PERFORMANCE CRITERIA CHECKLIST

TOPICAL, PARENTERAL DRUG ADMINISTRATION AND IV REMOVAL

Trainee’s Name:_______________________Date:___________________________

CRITERIA YES NO
CRITERIA Did you……
A. ORAL MEDICATION
1. Perform handwashing and gather supplies
2. Check doctor’s order and make a medication card
3. Check drug label and compare it with MAR
4. Prepare the required medication
5. Transport the medication to the patient's bedside carefully and introduce self
6. Confirm patient ID using two patient identifier name and birthday.
7. Assist the patient to an upright position
8. Explain the drug action
9. Give the medicine and offer water
10. Leave the room after the patient swallowed the medicine, and thank the patient
for her time.
11. Ensure safety measures before you leave. Document.
A. OPTIC DROP MEDICATION
1. Check the medication administration record (MAR) and compare drug label.
2. Confirm the identity of the client. Introduce self and explain what you are going to
do, why it is necessary, and how she can cooperate
3.  Wash hands prior to instilling medication.
4. Cleanse the eyelids and lashes with cotton balls or gauze pledgets moistened with
normal saline. Use each cotton ball or pledget for only one stroke, moving from the
inner to the outer canthus of the eye.
5. Tilt the patient’s head back slightly if he is sitting or place the head over a pillow if
he is lying down.
6. Using forefinger, pull lower lid down gently.
7. Instruct the client to look up to the ceiling
8. Holding the medication in the dominant hand, place hand on the client’s forehead
to stabilize hand. Approach the eye from the side and instill the correct number of
drops onto the outer third of the lower conjunctiva sac.
9. Release the lower lid after the drops are instilled. Instruct the patient to close eyes
slowly, move the eye and not to squeeze or rub.
10. For liquid medications, press firmly or have the client press firmly on the
nasolacrimal duct for at least 30 seconds.
11. Wipe off excess solution with gauze or cotton balls.
12. Wash hands after instilling the medication.
B. OTIC DROP ADMINISTRATION
1. Check MAR against doctor’s orders.
2. Perform Handwashing
3.Confirm the identity, introduce self and explain what you are going to do, why it is
necessary, and how she can cooperate.
4. Before instilling ear drops, don clean non-sterile gloves.
5. Cleanse external ear of any drainage using cotton-tipped applicators
6. Warm the medication container in your hand. This promotes client‘s comfort
7. Position patient with affected ear uppermost, on unaffected side if lying down, or
tilt head to side if sitting up.
8. Straighten the ear auditory canal. Pull pinna upward and backward for clients over
3 years of age/adult. For children below 3 years. Pull pinna downward and backward.
To allow solution flow the entire length of the canal.
9. Instill the correct number of drops along the side of the ear canal and press gently
but firmly a few times on the tragus of the ear (the cartilaginous projection in front of
the exterior meatus of the ear). This will assist the flow of medication into the ear
canal.
10. Tell the client to remain in the side-lying position for about 5 minutes. To prevent
the drops from escaping and allows the medication to reach all side of the canal
cavity.
11. Remove gloves and assist patient to a comfortable and safe position.
12. Perform hand hygiene.
13. Document as per agency policy. Include date, time, dose, route; which ear the
medication was instilled into; and patient’s response to procedure.
C. INTRADERMAL INJECTION
1. Gather all the equipments needed and check the physician order.
2. Explain the procedure to the patient.
3. Wash hands and don the gloves.
4. Prepare the medication in the nurses station and discard all the unwanted
equipments
5. Position the client and select the appropriate site for the injection.
6. Cleanse the site with the alcohol swab in circular motion i.e from inner to outer
aspect.
7. Remove the needle cap with non- dominant hand by pulling straight away.
8. Now spread the skin taut and place the needle almost flat against patients skin.
9. Insert 1/8 inch bevel up so that needle can be seen through the skin.
10. Slowly inject the drug watching for a bleb to develop.
11. Withdraw the needle from the same angle as it was inserted.
12. Do not recap the needle. Discard syringe and needle into appropriate bag. Do not
massage the site.
13. Draw circle using pen around the injection site . Write the date and time of
medication administration
14. Remove the gloves and do wash the hands.
15. Perform documentation
D. INTRAMUSCULAR
1. Perform hand hygiene.
2. Compare MAR to patient wristband and use two patient identifiers to confirm
patient.
3. Assess the patient’s symptoms, knowledge of the medication to be received,
history of allergies, drug allergies, and types of allergic reactions.
4. Assess for any factors that may contraindicate an IM injection.
5. Verify practitioner’s order and MAR
6. Review medication information, such as purpose, action, side effects, normal dose,
rate of administration, time of onset, peak and duration, and nursing implications.
7. Assemble supplies.
8. Prepare medication from an ampule or a vial as per hospital policy. Always compare
MAR to the practitioner’s original orders to ensure accuracy and completeness.
9. NEVER leave the medication unsupervised once prepared.
10. Perform hand hygiene.
11. Close curtains or door.
12. Verify patient using two unique identifiers and compare to MAR.
13. Explain the procedure and the medication, and give the patient time to ask
questions
14. Don non-sterile gloves and prepare the patient in the correct position. Ensure a
sharps disposal container is close by for disposal of needle after administration.
15. Locate correct site using landmarks, and clean area with alcohol or antiseptic
swab. Allow site to dry completely.
16. Place a clean swab or dry gauze between your third and fourth fingers.
17. Remove needle cap by pulling it straight off the needle. Hold syringe between
thumb and forefinger on dominant hand as if holding a dart.
18. With non-dominant hand, hold the skin around the injection site.
19. With the dominant hand, inject the needle quickly into the muscle at a 90-degree
angle, using a steady and smooth motion.
20. After the needle pierces the skin, use the thumb and forefinger of the non-
dominant hand to hold the syringe.
21. If required by agency policy, aspirate for blood. If no blood appears, inject the
medication slowly and steadily. If blood appears, discard syringe and needle, and
prepare the medication again.
22. Once medication is completely injected, remove the needle using a smooth,
steady motion. Remove the needle at the same angle at which it was inserted.
23. Cover injection site with sterile gauze, using gentle pressure, and apply Band-Aid
as required.
24. Place safety shield on needle and discard syringe in appropriate sharps container.
25. Discard supplies, remove gloves, and perform hand hygiene.
26. Document procedure as per agency policy.
27. Assess patient’s response to the medication after the appropriate time frame.

Comment: _______________________________

______________________________
Name and Signature of Trainer