Practicum Procedure – I FORM

PARTICIPANT: _________________________________ Date: __________________

Score I. A _______ I. B _______ I. C _______ I. D _______ Total: __________________

INSTRUCTIONS: Please check (4) on the space provided to assure whether the participant is
able to perform the procedure correctly or whether it is incorrectly done.

CD – Correctly Done ID – Incorrectly Done

Procedure: I: A. Setting Up, B. Inserting IV utilizing the Dummy Arm, C. Changing an IV

solution, D. Discontinuing an IV infusion.

STEPS CD ID REMARKS
I. A. Setting up:
1. Verify written prescription and make IV label
2. Observe ten (12) Rs when preparing and administering IVF
3. Explain procedure to reassure patient and/or significant
other, secure consent if necessary.
4. Assess patient’s vein; choose appropriate site, location,
size/condition.
5. Do hand hygiene before and after procedure
6. Prepare necessary materials for procedure (IV tray with IV
solution, administration set, IV cannula, forceps soaked in
antiseptic solution, alcohol swabs or cotton balls soaked in
alcohol with cover (this should be exclusively used for IV),
plaster, tourniquet, gloves, splint, and IV hook), sterile 2x2
gauze or transparent dressing.
7. Check the sterility and integrity of the IV solution, IV set
and other devices
8. Place IV label on IVF bottle duly signed by RN who
prepared it (patient’s name, room number, solution, time
and date)
9. Open IV administration set aseptically following the
infection control measures
10. Open IV administration set aseptically and close the roller
clamp and spike the infusate container aseptically
11. Fill drip chamber to at least half and prime it with IV fluid
aseptically
12. Expel air bubbles if any and put back the cover to the distal
end of the IV set (get ready for IV insertion).

I. B. Inserting IV Cannula utilizing dummy arm

Prepare complete IV tray with IV infusions; Dummy
arm and over-the-needle catheter or Butterfly needle
1. Verify the written prescription for IV therapy; check
prepared IVF and other things needed.
2. Explain procedure to reassure the patient and significant
others and observe the 10 Rs
3. Do hand hygiene before and after the procedure
4. Choose site for IV
5. Apply tourniquet 5 to 12 cm (2 – 6 in) above injection site
depending on condition of patient
6. Check for radial pulse below tourniquet

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 STEPS CD ID REMARKS
7. Prepare site with effective topical antiseptic according to
hospital policy or cotton balls with alcohol in circular
motion and allow 30 seconds to dry (No touch technique)
Note: CDC Universal precaution: always wear gloves when
doing any venipuncture
8. Using the appropriate IV cannula, pierce skin with the
correct technique.
9. Upon backflow visualization, continue inserting the
catheter into the vein
10. Position the IV catheter parallel to the skin.
11. Hold stylet stationary and slowly advance the catheter until
the hub is 1mm to puncture site.
12. Slip a sterilize gauze under the hub. Release the tourniquet;
remove the stylet while applying digital pressure over the
catheter with one finger about 1-2 inches from the tip of the
inserted catheter
13. Connect the infusion tubing of the prepared IVF aseptically
to the IV catheter.
Note: When steel-winged needle butterfly is used:
A. Connect the IV tubing to the steel winged needle
connector and prime the needle with IV fluid
B. Using the steel-winged needle, pierce skin with the
needle bevel up, positioned on a 5-10 degree angle
C. With steel-winged needle, parallel on the skin enter the
vein directly and advance needle ¼ inch after
successfully performing venipuncture check for
backflow. Remove tourniquet.
D. Do not reinsert stylet once pulled out to prevent
breakage of catheter that may cause embolism
14. Open the clamp and regulate the flow rate.
15. Reassure patient.
16. Anchor needle firmly in place with the use of:
a. Transparent tape / dressing directly on puncture site
b. Tape (using any appropriate anchoring style)
c. Band aid
Note: Never place unsterile tape directly on IV insertion site.
Instead, place a small piece of sterile OS and then secure it with
adhesive tape.
17. Tape a small loop of tubing for additional anchoring.
Apply splint, if needed.
18. Calibrate the IVF bottle and regulate flow of infusion
according to prescribed duration
19. Label on IV tape near the IV site to indicate the date of
insertion, type and gauge of IV catheter and countersign
20. Label with plaster on the IV tubing to indicate the date
when to change the IV tubing
21. Observe patient and report any untoward effect
22. Document in the patient’s chart and endorse to incoming
shift
23. Discard sharps and waste according to Health Care Waste
Management (DOH/DENR)

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 STEPS CD ID REMARKS
I. C. Changing an IV Solution
1. Verify doctor’s prescription in doctor’s order sheet;
countercheck IV label, IV card, infusate sequence, type,
amount, additives (if any), and duration of infusion
2. Observe 12 Rs
3. Explain procedure to reassure the patient and significant
others and assess IV site for redness, swelling, pain, etc.
4. Change IV tubing upon the discretion of the healthcare
practitioner when clinically indicated and not routinely,
utilizing the VIP score.
5. Wash hands before the procedure
6. Prepare necessary materials; place on an IV tray.
7. Check sterility and integrity of IV solution
8. Place IV label on the IV bottle
9. Calibrate new IV bottle according to duration of infusion as
per prescription
10. Open and connect the IV tubing into the solution bottle
11. Close the roller clamp
12. Regulate the flow rate according to the prescribed infusion
rate. Expel air bubbles, if evident
13. Reiterate assurance to patient and significant others
14. Discard all waste materials according to health care waste
management (DOH/DENR)
15. Document and endorse accordingly

I. D. Discontinuing an IV Infusion
1. Verify written doctor’s order to discontinue IV including
IV medications
2. Observe 12 Rs
3. Assess and inform the patient of the discontinuation of IV
infusion.
4. Prepare the necessary materials; IV tray or injection tray
with sterile cotton balls with alcohol, plaster, pick-up
forceps in antiseptic solution, kidney basin and band aid
5. Wash hands before and after procedure
6. Close the roller clamp of the IV administration set
7. Moisten adhesive tapes around the IV catheter with cotton
ball with alcohol; remove plaster gently.
8. Use pick-up forceps to get cotton ball with alcohol and
without applying pressure, remove needle or IV catheter
then immediately apply pressure over the venipuncture site
9. Inspect IV catheter for completeness
10. Place dressing over the venipuncture site
11. Discard all waste materials including the IV cannula
according to health care waste management (DOH/DENR)
12. Reassure patient
13. Document time of discontinuance, status of insertion site
and integrity of IV catheter and endorse accordingly

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 Practicum Procedure – II FORM

PARTICIPANT: _________________________________ Date: __________________

Score: ______________________________________ Total: __________________

INSTRUCTIONS: Please check (4) on the space provided to assure whether the participant is
able to perform the procedure correctly or whether it is incorrectly done.
CD – Correctly Done ID – Incorrectly Done

Procedure: II Blood Transfusion

STEPS CD ID REMARKS
1. Verify doctor’s written prescription and make a treatment
card according to hospital policy
2. Observe ten 12 Rs when preparing and administering any
blood or blood components
3. Explain the procedure/rationale for giving blood
transfusion to reassure patient and significant others and
secure consent. Get patient histories regarding previous
transfusion.
4. Explain the importance of the benefits on voluntary blood
donation (RA 7719 – National Blood Service Act of
1994)
5. Request prescribed blood/blood components from blood
bank to include blood typing and cross matching and
blood result of transmissible disease.
6. Use a clean and safe container to get the prescribed blood
or blood product from hospital blood bank and keep it at
room temperature.
7. Assess patient’s condition. The doctor and nurse should
countercheck the compatible blood and blood product to
be transfused against the x-matching sheet noting ABO
grouping and RH, serial number of each blood unit, and
expiry date with the blood bag label and other laboratory
blood exams as required before transfusion (Hgb and
Hct).
8. Get the baseline vital signs – BP, RR and Temperature
before transfusion. Refer to MD accordingly.
9. Give pre-med 30 minutes before transfusion as
prescribed.
10. Prepare equipment needed for BT (IV injection tray,
compatible BT set, IV catheter/needle G19/19, plaster,
tourniquet, blood, blood components to be transfused,
plain NSS 500 cc, IV set, needle gauge 18 (only if
needed), IV hook, gloves, sterile 2x2 gauze or transparent
dressing, etc.
11. Do hand hygiene before and after the procedure
12. If main IVF is with dextrose 5% initiate an IV line with
appropriate IV catheter with plain NSS on another site,
anchor catheter properly and regulate IV drops
13. Open compatible blood set aseptically and close roller
clamp. Spike blood bag carefully; fill the drip chamber at
least half full; prime tubing and remove air bubbles (if
any). Use needle g.18 or 19 for side drip (for adults) or
g.22 for pedia (if blood is given through the Y injection
port, the gauge of needle is disregarded.

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 STEPS CD ID REMARKS
14. Disinfect the Y injection port of IV tubing (plain NSS)
and insert the needle from BT administration set and
secure with adhesive tape.
15. Close roller clamp of IV fluid of plain NSS and regulate
to KVO while transfusion is going on
16. Transfuse the blood via the injection port and regulate at
10-15gtts/min initially for 15 minutes and then at the
prescribed rate (usually based on the patient’s condition)
17. Monitor the patient within the first 5-10 minutes of
transfusion and refer immediately to the MD for any
adverse reaction
18. Observe/Assess patient on an on-going basis for any
untoward signs and symptoms such as flushed skin,
chills, elevated temperature, itchiness, urticaria and
dyspnea. If any of these symptoms occur, stop the
transfusion, open the IV line with plain NSS and regulate
accordingly, and report to the doctor immediately.
19. Swirl the bag gently from time to time to mix the solid
with the plasma N.B. one B.T. set should be used for 1 –
2 units of blood
20. When blood is consumed, close the roller clamp of BT,
and disconnect from IV lines then regulate the IVF of
plain NSS as prescribed.
21. Continue to observe and monitor patient post transfusion,
for delayed reaction could still occur
22. Re-check Hgb and Hct, bleeding time, serial platelet
count within specified hours as prescribed and/or per
institution’s policy
23. Discard blood bag and BT set and sharps according to
health care waste and management (DOH/DENR)
24. Fill out adverse reaction sheet as per institutional policy
and return the blood bag and whole set to the blood bank
or laboratory for examination.
25. Remind the doctor about the administration of Calcium
Gluconate if patient has several units of blood transfusion
(3-5 more units of blood)
26. Document time or discontinuance, status of insertion site
and integrity of IV catheter and endorse accordingly.

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 Practicum Procedure – III FORM

PARTICIPANT: _________________________________ Date: __________________

Score III. A _______ III. B _______ III. C ______ III. D _______ Total: __________________

INSTRUCTIONS: Please check (4) on the space provided to assure whether the participant is
able to perform the procedure correctly or whether it is incorrectly done.

CD – Correctly Done ID – Incorrectly Done

Procedure: III: Administering IV Drugs

STEPS CD ID REMARKS
III. A. IV MEDICATION INCORPORATION OF DRUG
INTO IVF BOTTLE/BAG
Note: Put the Protocol of the Hospital in consideration
1. Verify the written medication card against the M.D.
prescription; observe hospital policy on drug
administration
2. Observe 10 R’s when preparing and administering
medication
3. Explain procedure (medication and action) to reassure
patient and significant others and check patency and IV
site
4. Verify for skin test of drug for IV incorporation (if skin
testing is necessary).
5. Do hand hygiene before and after the procedure
6. Prepare the necessary materials needed for the procedure
such as injection trays, syringes needed, right drug to be
incorporated either in vial or ampule
7. Disinfect injection port of the vial and the ampule before
breaking then aspirate the right dose aseptically
8. Remove the cover of the administration set, maintain
sterility and incorporate prepared drug into the airway
aseptically. Recap airway after.
Note: if the administration set has no airway, pull out the
set and incorporate the prepared drug and re-spike the IV
set to the bottle then place the label (all these should be
done aseptically)
9. Swirl the IV bottle to mix the drug with IVF and regulate
the flow rate accordingly
10. Observe for 5-10mins for any drug interaction while
reassuring the patient; monitor VS
11. Document the procedure done on the patient’s chart
12. Discard sharp and other wastes according to Health Care
Waste Management (DOH/DENR)

III.B. IV MEDICATION PUSH THROUGH THE IV PORT

1. Verify medication card against the written doctor’s
prescription
2. Observe the 10 Rs when preparing and administering
medication
3. Explain procedure to reassure patient and significant
others (the name of medicine and action/interaction of
medication) before administration
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 STEPS CD ID REMARKS
4. Do hand hygiene before and after the procedure (use
gloves especially for chemotherapeutic and other vesicant
drugs)
5. Check patency and other reaction signs of swelling,
redness, phlebitis, etc. if any of these are evident, do not
give the drug
6. Check for skin test result of drug for IV push, drug-drug,
drug-IV fluid incompatibility, dosage (computation)
7. Prepare the necessary materials for the procedure such as,
right drug, right diluent needed, IV injection tray, syringes
with needles, alcohol, etc.
8. Disinfect injection port of the diluent, vial or ampule as
may be appropriate
9. Aspirate right amount of diluent for the drug (if the drug
needs to be diluted)
10. Aspirate the right drug dose, disinfect the Y-injection port
of the IV administration set/catheter IV port
11. Close the roller clamp of the IV tubing from the bottle and
push IV drug aseptically and slowly according to the
manufacturer’s recommendation
12. Using same syringe, aspirate 1-2cc of IVF to flush the
medicine given
13. Regulate rate of IV fluid infusions as prescribed (if
needed)
14. Reassure patient and observe for signs and symptoms of
adverse drug reaction
15. Discard sharps and other waste according to the Health
Care Waste Management (DOH/DENR)

III.C. IV MEDICATION INCORPORATION INTO

VOLUMETRIC CHAMBER
1. Verify the written M.D. prescription and follow hospital
policy on drug administration
2. Observe 10 Rs when preparing and administering medication
3. Explain procedures to patients (medicine and action) and
check IV site. Verify for skin test of the drug before IV
incorporation
4. Prepare the necessary materials for the procedure such as
right drug and dose, right diluent needed, IV injection tray,
syringes and needles
5. Do hand hygiene before and after procedure
6. Check present IV fluid label, level and the incorporated
medicine in the volumetric Chamber or IV bottle if with
incorporated medicine, check for drug-drug incompatibility
and if the on-going IV fluid in the Volumetric chamber is to
be consumed in 6-8hours, request a prescription and keep the
whole set sterile for succeeding doses
7. Aspirate prepared right drug with correct dose
8. Add desired IVF diluent into volumetric chamber by opening
the sliding clamp from the bottle then close the clamp.
9. Disinfect rubber injection port of the volumetric chamber and
incorporate the drug. Mix gently.
10. Open the clamp of the airway at the volumetric chamber and
incorporate the drug. Mix gently.
11. Regulate the flow rate of IVF infusion accordingly.
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 STEPS CD ID REMARKS
12. Place IV label on volumetric chamber indicating drug
incorporated and flow rate
13. Reassure/monitor patient when incorporated medicine is
consumed; clamp airway of volumetric chamber, add IVF
and regulate flow rate of main IVF as prescribed
14. Discard waste according to Health Care Waste Management
(DOH/DENR)
15. Document in the patient’s chart the drug administered and
patient’s condition
16. Document in the patient’s chart the IVF Sheet and Kardex
(of changes in IV rate/time due)

III.D. MEDICATION PUSH THROUGH THE HEPARIN-

LOCK DEVICE
Note: Some hospitals does not use Heparin anymore
1. Check Medication card against the written doctor’s
prescription
2. Observe 10 Rs when preparing and administering medication
3. Explain procedure to the patient (name of the medicine and
action) before administration
4. Gather equipment to include/but not limited to IV tray,
Normal Saline diluent or Isotonic solution, 2.5 cc syringes
(2-3pcs) as needed
5. Do hand hygiene before and after the procedure (use gloves
especially for chemo drugs)
6. Prepare medication to be administered, e.g. antibiotic and
draw it up into a syringe
7. Fill a tuberculin syringe with heparin solution N.B. Heparin
solution is usually prepared with 0.1cc Heparin plus 0.9cc
Normal Saline or isotonic solution as prescribed by the
Doctor
8. Fill the 2.5cc syringe with isotonic solution or normal saline
solution; 1cc each
9. If using Heparin lock device with 3-way stop cock with luer-
lock, rotate the stop cock so that the line going to the patient
is closed (this will prevent backflow of blood)
10. Remove the cover of the injection port aseptically and keep
the sterility of the cover
11. Check the patency, open the IV line and inject NSS or
isotonic solution to flush the Heparin Solution as prescribed
by the Doctor
12. Close the IV line and remove saline syringe and insert
medication syringe into the port. Give IV push 5-10mins for
IV potent drug. For 2-3 IV medications, give at least 30mins-
1hr interval. After each drug administered via IV push, flush
with 2-3 cc saline solution
13. Observe patient for any adverse reactions and do nursing
intervention accordingly
14. Document
15. Discard waste according to Health Care Waste Management
(DOH/DENR)
Note: Normal Saline can take the place of Heparin. Studies
have shown the efficacy of NSS. Heparin solution can be
used if normal saline or isotonic solution is not available
and as prescribed by the MD.
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 Practicum Procedure – IV FORM

PARTICIPANT: _________________________________ Date: __________________

Score IV. A _______ IV. B _______ IV. C _______ Total: __________________

INSTRUCTIONS: Please check (4) on the space provided to assure whether the participant is
able to perform the procedure correctly or whether it is incorrectly done.

CD – Correctly Done ID – Incorrectly Done

Procedure IV: Parenteral Nutrition Administration, peripheral Access/Central Vascular

Access

STEPS CD ID REMARKS
Procedure IV-A: Parenteral Nutrition Infusion. Utilizing
the Peripheral Access
1. Verify doctor’s prescription
2. Explain the procedure to reassure patient and significant
others (Benefits, risks, duration, changes in volume and
flow rate, etc.)
3. Secure consent from patient or/and authorized member
of the family.
4. Prepare parenteral solution and all other devices needed
for the parenteral administration, taking into
consideration the mode of administration such as:
 Peripheral Access
 Central Access
5. Check the integrity and functionality of the parenteral
solution and IV devices
6. Observe 10 Rs in safe drug administration
7. Assess patient and choose suitable vein, location and get
baseline vital signs
8. Do hand hygiene and maintain asepsis throughout the
procedure
9. Prepare Parenteral Nutrition solution (follow procedure
I: Setting up)
10. Insert the IV Catheter aseptically (large, bore catheter:
Follow procedure I in IV insertion)
11. Connect the tubing to the prepared parenteral solution
and regulate flow rate as prescribed
12. Dress IV sites as per IV standard
13. Label IV site and solution as per IV standard
14. Continue to reassure patient and do pertinent health
education
15. Dispose waste materials according to Heath Care Waste
Management (DOH/DENR)
16. Document procedure and observations with
corresponding nursing intervention in the patient’s chart
like I and O, weigh daily, etc.
17. Monitor patient periodically and report unusual findings
if there are signs of infection, hyper or hypoglycemia,
change of color and consistency of solution, etc.
18. Document observation and intervention as necessary
19. Reassure patient

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 STEPS CD ID REMARKS
Procedure IV-B: Parenteral Nutrition Infusion utilizing
central vascular access
1. Follow procedures in Procedure IV-A in Peripheral
Access from steps 1-9
2. Assist surgeon in open or closed central vascular access
procedures (maintain asepsis throughout the procedure)
3. Connect the IV administration set to the central vascular
access catheter aseptically and regulate flow rate as
prescribed
4. Assess dressing over central vascular access for
swelling, redness, pain and foul smelling discharges
5. Monitor/reassure patient
6. Document observations and circumstances as necessary
7. Discard waste materials according to Health Care Waste
Management (DOH/DENR)

Procedure IV-C: Discontinuing Parenteral Solution

Infusion
1. Verify written prescription (Discontinues upon
completion of TPN requirements, (e.g. 24 hrs, 12 hrs or
in the occurrence of any adverse reaction)
2. Observe 10 Rs
3. Explain procedure to the patient and significant others
4. Prepare the necessary materials to be used in
discontinuing TPN utilizing Peripheral/Central Vascular
Access (Prepare sterile dressing set and stitch scissor for
open central vascular access
5. Follow doctor’s prescription. e.g. electrolyte; weight;
blood laboratory monitoring
6. Monitor patient closely and document observation and
intervention
7. Refer to M.D. for any unusual observations
8. Discard waste materials according to Health Care Waste
Management (DOH/DENR)

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 Practicum Procedure – V FORM

PARTICIPANT: _________________________________ Date: __________________

Score: ________________________________________ Total: __________________

INSTRUCTIONS: Please check (4) on the space provided to assure whether the participant is
able to perform the procedure correctly or whether it is incorrectly done.
CD – Correctly Done ID – Incorrectly Done

Procedure V: ONE ON ONE IV INSERTION

STEPS CD ID REMARKS
1. Do hand hygiene before and after the procedures
2. Follow procedure in IV insertion aseptically and
accordingly
3. Discard Waste Materials according to Health Care
Waste Management (DOH/DENR)
Suggested Score Score
_______ 1 attempt
st
20 pts highest score
_______2 attempt
nd
15 points only
_______2nd attempt with Less 2-3 points
hematoma
_______3rd attempt 10 points only
_______3 attempt with
rd
Less 2-3 points
hematoma

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