VMC ASIAN COLLEGE
FOUNDATION, INC.
28 National Highway, Tacurong City
Tel. No. 064-200+6466/Fax No. 064-477-0354
Website: [Link]/email:officialvmcacfi@[Link]
Performance Checklist
Legend: 5-excellent; 4 – Very good; 3- Good; 2- Fair; 1- Poor
Name: _________________________________________________ Section: ___________
Procedure 5 4 3 2 1
Intravenous Infusion
1. Check the Doctor’s Order
2. Explains the Procedure to the client.
3. Washes Hands
4. Assembles needed equipment
5. Closes the roller Champ in the tubing
6. Remove the protective covering of the IV bag/ Bottle and tubing without
contamination.
7. Incorporate additives aseptically
8. Connects the tubing to the IV bag/bottle
9. Partially fills the dip chamber
10. Opens the champ and flushes air from the tubing( primes the tubing)
11. Bring the preparation beside
12. Identifies the client
13. Hand the fluid bottle in the IV stand
14. Assist the client in comfortable position
15. Apply hand antiseptic and done gloving
16. Provide good source of light
17. Select the non-dominant hand and Locate the suitable vein
18. Call assistant if needed ( Pedia Patient)
19. Apply tourniquet
20. Antiseptic the site by apply cotton swab
21. Open the roller clamp to allow the flow but gradual infusion of solution wait until
dries
22. Do not touch the site after skin preparation or application of antiseptic solution.
23. Inspect the cannula before insertion. To insure that the needle is fully inserted in the
plastic cannula and check the tip of cannula for damage.
24. Do not touch the needle and tip of cannula.
25. Ensure that the bevel of the cannula is facing upward
26. Hold the cannula in your dominant hand, stretch the skin over the vein to anchor the
vein in your dominant hand.
27. Hold the cannula bevel at 15 to 30 degrees angle to the skin observe for the back
flow of blood cannula chamber.
28. Partially withdraw the advance the cannula
29. Release the tourniquet
30. Apply gentle pressure over the vein
31. Remove the needle from the cannula and dispose it into sharp container
32. Secure the hub of the cannula with clean adhesive tape
33. Do not cover the puncture wound
34. Cover the IV area with dressing
35. Apply spent
36. Adjust the flow rate at prescribed.
37. Position the patient comfortably
38. Attaches the completed IVF label
39. Does after care of equipment
40. Wash hands
41. Proper documentation
42. Observe courtesy
43. Manifest Neatness
44. Receptive to Criticisms
45. Show calmness and mastery of the procedure
46. Uses correct English
Intradermal
1. Prepare medication or solution as per agency policy. Ensure all medication is properly
identified. Check physician orders, Parenteral Drug Therapy Manual (PDTM), and MAR to
validate medication order and guidelines for administration.
2. Perform hand hygiene.
3. Enter room and introduce yourself, explain procedure and the medication, and allow
patient time to ask questions.
Keen Brian Valle Arguelles, RN, MAN, MPA, PhD
Dean, College of Midwifery
VMC ASIAN COLLEGE
FOUNDATION, INC.
28 National Highway, Tacurong City
Tel. No. 064-200+6466/Fax No. 064-477-0354
Website: [Link]/email:officialvmcacfi@[Link]
4. Close the door or pull the bedside curtains.
5. Compare MAR to patient wristband and verify this is the correct patient using two
identifiers.
6. Assess patient for any contraindications to the medications.
7. Select appropriate site for administration. Assist the patient to the appropriate position as
required.
8. Perform hand hygiene and apply non-sterile gloves.
9. Clean the site with an alcohol swab or antiseptic swab. Use a firm, circular motion. Allow
the site to dry.
10. Remove needle from cap by pulling it off in a straight motion.
11. Using non-dominant hand, spread the skin taut over the injection site.
12. Hold the syringe in the dominant hand between the thumb and forefinger, with the bevel
of the needle up.
13. Hold syringe at a 5- to 15-degree angle from the site. Place the needle almost flat
against the patient’s skin, bevel side up, and insert needle into the skin. Insert the needle
only about 1/4 in., with the entire bevel under the skin.
14. Once syringe is in place, slowly inject the solution while watching for a small weal or
bleb to appear.
15. Withdraw the needle at the same angle as insertion, engage safety shield or needle
guard, and discard in a sharps container.
Do not massage area after injection.
16. If injection is a TB skin test, circle the area around the injection site to allow for easy
identification of site in three days.
17. Discard remaining supplies, remove gloves, and perform hand hygiene
18. Document the procedure and findings according to agency policy.
19. Evaluate the patient response to injection within appropriate time frame.
Intramuscular
1. Assemble equipment and check the Dr.’s order
2. Explain the procedure to the client
3. Perform hand hygiene and put on gloves if available
4. Withdraw medications from an ampoule or a vial as described in the procedure
“Removing medication from an ampoule” or ” Removing medication from a vial”
5. Identify the client carefully using the following way:
a. Check the name in the identification bracelet b. Ask the client his/her name
c. Verify the client’s identification with a staff member who knows the client
6. Close the door and put a screen.
7. Continue to assist
1) Assist the client to a comfortable position.
2) Select the appropriate injection site using anatomic landmarks
3) Locate the site of choice
❖Nursing Alert❖ Ensure that the area is not tender and is free of lumps or nodules
8. Cleanse the skin with a spirit swab: 1) Start from the injection site and move outward in a
circular motion to a circumference of about 2” (5 cm) from the injection site
2) Allow the area to dry
3) Place a small, dry gauze or spirit swab on a clean, nearby surface or hold it between the
fingers of your non-dominant hand.
9. Remove the needle cap by pulling it straight off
10. Spread the skin at the injection site using your non-dominant hand
11. Hold the syringe in your dominant hand like a pencil or dart.
12. Insert the needle quickly into the tissue at a 90 degree angle
13. Release the skin and move your non-dominant hand to steady the syringe’s lower end
14. Aspiration blood: 1) Aspirate gently for blood return by pulling back on the plunger with
your dominant hand
2) If blood enters the syringe on aspiration, withdraw the needle and prepare a new injection
with a new sterile set-up.
15. If no blood appears, inject the medication at a slow and steady rate(; 10 seconds/ mL of
medication)
16. Remove the needle quickly at the same angle you inserted it
17. Massage the site gently with a small, dry gauze or spirit swab, unless contraindicated for
specific Medication. If there are contraindications to massage, apply gentle pressure at the
site with a small, dry gauze or a spirit swab.
18. Discard the needle:
1) Do not recap the needle
Keen Brian Valle Arguelles, RN, MAN, MPA, PhD
Dean, College of Midwifery
VMC ASIAN COLLEGE
FOUNDATION, INC.
28 National Highway, Tacurong City
Tel. No. 064-200+6466/Fax No. 064-477-0354
Website: [Link]/email:officialvmcacfi@[Link]
2) Discard uncapped needle and syringe in appropriate container if available
19. Assist the client
20. Remove your gloves and perform hand hygiene
[Link]: Record the medication administered, dose, date, time, route of
administration, and IM site on the appropriate form.
22. Evaluation the client’s response:
1) Check the client's response to the medication within an appropriate time
2) Assess the site within 2 to 4 hours after administration
Comments:___________________________________________________________________________
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Score:____________________________
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Clinical Instructor
Keen Brian Valle Arguelles, RN, MAN, MPA, PhD
Dean, College of Midwifery
