Southville International School and CollegesCollege of Nursing

IVT CHECKLIST

NAME: _______________________________________________ SECTION:________________________

PROCEDURE I: SETTING UP/ CHANGING/ DISCONTINUING IV INFUSION

STEPS CD ID REMARKS

A. SETTING UP:1. Verify doctor’s order and make IV label.2. Explain procedure to patient / SO.3. Assess patient’s vein: choose appropriate vein,

location, size condition.4. Wash hands before and after procedure.

Maintain asepsis throughout the preparation and during therapy.

5. Prepare necessary materials for procedure(IV tray with IV solution, IV set, IV cannula/insyte, forcep soaked in antiseptic solution , alcohol swabs or cotton balls soaked with alcohol in a closed container, plaster, tourniquet, splint and IV hook/pole) gloves; optional prn.

6. Check sterility and integrity of the IV solution, IV set and other devices.

7. Place IV label on IV bottle8. Open the seal of the IV bottle aseptically9. Open IV set aseptically and close clamp10. Spike the infusate aseptically11. Fill drip chamber to at least half and prime the

tubing aseptically12. Remove air bubbles if any and put back the cover

to the distal end of tubing.

(get ready for insertion)

B. CHANGING AN IV INFUSION:1. Verify doctor’s order and make IV label2. Explain procedure to patient/SO3. Assess IV site for any complications4. Check date of IV insertion, re-site if 48-72hours

has lapsed.5. Check date of changing of IV tubings, change if

due for changing (within 72 hours)6. Wash hands before and after procedure7. Prepare necessary materials. (IV solution,

STEPS CD ID REMARKSdisinfectant, kidney basin on IV tray)

8. Check sterility and integrity of solution9. Place IV label on IV bottle10. Open and disinfect rubber port of IV solution to

follow11. Close the clamp or kink tubing and pull infusate

from the runaway IV bottle aseptically12. Spike the infusate into the rubber port of the

new IV solution bottle aseptically13. Regulate flow as ordered.14. Reassure patient /SO15. Discard all waste materials according to hospital

policy16. Document accordingly on patient’s chart.

C. DISCONTINUING AN IV INFUSION:1. Verify doctor’s order2. Explain procedure to patient/SO3. Assess patient and IV site for any complications4. Wash hands before and after procedure5. Prepare necessary materials ( On IV tray – cotton

balls soaked with alcohol in covered container, dry cotton balls, forcep in antiseptic solution, kidney basin, plaster)

6. Close IV clamp of the tubing7. Moisten adhesive tapes around the IV catheter

with cotton ball soaked in alcohol, remove plaster gently

8. Hold a sterile gauze above the venipuncture site without applying any pressure.

9. Withdraw the needle/ cannula by pulling it out along the line of vein.

10. Immediately apply firm pressure to the site, using sterile gauze for 2-3 minutes.

11. Inspect IV catheter for completeness.12. Hold client’s arm or leg above the body if

bleeding persists.13. Place sterile dressing over venipuncture site and

secure with plaster.14. Reassure patient/SO15. Discard all used materials according to hospital

policy16. Document accordingly on patient’s chart.

TOTAL SCORE: ______________

Prepared by: Reviewed by: Approved by:

Monet Davidson, RN April Apple Gareza, RN Carmel Villegas, RN, MAN

Clinical Instructor Level IV Coordinator DeanSouthville International School and Colleges

College of Nursing

IVT CHECKLIST

NAME: _______________________________________________ SECTION:________________________

PROCEDURE II: BLOOD TRANSFUSION

STEPS CD ID REMARKS1. Verify doctor’s order 2. Explain the procedure to patient/SO. Secure informed

consent3. Assess patient’s condition, patency of IV site and

infusing IV solution (ongoing IV fluids should be compatible for blood transfusion). If no IV access, start a peripheral IV line according to hospital policy.

4. Request blood and blood component from blood bank to include blood typing and crossmatching

5. Obtain blood from blood bank once available6. Warm blood at room temperature by using blood

warmer or simply wrap blood bag in towel7. Countercheck the compatible blood to be transfused.

Double/triple check crossmatching results, serial number, expiration date and type of blood component with another colleague.

8. Monitor patient’s VS and assess for any untoward s/s9. Administer premedications as ordered, usually 30

minutes before transfusion.10. Wash hands before and after procedure11. Prepare materials to be used (On IV tray, BT set,

needle G18/19, cotton balls soaked in antiseptic, plaster, blood component to be transfused)

12. Open compatible blood set aseptically and spike blood bag carefully. Prime tubings and remove air bubbles (if any). Use needleG18/19 for side drip.

13. Disinfect Y-port of IV tubing and insert the needle from BT set, secure with plaster.

14. Close IV fluid of PNSS or KVO (based on doctor’s order) while transfusion is going on.

15. Regulate transfusion to 20 gtts/min for 15 minutes, observe patient for any untoward s/s, then regulate as ordered.

16. Continue monitoring patient for any reactions and check VS from time to time, usually every 30 minutes

17. Swirl the bag once in awhile to mix the solid and liquid elements. Note: one blood set should be used for one or two

STEPS CD ID REMARKSunits of blood to prevent sluggish transfusion rate.

18. If blood is consumed, close roller clamp of BT setthen disconnect from Y-port, flush tubing with IV fluids and regulate flow as ordered.

19. Continue to observe patient for any delayed reaction. Monitor VS after transfusion.

20. Discard blood bag and other used devices according to hospital policy

21. Carry out post BT orders and remind doctor about administration of Ca Gluconate if patient has received four (4) or more units of blood.

22. Document accordingly

TOTAL SCORE: _______________

Prepared by: Reviewed by: Approved by:

Monet Davidson, RN April Apple Gareza, RN Carmel Villegas, RN, MANClinical Instructor Level IV Coordinator Dean

Southville International School and CollegesCollege of Nursing

IVT CHECKLIST

NAME: _______________________________________________ SECTION:________________________

PROCEDURE III – ADMINISTERING OF DRUGS: IV PUSH / DRUG INCORPORATION INTO IVF BOTTLE/DRUG INCORPORATION INTO SOLUSET

STEPS CD ID REMARKS

A. IV PUSH:1. Countercheck medication card against the

written doctor’s order2. Observe “10 Rights” when preparing and

administering medications3. Explain procedure to patient/SO4. Assess patient for any untoward s/s, check IV

site for any complications, check for skin test result of drug for IV push

5. Wash hands before and after procedure6. Prepare the necessary materials to be used (on

IV injection tray-right drug, right diluents, syringes, needles, cotton balls soaked in alcohol in closed container)

7. Disinfect injection port of the diluents (if in vial)8. Aspirate right amount of diluent and dilute the

drug (if drug needs to be diluted) and mix gently9. Aspirate the right drug dose, disinfect the Y-

injection port of the IV tubing, pierce through the bull’s eyed rubber port

10. Kink the tubing from the bottle, push IV drug slowly as ordered or as per manufacturer’s instructions. Observe precautionary measures during drug administration

11. Release the tubing from the bottle, do not remove syringe from injection port

12. Kink the tubing from the patient and aspirate 1-2 cc of IV fluid from the bottle and release the tubing.

13. Kink the tubing from the bottle and flush IV tubing going to the patient to be sure that drug is completely administered before removing the syringe from injection port.

14. Regulate rate of IV fluid infusion as ordered (if needed)

15. Reassure patient and observe for signs and symptoms of adverse drug reaction, if any.

STEPS CD ID REMARKS

16. Discard sharps and wastes according to hospital policy

17. Document accordingly

(If the patient has a Heparin –lock device (Heplock)1. Do steps 1-52. Prepare all needed materials (on IV injection

tray- Heparin solution, Normal Saline diluents, 3 pcs. 2.5cc syringe, 1 pc. tuberculin syringe, cotton balls soaked in alcohol in closed container)

3. Prepare medication to be administered and draw it up into a syringe. (do steps 7 and 8)

4. Fill a tuberculin syringe with Heparin solution. (Heparin solution is usually prepared with 0.1cc Heparin plus 0.9cc Normal Saline/Isotonic solution)

5. Fill the two other 2.5cc syringes with Normal Saline, 1cc each

6. Swab injection port with alcohol and insert saline syringe into port

7. Pull back on-syringe plunger and observe for any blood into the syringe, flush system

Rationale: the presence of blood indicates that needle/cannula was placed into the vein and not into surrounding tissues.

8. Remove saline syringe and insert medication syringe into the port. Inject medication into the vein slowly

9. Observe patient for any adverse reaction10. Remove the medication syringe and insert

another saline syringe into the port, flush the system to ensure complete administration of medication

11. Remove saline syringe and insert the Heparin syringe into the port. Inject the Heparin to fill the catheter / needle lumen.

Rationale: The Heparin should prevent the formation of clot in the catheter

12. Do steps 15 -17

STEPS CD ID REMARKS

B. DRUG INCORPORATION INTO IVF CONTAINER:1. Countercheck with written doctor’s order, make

a medication card2. Observe “10 Rights” when preparing and

administering medication3. Explain procedure to patient/SO4. Assess patient, IV site, and verify skin test result

of the drug to be administered.5. Wash hands before and after procedure6. Prepare all materials needed (on IV injection

tray- the right dose of drug to be incorporated (in vial or ampule),appropriate syringes, cotton balls soaked in alcohol in closed container)

7. Disinfect the injection port of the vial and aspirate the drug aseptically

8. While supporting and stabilizing the bag with your thumb and forefinger, carefully insert syringe needle through the port, and inject the medication.

9. Swirl the IV container gently to mix the drug with IV fluids

10. Observe and reassure patient11. Discard all used devices according to hospital

policy12. Document accordingly

C. DRUG INCORPORATION INTO SOLUSET:1. Countercheck with written doctor’s order and make

medication card2. Observe “10 Rights” when preparing and

administering medications3. Explain procedure to patient/SO4. Assess patient for any untoward S/S, check IV

site, on-going IV fluid / incorporations and verify skin test result of drug to be administered

5. Wash hands before and after procedure6. Prepare the necessary materials needed (on IV tray-

separate IV solution compatible with drug dilution, drug to be incorporated in vial or ampule, solu-set, needle, syringe, plaster, cotton balls soaked in alcohol in covered container)

Note: Solu-set is to be consumed in 6-8 hours, confirm with doctor if IV fluid is to be used solely for drug administration and keep the whole set sterile for succeeding doses.

(Spike solu-set to new IVF container, prime the tubing, place an appropriate needle to distal end of tubing, and connect to

STEPS CD ID REMARKSthe IV main line through the Y-injection port, secure with tape)

7. Aspirate prepared right drug with correct dose8. Add desired IVF diluents into solu-set by opening the

clamp from the bottle then close the clamp after9. Disinfect rubber injection port of the soluset and

incorporate the drug. Mix gently10. Open the clamp of the airway at the soluset and

regulate flow rate as ordered or per manufacturer’s instruction

11. Place IV label on solu-set indicating drug incorporation

12. When drug is consumed, add more 20 cc of IV fluid to solu-set for flushing to ensure complete administration of the drug.

13. Close clamp, remove needle from the Y-injection port and keep the whole system sterile for succeeding dose.

14. Observe patient for any adverse reaction15. Regulate flow rate of main IV fluid16. Discard all waste according to hospital policy17. Document accordingly

TOTAL SCORE: ______________

Southville International School and CollegesCollege of Nursing

IVT CHECKLISTNAME: _______________________________________________ SECTION:________________________

PROCEDURE IV: INSERTING IV

STEPS CD ID REMARKS

1. Verify written order for IV therapy, check prepared IVF and other things needed (Procedure I-A Setting up IV Infusion)

2. Explain procedure to patient / SO3. Observe “10 Rights” of medication administration4. Wash hands before and after procedure5. Choose site for IV6. Apply tourniquet 2-6 inches above injection site

depending on condition of patient7. Check for radial pulse below tourniquet8. Put on clean gloves

Note: CDC Universal precaution: Always wear gloves when doing any venipuncture

9. Clean venipuncture site with effective topical antiseptic according to hospital policy or cotton balls soaked with alcohol in circular motion and allow to dry (no touch technique)

10. Using the appropriate IV cannula, pierce skin with needle positioned on a 15-30 degree angle

11. Once blood appears in the lumen of the needle catheter, reduce the angle of the catheter almost parallel to skin and advance the needle ¼ inch more into the vein.

12. Holding the needle steady in its position, advance the catheter until the hub is at the venipuncture site.

13. Slip a piece of sterile gauze under the hub14. Release the tourniquet, remove the stylet while

applying digital pressure over the catheter and stabilizing hub with the thumb or index finger of your non-dominant hand

15. Connect the infusion tubing of the IVF prepared in Procedure I-A setting, as aseptically to the IV catheter.

16. Open the clamp slowly and start the infusion17. Anchor cannula in place with the use of:

a. Transparent tape (tegaderm) or sterile dressing

STEPS CD ID REMARKSover the venipuncture site.

b. Tape (using any appropriate anchoring style)

Note: Never place unsterile tape directly on IV insertion site, instead place a small piece of sterile OS then secure with adhesive tape.

18. Tape a small loop of IV tubing for additional anchoring, apply splint if necessary.

19. Calibrate the IVF bottle and regulate flow of infusion according to prescribed duration

20. Label on IV tape near the IV site to indicate the date of insertion, type and gauge of IV catheter and countersign

21. Label with plaster on IV tubing to indicate the date when to change IV tubing

22. Observe and report any untoward effect23. Discard all used devices according to hospital policy24. Document in the patient’s chart accordingly

TOTAL SCORE: ________________

Legend:

CD - correctly doneID - incorrectly done

Prepared by: Reviewed by: Approved by:

Monet Davidson, RN April Apple Gareza, RN Carmel Villegas, RN, MANClinical Instructor Level IV Coordinator Dean