BATAAN PENINSULA STATE UNIVERSITY
MAIN CAMPUS
College of Nursing and Midwifery www.bpsu.edu.ph
City of Balanga, 2100 Bataan [email protected]
BASIC INTRAVENOUS THERAPY FOR STUDENT NURSES
Name ________________________________________________ Group ______ Date_________________
Score: ____________
A. SETTING UP
Note: CDC Universal precaution. Always wear gloves when doing any venipuncture.
STEPS CD ID REMARKS
1. Verify written prescription and make IV label.
2. Observe ten (10) Rs when preparing and administering
IVF.
3. Explain procedure to reassure patient and/or
significant others, secure consent if necessary.
4. Assess patient’s vein; choose appropriate site, location,
size/condition.
5. 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.
6. Check the sterility and integrity of the IV solution, IV
set and other devices.
7. Place IV label on IVF bottle duly signed by RN who
prepared it (patient’s name, room no., solution, drug
incorporation, bottle sequence and duration, time and
date).
8. Do hand hygiene before and after the procedure.
9. Open IV administration set aseptically and close the
roller clamp and spike the infusate container aseptically
following the infection control measures.
10. Fill drip chamber to at least half and prime it with IV
fluid aseptically.
11. Expel air bubbles if any and put back the cover to the
distal end of the IV set (get ready for IV insertion).
______________________________
Signature over Printed Name
Of Clinical Instructor
REFERENCE:
Nursing Standards on Intravenous Practice (9th edition) by Association of Nursing Service
Administrators of the Philippines, Inc. (ANSAP)
BATAAN PENINSULA STATE UNIVERSITY
MAIN CAMPUS
College of Nursing and Midwifery www.bpsu.edu.ph
City of Balanga, 2100 Bataan [email protected]
BASIC INTRAVENOUS THERAPY FOR STUDENT NURSES
Name ________________________________________________ Group ______ Date_________________
Score: ____________
B. IV INSERTION
Prepare complete IV tray with IV infusions; Dummy arm and other safety devices.
STEPS CD ID REMARKS
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 2 to 6 inches above injection site depending on
condition of patient.
6. Check for radial pulse below tourniquet
7. Disinfect the insertion site with alcohol swab.
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 1 mm to the puncture site.
12. Slip sterile gauze under the hub. Release the tourniquet, remove the
stylet while applying digital pressure over the catheter with one finger
about 1 to 2 inches from the tip of the inserted catheter.
13. Connect the infusion tubing of the prepared IVF aseptically to the
IV catheter.
14. Open the clamp, regulate the flow rate.
15. Reassure the patient
16. Anchor needle firmly in place.
17. Tape a small loop of IV 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. Discard sharps and waste according to Health Care Waste
Management (DOH/DENR).
23. Document in the patient’s chart and endorse to incoming shift.
_________________________________________
Signature over Printed Name of Clinical Instructor
REFERENCE:
Nursing Standards on Intravenous Practice (9th edition) by Association of Nursing Service
Administrators of the Philippines, Inc. (ANSAP)
BATAAN PENINSULA STATE UNIVERSITY
MAIN CAMPUS
College of Nursing and Midwifery www.bpsu.edu.ph
City of Balanga, 2100 Bataan [email protected]
BASIC INTRAVENOUS THERAPY FOR STUDENT NURSES
Name ________________________________________________ Group ______ Date_________________
Score: ____________
C. CHANGING AN IV SOLUTION
STEPS CD ID REMARKS
1. Verify doctor’s prescription in doctor’s order sheet;
countercheck IV label, IV tag, infusate/solution sequence, type,
amount, additives (if any), and duration of infusion.
2. Observe 10 Rs.
3. Explain procedure to reassure the patient and significant
others and assess IV site for redness, swelling, pain and etc.
4. Change IV tubing and cannula within 72 hours after IV
insertion or upon the discretion of the attending medical doctor.
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.
_________________________________________
Signature over Printed Name of Clinical Instructor
REFERENCE:
Nursing Standards on Intravenous Practice (9th edition) by Association of Nursing Service
Administrators of the Philippines, Inc. (ANSAP)
BATAAN PENINSULA STATE UNIVERSITY
MAIN CAMPUS
College of Nursing and Midwifery www.bpsu.edu.ph
City of Balanga, 2100 Bataan [email protected]
BASIC INTRAVENOUS THERAPY FOR STUDENT NURSES
Name ________________________________________________ Group ______ Date_________________
Score: ____________
D. DISCONTINUING AN IV INFUSION
STEPS CD ID REMARKS
1. Verify written doctor’s order to discontinue IV including
IV medications.
2. Observe 10 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 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. Reassure patient.
12. Discard all waste materials including the IV cannula
according to Health Care Waste Management (DOH/DENR).
13. Document and endorse accordingly.
_________________________________________
Signature over Printed Name of Clinical Instructor
REFERENCE:
Nursing Standards on Intravenous Practice (9th edition) by Association of Nursing Service
Administrators of the Philippines, Inc. (ANSAP)
BATAAN PENINSULA STATE UNIVERSITY
MAIN CAMPUS
College of Nursing and Midwifery www.bpsu.edu.ph
City of Balanga, 2100 Bataan [email protected]
BASIC INTRAVENOUS THERAPY FOR STUDENT NURSES
Name ________________________________________________ Group ______ Date_________________
Score: ____________
E. IV MEDICATION INCORPORATION INTO IV BOTTLE/BAG
Note: Put the protocol of the Hospital in consideration
STEPS CD ID REMARKS
1. Verify the written medication card against the M.D.
prescription; observe hospital policy on drug administration.
2. Observe 10 Rs 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 if skin test is necessary before IV drug incorporation.
5. Prepare the necessary materials needed for the procedure such
as: injection tray, syringes needed, right drug to be incorporated
either in vial or ampule.
6. Do hand hygiene before and after the procedure.
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 gently to mix the drug with IVF and
regulate the flow rate accordingly.
10. Observe for 5-10 minutes for any drug reaction while
assuring the patient; monitor the VS.
11. Discard sharp and other wastes according to Health Care
Waste Management (DOH/DENR).
12. Document the procedure done on the patient’s chart.
_________________________________________
Signature over Printed Name of Clinical Instructor
REFERENCE:
Nursing Standards on Intravenous Practice (9th edition) by Association of Nursing Service
Administrators of the Philippines, Inc. (ANSAP)
BATAAN PENINSULA STATE UNIVERSITY
MAIN CAMPUS
College of Nursing and Midwifery www.bpsu.edu.ph
City of Balanga, 2100 Bataan [email protected]
BASIC INTRAVENOUS THERAPY FOR STUDENT NURSES
Name ________________________________________________ Group ______ Date_________________
Score: ____________
F. MEDICATION INCORPORATION INTO VOLUMETRIC CHAMBER OR SOLUSET
STEPS CD ID REMARKS
1. Verify the written MD prescription and follow hospital policy
on drug administration.
2. Observe 10 Rs when preparing and administering doctor’s
prescription.
3. Explain procedure to the patient (medicine and action) and
check IV site. Verify for skin test of the drug before IV
incorporation.
4. Do hand hygiene before and after the procedure.
5. Prepare the necessary materials for the procedure such as:
right drug and dose, right diluent needed, IV injection tray,
syringes and needles, alcohol etc.
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 ongoing IV fluid in the volumetric chamber is to be
consumed in 6-8 hours, 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.
11. Regulate flow rate of IVF infusion accordingly.
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
_________________________________________
Signature over Printed Name of Clinical Instructor
REFERENCE:
Nursing Standards on Intravenous Practice (9th edition) by Association of Nursing Service
Administrators of the Philippines, Inc. (ANSAP)
BATAAN PENINSULA STATE UNIVERSITY
MAIN CAMPUS
College of Nursing and Midwifery www.bpsu.edu.ph
City of Balanga, 2100 Bataan [email protected]
BASIC INTRAVENOUS THERAPY FOR STUDENT NURSES
Name ________________________________________________ Group ______ Date_________________
Score: ____________
G. MEDICATION PUSH THROUGH THE IV PORT
STEPS CD ID REMARKS
1. Verify medication card against the written doctor’s
prescription.
2. Observe 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.
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. In 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
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 1-2 cc of IVF to flush the
medicine given.
13. Regulate rate of IV fluid infusion 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 Health Care
Waste Management (DOH/DENR).
16. Document the procedure done on the patient’s chart.
_________________________________________
Signature over Printed Name of Clinical Instructor
REFERENCE:
Nursing Standards on Intravenous Practice (9th edition) by Association of Nursing Service
Administrators of the Philippines, Inc. (ANSAP)
BATAAN PENINSULA STATE UNIVERSITY
MAIN CAMPUS
College of Nursing and Midwifery www.bpsu.edu.ph
City of Balanga, 2100 Bataan [email protected]
BASIC INTRAVENOUS THERAPY FOR STUDENT NURSES
Name ________________________________________________ Group ______ Date_________________
Score: ____________
H. IV MEDICATION PUSH THROUGH HEPARIN-LOCK DEVICE
Note: Some hospitals do not use heparin anymore.
STEPS CD ID REMARKS
1. Check 10 Golden Rules in the administration of medication when
preparing and administering medication.
2. Verify doctor’s prescription
3. Check medication card against the written doctor’s prescription
4. Explain procedures to the patient (name of the medicine and action)
before administration
5. Do hand hygiene before and after the procedure (use gloves
especially for chemo drugs)
6. Gather equipment, to include but not limited to IV tray, Heparin
solution, NSS diluent or isotonic solution, 2.5 cc syringes (2-3 pieces) as
needed.
7. Prepare medication to be administered (e.g. antibiotic), and draw up
into a syringe.
8. Fill a tuberculin syringe with heparin solution. Heparin solution is
usually prepared with 0.1 cc heparin plus 0.9 NSS or isotonic solution
as prescribed by the doctor.
9. Fill the 2.5 cc syringe with isotonic solution or normal saline solution;
1 cc each.
10. 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).
11. Remove the cover of the injection port aseptically and keep the
sterility of the cover.
12. Check the patency, open the IV line, and inject NSS or isotonic
solution to flush the heparin solution as prescribed by the doctor.
13. Close the IV line and remove saline syringe and insert medication
syringe into port. Give IV push 5-10 minutes for IV potent drug. For 2-
3 IV medications, give at least 30 minutes to 1 hour interval. After each
drug is administered via IV push, flush with 2-3 cc saline solution.
14. Observe patient for any adverse reactions and do nursing
intervention accordingly.
15. Discard waste according to Health Care Waste Management
(DOH/DENR).
16. Document in the patient’s chart.
Note: Normal saline can still take the place of heparin. Studies have shown the efficacy of NSS. Heparin solution
can be used if normal saline solution or isotonic solution is not available and as prescribed by the MD.
_________________________________________
Signature over Printed Name of Clinical Instructor
REFERENCE:
Nursing Standards on Intravenous Practice (9th edition) by Association of Nursing Service
Administrators of the Philippines, Inc. (ANSAP)
