UNIVERSITY OF NEGROS OCCIDENTAL – RECOLETOS

Bacolod City
COLLEGE OF ALLIED MEDICAL HEALTH SCIENCES | Nursing Department

Procedure Checklist / Evaluation Tool

Name:
Section: Group: ☐A ☐B ☐C ☐D ☐E Date: mm | dd | 20yy
IVF Infusion
Proficiency Scale
# Steps Remarks
E P D I
Assessment
1. Identify the patient
Assess the patient health status such as cognitive level,
2. musculoskeletal functions, skin integrity and breathing
pattern.
Assess the possible site for insertion (The IV site should be
3.
free of redness, swelling, coolness, or warmth to the touch)
Planning E P D I Remarks
4. Verify written prescription .
Observed the ten rights when preparing materials and prior
5.
to IV infusion
Prepare the necessary materials for the infusion (tray, start
pack, IV solution as prescribed, cannula varies in sizes,
6.
alcohol and cotton/ alcohol swab, bandage scissors,
gloves, torniquet, splint, micropore, micro/macro set)
Secure security and safety of the patient by putting the side
7.
rails up especially when catering the pediatric patient
Implementation E P D I Remarks
8. Explain the procedure to patients and/ or significant other
9. Secured consent if necessary
10. Do hand hygiene before the procedure
Check the sterility and integrity of the IV solution, IV set
11.
and other devices
12. Place the exact label on IVF bottle
Open the seal of the IV solution and disinfect port with cotton balls
13.
with alcohol/ alcohol swab
Open the IV administration set aseptically and close the roller clamp
14.
and spike the infusate container aseptically.
Fill drip chamber to at least half and prime it with fluid aseptically
15.
Expel air bubbles if any and sealed with its cover of the distal end of the
16. IV tubing (IV insertion will follow)

Regulate the IVF as prescribed by the Physician

17.
Do after care and discard the materials with blood while observing the
18. hospital/ clinical disposal standard policy

19. Do hand hygiene

Document the time, date, IVF solution and other vital observation in
20.
patient condition (refer untoward health issue to the physician)
Evaluation E P D I Remarks
IVF is regulated and infusing well
Summary and Recommendation

Score: Total 60
UNO-R CAMHS Nursing Department Revised on August
2023
Comments, Remarks
and
Score:
Recommendations:

mm | dd |
Clinical Instructor: Signature: Date:
20yy
(E) Exemplary (3 points)
 The nursing student can perform the procedure independently and spontaneously. He/she does
Legend: not require assistance,
(P) Proficient (2 points)
 The nursing student can perform the procedure with minimal assistance. When given a hint,
he/she can immediately perform the step/procedure
(D) Developing (1 point)
 The nursing student is unable to perform the step/procedure unless given a hint. He/she tends to
wait for a cue clue, then performs the step/procedure.
(I) Inadequate (0 points)
 The nursing student is unable to perform the step/procedure despite the hint or cue clue given.
 Student nurse must attain a score of at least half of the total score. If the student nurse fails to do so,
he/she must repeat the GRD.
Note:
 Student nurse who attains at least half of the total score during repeat GRD will only receive the half
of total score, regardless if he/she perform better.

UNO-R CAMHS Nursing Department Revised on August

2023