UNIVERSITY OF SAINT ANTHONY

(Dr. Santiago G. Ortega Memorial)

Iriga City

COLLEGE OF HEALTH CARE EDUCATION

INTRAVENOUS THERAPY
CHECKLIST

Name: _______________________________ Year & Section: ____________________

Date Performed: _______________________ Rating/Grade: _____________________
Clinical Instructor: ______________________ Signature of CI: ____________________

Legend:
4– Action is correct, complete and performed in proper order and time
3– Action is correct, complete, but not in order and performed action slowly or very fast
2– Action is incorrect or incomplete and performed action very slowly or very fast
1– Action is not performed but mentioned
0– Did not perform the procedure

Procedure: I: A. Setting Up, B. One-on-one I.V. Insertion, C. Changing an IV solution,

D. Discontinuing an IV infusion.
STEPS 4 3 2 1 CI
COMMENTS
I. A. Setting up:
1. Verify written prescription and make IV label
2. Observe twelve (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
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Iriga City

COLLEGE OF HEALTH CARE EDUCATION

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. One-on-one IV Insertion
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 12 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

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
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Iriga City

COLLEGE OF HEALTH CARE EDUCATION

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)

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
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Iriga City

COLLEGE OF HEALTH CARE EDUCATION

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

GRADING FOR ONE-ON-ONE IV INSERTION:

Suggested Score Score

_______ 1st attempt 20 pts highest score
_______2nd attempt 15 points only
_______2nd attempt with Less 2-3 points
hematoma
_______3rd attempt 10 points only
_______3rd attempt with Less 2-3 points
hematoma