PERFORMANCE EVALUATION TOOL FOR

INTRADERMAL INJECTION

NAME: __________________________________________________________ SCORE: _________________________

SECTION / GROUP NO: __________________ DATE: ________________ FACULTY: ____________________________

Direction: Rate the learners based on the competencies listed below.

NUMERICAL RATING DESCRIPTION

3 – ACCEPTABLE Demonstrates expected procedure/behavior completely.
2 – MODERATELY
Demonstrates expected procedure/behavior with minimal error.
ACCEPTABLE
1 – SLIGHTLY Demonstrates expected procedure/behavior with many errors.
ACCEPTABLE
0 - UNACCEPTABLE Missed procedure or procedure done but entirely incorrect.

A. PREPARATION RATING REMARKS

1. Checks physician’s order 0 1 2 3
2. Studies drug action and expected response 0 1 2 3
3. Checks agency protocol about the sites to use for skin test 0 1 2 3
4. Assembles articles and supplies 0 1 2 3
5. Performs hand hygiene 0 1 2 3

B. PROCEDURE
1. Follows the three checks for administering medications. Read the
0 1 2 3
label on the vials/ampule
2. Dilutes the powder of the antibiotic in the vial using distilled water
0 1 2 3
as diluent
3. Shakes the vial gently to dissolve medicine 0 1 2 3
4. Takes a tuberculin syringe with g. 23 needle, aspirates 0.9 cc from the
0 1 2 3
distilled water then 0.1 cc from the vial of the antibiotic for testing
5. Allows the distilled water and the antibiotic to mix inside the
0 1 2 3
tuberculin syringe
6. Replaces the needle to gauge 25 or 26 and expel air from the syringe 0 1 2 3
7. Puts the syringe on the medicine tray with the medicine card,
0 1 2 3
cotton balls (dry and with alcohol), pen and bring to the bedside
8. Identifies the patient and introduces self 0 1 2 3
9. Explain the procedure to the patient and that the medication will
0 1 2 3
produce a small wheal which she should not touch
10. Selects a site 0 1 2 3
11. Puts on the gloves as indicated by agency policy 0 1 2 3

Name:_____________________________________ Intradermal Injection Page 2

 RATING REMARKS
12. Cleanses the skin at the site using cotton balls with alcohol in firm 0 1 2 3
circular motion, starting at the center and widening the circle outward
13. Allows the area to dry thoroughly 0 1 2 3
14. Removes the needle cap while waiting for the antiseptic to dry
15. Expels any air bubbles from the syringe 0 1 2 3
16. Grasps the syringe in dominant hand, holding it between thumb and
forefinger. Holds the needle almost parallel to the skin surface with 0 1 2 3
the bevel of the needle up
17. With the non-dominant hand, pull the skin at the site until it is taut 0 1 2 3
18. Inserts the tip of the needle far enough to place the bevel through
the epidermis. The outline of the bevel should be visible under 0 1 2 3
the skin surface
19. Stabilizes the syringe and the needle 0 1 2 3
20. Injects the medication carefully and slowly so that it produces a
0 1 2 3
small wheal on the skin
21. Withdraws the needle quickly at the same angle it was inserted 0 1 2 3
22. Does not massage the area 0 1 2 3
23. Draws a circle around the wheal with ink to observe for redness
0 1 2 3
or induration per agency policy
24. Waits for 30 minutes to interpret the result 0 1 2 3

C. AFTER CARE
1. Disposes of the syringe and needle in the sharps container 0 1 2 3
2. Removes gloves if used 0 1 2 3

D. DOCUMENTATION
1. Documents the procedure and nursing assessment
a. Antibiotic tested
b. Time, route and site used
0 1 2 3
c. Other observations
d. Result of the skin test
e. Record on the medication sheet

Total Score ÷ 96 X 100 = _________________

______________________________________ _________________________________________
Signature of Student Signature of Faculty