct rate
DOCUMENTATION
2. Record information in correct location according to your
hospital policy
 Time started and stopped, and the exact contents of
IV
 Fluid intake from discontinued container
 Assessment of IV line and site and patient’s response

____________________________ _______________________________ __________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

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 PERFORMANCE CHECKLIST LEVEL II

ADMINISTERING MEDICATIONS VIA:

(1) IV PUSH, (2) DRUG INCORPORATION & (3) VOLUMETRIC CHAMBER

Procedures Done Not Remarks

done
ASSESSMENT
1. Validate the orders
2. Examine the medication administration record for accuracy
and completeness
3. Review information on the drug, including:
 Effects
 Dilution
 Rate of administration
 Potential for incompatibility with other fluids or
medications to be given
4. Assess for what type of IV access is present
PLANNING
5. Determine equipment you will need
6. Wash your hands
7. Select materials needed:
IMPLEMENTATION
8. IV Push
a. Explain procedure (Name of medicine and action)
before administration
b. Check the IV site placement. Check for ANST of the
drug for IV push (if applicable )
c. Disinfect the Y-port using an alcohol swab.
d. Kink tubing, pierce through the Y-injection site and
push prepared drug slowly as ordered
e. Flush IV tubing after drug administration
f. Regulate rate of IVF infusion as ordered
9. Incorporation of drug into IVF
a. Follow procedure a and b on IV push
b. Locate and disinfect the injection port with an
alcohol swab.
c. Close the roller clamp. Remove the IV bottle from the
stand.
d. Incorporate prepared drug aseptically.

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e. Shake the bottle to mix incorporated medicine with

the IV solution, hang the bottle, regulate flow rate,
and place an IV label
10. Incorporation into the volumetric chamber
a. Follow procedure 1 and 2 on IV push
b. Set up the Volumetric Chamber
c. Open the package and close all the clamps.
d. Spike into the ordered IV fluid.
e. Open the roller clamp above the volumetric chamber
and run down the ordered amount of IV solution.
Close clamp once the amount is reached.
f. Open the roller clamp below the volumetric chamber
to prime the tubing. Close the clamp and attach a
needle at the end of the tubing.
g. Disinfect injection port at the volumetric chamber.
h. Incorporate prepared drug.
i. Clamp tubing from the main IV bottle and attach the
needle of the volumetric chamber to the y-port.
j. Regulate the flow rate of IVF infusion as ordered.
k. Place IV label on the volumetric chamber
EVALUATION
1. Evaluate using the following criteria:
 Patients’ rights followed
 Correct route used
 Effectiveness of medication assessed
 Any side effect promptly identified
DOCUMENTATION
1. Record pertinent data in terms of:
 Medication dosage
 Route of administration
 Time of administration
 Signature

____________________________ _______________________________ __________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

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 PERFORMANCE CHECKLIST LEVEL II

DISCONTINUING AN INTRAVENOUS INFUSION

Definition:
 Termination of intravenous infusion when the clients’ oral fluid intake and hydration
status are satisfactory when intravenous routes are no longer required.
Materials Needed:
 Sterile cotton balls  Plaster
 Alcohol swabs  Clean gloves
Procedures Done Not Remarks
done
ASSESSMENT
1. Check order for IV discontinuation
PLANNING
1. Determine what you will need
2. Wash your hands
3. Gather necessary materials
IMPLEMENTATION
1. Identify patient
2. Explain the procedure to the patient
3. Turn off IV flow
4. Put on gloves.
5. Remove tape and dressing
6. Hold the swab above the entry site
7. Remove cannula by pulling straight out
8. Put pressure on site
9. Elevate patient’s arm for 1 minute, keeping pressure on-site
until bleeding is controlled
10. Remove all equipment
11. Wash your hands
EVALUATION
1. Evaluate using the following criteria:
 Intravenous infusion is discontinued
 Any bleeding is controlled
 Cannula is intact
DOCUMENTATION
1. Document that IV was discontinued with cannula intact,
assessment of site and time.

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____________________________ _______________________________ __________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

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 PERFORMANCE CHECKLIST LEVEL II

MANAGING BLOOD TRANSFUSION

Definition:
 Provides replacement of blood products to increase client’s fluid volume, hemoglobin,
and hematocrit for improved circulation and oxygen distribution.
 Prevents over administration of blood products or the development of complications
associated with a transfusion.

Materials Needed:
 Blood transfusion tubing (blood Y set with in-line filter)
 1L Normal saline solution (0.9 NaCl)
 Packed cells or whole blood (as ordered)
 Blood crossmatching result
 Vital signs flow sheet (for monitoring)
 Non-sterile gloves
 Alcohol swabs

Procedures Done Not Remarks

done
ASSESSMENT
1. Review physician’s order for type, amount, and rate of
infusion
2. Obtain baseline vital signs, circulatory, respiratory, and skin
status.
3. Review baseline complete blood count, blood type and
cross-match
PLANNING
1. Determine equipment you will need
2. Wash your hands
3. Gather materials needed
IMPLEMENTATION
1. Explain the procedure to the client particularly the need for
frequent vital sign checks.
2. Request blood/blood component from hospital blood bank
to include blood typing and cross matching
3. Warm blood at a room temperature by wrapping the blood
bag with a towel. Blood should be transfused not more than
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20 minutes from the time it arrives from the blood bank.

4. Have a co-nurse countercheck the compatible blood to be
transfused:
 Name and identification number
 Clients’ blood group and Rh type
 Donor’ blood group and Rh type
 Crossmatch compatibility
 Blood unit and serial component
 The expiration date of blood product
5. Give pre-medication 30 minutes before transfusion if any is
ordered
6. Wash hands and don gloves
7. Initiate an IV line with appropriate IV catheter with Plain
NSS, anchor catheter properly, and regulate the rate
8. Open compatible blood aseptically and spike blood bag
carefully with the BT set, hang the bag, prime the tubing,
and remove bubbles.
9. Disinfect the Y injection port of the IV tubing and insert the
needle from the BT administration set, and secure with
adhesive tapes.
10. Close IV fluid of Plain NSS or regulate to KVO while
transfusion is ongoing.
11. Transfuse the blood (4-6 hrs) via injection port at 10-12 gtts
initially for 15 minutes, then regulate at the ordered rate.
12. Observe for any untoward signs and symptoms (flushed
skin, chills, elevated temperature, itchiness, urticaria, and
dyspnea); if any occurs, STOP the infusion, open IV line
with NSS, and report to the physician
13. Remove gloves.
14. Swirl the bag once in a while
15. If blood is consumed, close roller clamp of BT set then
disconnect from IV line then regulate the IVF as ordered
EVALUATION
1. Carry out post BT order such as rechecking hemoglobin and
hematocrit levels, bleeding time, etc.
DOCUMENTATION
1. Document observations and interventions done

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____________________________ _______________________________ __________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

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