For faculty use only Date

Educator’s name
Score

ATI Skills Modules Checklist for Intravenous Therapy

Student’s name Date

Check/
Item Comments
initial
Verify order Patient record

Assess for procedure need

Identify, gather, Preparing intravenous (IV) tubing

and prepare (primary tubing, extension tubing, IV solution,
equipment and time tape, labels, IV pole)
supplies Initiating IV therapy
(prepared IV solution and tubing, IV pole,
protective pad, IV start kit with catheter,
antimicrobial wipes, tourniquet, securement
device, transparent dressing, tape, label,
gauze)
Replacing IV solution
(prepared IV solution, IV pole, needleless
syringe)
Replacing IV tubing
(IV tubing, IV pole, tape, gauze)
Preparing a saline lock
(extension tubing, injection cap,
antiseptic wipes, 10-mL syringe filled with
normal saline solution)
Converting an IV infusion to a saline lock
(IV lock adapter, prepared tubing, antiseptic
wipes, 10-mL syringe filled with normal saline
solution)
Converting a saline lock to an IV infusion
(prepared IV solution and tubing, antiseptic
wipes, 10-mL syringe filled with normal saline
solution)
Discontinuing a peripheral IV catheter
(gauze pads, tape)

Apply principles of Hand hygiene

aseptic practice
Personal protective equipment

Disposal of waste

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 Check/
Item Comments
initial
Communicate Privacy
effectively Patient identification
Patient teaching
Ensure consent form has been signed

Provide for a safe Body mechanics

environment Equipment placement
Patient safety

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Demonstrate procedural steps
Check/
Item Task Comments
initial
Preparing Access medical record.
intravenous Perform medication checks.
(IV) tubing
Remove IV solution from packaging and gently apply
pressure to bag while inspecting for tears or leaks.

Check color, clarity, and expiration date.

Remove primary IV tubing and extension tubing
from packaging.
Remove caps from proximal end of extension tubing
and distal end of primary tubing and connect.
Move roller clamp to 1 to 2 inches below drip chamber
and close clamp.
Perform medication checks.
Remove cover from tubing port on bag.
Remove cap insertion spike and insert spike into tubing
port of bag.
If using glass bottle, cleanse rubber stopper before
inserting spike.
Hang bag on IV pole and squeeze drip chamber two or
three times to fill at least halfway.
Loosen cap from end of tubing and open clamp to
prime tubing.
Check entire length for air bubbles; tap tubing and
invert ports to remove air.
Replace or tighten cap on end of tubing.
Place time tape on bag and tubing label on tubing near
drip chamber.

Initiating Identify patient.

IV therapy Place IV tubing within reach and prepare supplies.
Place tourniquet on patient’s arm.

Inspect hand and arm, palpating and selecting vein.

Release tourniquet.
Cleanse insertion site and allow it to dry.
Reapply tourniquet.

Anchor vein by pulling skin taut below insertion site.

Pierce skin, stabilize catheter, and pierce vein.

Confirm blood return. If no return, pull slightly back
and re-attempt.
With placement confirmed, lower and advance catheter.

Loosen needle from catheter and slightly pull back

on needle.
Advance catheter until hub rests against insertion site.

Stabilize catheter and remove tourniquet.

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Demonstrate procedural steps
Check/
Item Task Comments
initial
Initiating Remove needle and activate safety device.
IV therapy Connect tubing to hub.
(continued)
Confirm patency.
Secure catheter.
Apply transparent dressing over insertion site up
to where hub and tubing connect.
Place support under tubing.
Loop tubing next to IV site and tape to patient’s
arm.
Label as per facility policy.
Set prescribed flow rate.

Replacing Place prepared IV bag and tubing near bedside.

IV solution Identify patient.
Perform medication checks.
Remove cover from tubing port on bag.
Take empty bag off IV pole and invert it.
Move roller clamp to off position.
Remove spike from bag.
Invert new bag and insert spike.
Hang new bag on IV pole.
Inspect tubing for air bubbles; gently tap to
remove them.
For large amount of air, cleanse port below air and
attach needleless syringe to port, then aspirate air
into syringe.
Verify that drip chamber is at least half full.
Adjust roller clamp to set appropriate rate.

Replacing Place new tubing near bedside.

IV tubing Identify patient.
Verify when tubing was last replaced.
Remove tubing from packaging, leaving protective
caps in place.
Connect extension tubing to primary tubing.
Place roller clamp on new tubing in off position.
Place roller clamp on existing tubing in off position.
Take empty bag off IV pole and invert it.
Remove spike from bag.
Drape tubing over pole or table.
Remove protective cap from spike and insert
into bag.

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Demonstrate procedural steps
Check/
Item Task Comments
initial
Replacing Hang bag on IV pole and compress drip chamber
IV tubing two or three times to fill at least halfway.
(continued) Loosen cap and open roller clamp to prime tubing.
Close roller clamp and place cap back on end
of tubing.
Inspect tubing for air bubbles; tap to remove
them.
Place end of tubing near patient.
Prepare supplies.
Remove tape securing tubing to patient’s arm.
Place gauze pad under catheter’s hub.
Stabilize catheter and detach existing tubing
from hub.
Attach end of new tubing to hub and secure it.
Open roller clamp to check patency.
Remove gauze and secure tubing to patient’s arm.
Adjust roller clamp to set rate.

Preparing a Remove tubing and injection cap from packaging.

saline lock Remove cap from proximal end of tubing and from
injection cap and connect them.
Cleanse cap and attach saline-filled syringe.
Remove cap from distal end of tubing and
prime tubing.
Invert access port and tap to fill it with fluid and
remove air.
Inspect tubing for air bubbles; tap to remove
them.
Place cap back on distal end of tubing and leave
syringe attached to cap.
Gather additional supplies.

Converting an Place supplies near bedside.

IV infusion to a Assess IV site.
saline lock
Identify patient.
Move roller clamp to off position.
Remove IV lock adapter from packaging and
cleanse.
Attach 10-mL syringe filled with normal saline and
prime adapter.
Move slide clamp on extension tubing to pinch off
tubing.
Disconnect primary tubing from extension tubing.
Attach primed lock adapter to extension tubing
and flush to confirm patency.

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Demonstrate procedural steps
Check/
Item Task Comments
initial
Converting an Assess site for pain, redness, and swelling.
IV infusion to a Secure tubing to patient’s arm.
saline lock
(continued)

Converting a Place supplies near bedside.

saline lock to an Identify patient.
IV infusion
Perform medication checks.
Move slide clamp on saline lock to pinch off tubing.
Remove saline lock adapter.
Flush to check for patency.
Assess site for pain, redness, and swelling.
Remove protective cap from end of primary tubing
and attach to extension tubing.
Stabilize tubing.
Set flow rate.
Secure tubing to patient’s arm.

Discontinuing Place supplies near bedside.

a peripheral Identify patient.
IV catheter
Move roller clamp on tubing to off position.
Loosen edges of dressing and tape.
Place gauze pad over IV site.
Keeping catheter parallel to skin, pull it straight
back.
Apply pressure with gauze pad to site.
Inspect catheter.
Remove gauze pad.
Assess site.
Apply clean gauze and tape in place.

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Documentation
Check/
Item Task Comments
initial
Document per Inserting a peripheral IV catheter:
facility policy Date and time IV catheter was inserted
Type, length, and gauge of catheter inserted
Location where IV catheter was inserted
Number and location of attempts to insert
catheter
IV solution and any additives infused
Flow rate
Assessment of IV site
Name of person starting IV infusion

Discontinuing a peripheral IV infusion:

Date and time IV infusion was discontinued
Whether or not IV catheter was intact
Condition of IV site
Type of dressing applied (such as pressure
dressing)
Amount of fluid infused
Name of person discontinuing IV infusion

Comments

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