CENTRO ESCOLAR UNIVERSITY
Mendiola, Manila
School of Nursing
BSN – Level IV – Evaluation Checklist
NCM 118 (RLE) – USING AN INTRAVENOUS INFUSION PUMP
Name of Student Score
Year/ Section/ Group/ Number
Rate the student’s performance by checking this appropriate box using the following criteria:
5 - Excellent (Carries our procedures efficiently, systematically and independently)
4 - Very Satisfactory (Carries out the procedure efficiently and systematically but requires
minimal guidance and supervision)
3 - Satisfactory (Carries out the procedure efficiently and systematically but requires
moderate guidance and supervision)
2 - Fair ((Carries out the procedure efficiently and systematically but requires close guidance
and supervision)
1 - Poor ((Carries out the procedure inefficiently and unsystematically and requires close
guidance and supervision)
Ex*Average mean shall be computed and multiplies by factor 20. The product shall be transmutted
using the table for 100 points. Passing cut-off is 65%.
Criteria 5 4 3 2 1
Assessment
1. Test functionality of the infusion pump.
2. Check the doctor’s order for the prescribed
delivery (type and amount of fluids, medication
or nutrition).
3. Compute for the flow rate.
*Assess patients for (baseline data, indications and
contraindications) for the treatment.
Planning
4. Prepare all the needed materials:
Infusion Pump Machine
Compatible IV tubing
Hypodermic Needle (if needed)
Antiseptic swab
IV Pole
Prescribed fluid, nutrient or
medication (properly labeled)
Surgical tape (if needed)
Bandage Scissors (if needed)
Implementation
5. Wash hands
*Wear PPE (as indicated).
6. Identify the patient using two identifiers (i.e.
name and birth date or name and
hospital/account number). Compare identifiers
with information on the patient’s medical record.
7. Introduce yourself to the patient and family.
8. Explain the procedure and purpose to the patient
and family.
* Obtain consent (written or verbal).
9. Provide privacy.
10. Check the IV site if intact and free from infection
as well as the patency of the system..
11. Attach the infusion pump to the IV pole then
plug the machine.
5 4 3 2 1
12. Hang the prepared IV solution container with the
IV tubing already attached to the bag to the IV
pole. Ensure that the drip chamber is at least 30
inches above the infusion site
13. Fill the drip chamber of the IV tubing one-third
full.
14. Prime the tubing.
15. Attach the drip sensor device to the drip
chamber.
16. Lift the door handle and open the door of the
infusion pump.
17. Place the IV tubing through the guide of the
machine.
18. Close the door and push the handle down.
19. Press the power button ON.
20. Set the VTBI (Volume To Be Infused) and flow
rate using the key pad.
21. Attach the IV tubing to the connecting port.
Observe aseptic technique.
22. Open the IV controller pump completely.
23. Press the start button.
24. Assess the drops being delivered, the condition
of the tubing in the guide, and the fluid level in
the drip chamber at least every 4 hours.
25. Realign the tubing in the guide at least every 8
hours.
26. Listen for the alarm and respond immediately to
determine the problem.
Evaluation
27. Regularly check the client for any intended and
adverse effects of the infusion.
* Assess patient’s reaction to treatment.
28. Document and report any significant deviations
and the infusion made.
REMARKS
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Student’s Signature Clinical Instructor’s Date
Printed Name and Signature
Copy to: Faculty
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