1 Republic of the Philippines

PALAWAN STATE UNIVERSITY

College of Nursing and Health Sciences
Department of Midwifery

CHECKLIST ON IV INSERTION

NAME: _____________________ DATE: __________

YEAR LEVEL: ________________ SCORE:
________

Instruction: Check the corresponding score for every step of the

procedure using the legend
“3”-Has the skills and was able to perform the task correctly
“2”-Has the skills, seldom performs the task; lacks confidence (e.g.
display of nervousness,unsure of what should be done)
“1”- Task not performed, and needs verification.

Goal: To maintain or replace fluids for daily body fluid

requirements;to provide electrolytes to maintain or restore
electrolyte balance; to deliver glucose and nutrients for use as an
energy source, to deliver medication or blood products.

PROCEDURE 1 2 3
1. Verify the physician’s order for IV therapy including solution
type,amount, additives, and infusion rate.
2. Gather all equipment and bring it to the patient’s bedside.
3. Perform hand hygiene.
4. Identify the patient using two separate identifiers.
5. Close door or bed curtains and explain the procedure to the
patient.
PREPARATION
Choice of site:
1. Choose veins in the hand or lower arm
2. Non-dominant site
3. Avoid wrist or arm joints, small visible veins, areas of recent inflammation or
cannulation
4. The selected vein should feel round, elastic, firm, and engorged not hardened,
bumpy or flat.
PREPARE MATERIALS TO BE USED
5. IV fluid D5LR
6. IV needle/cannula g.18 or g.20
7. IV tubing/Macro set
8. Tourniquet
9. Cotton balls with alcohol
10. Micropore
11. Disposable gloves
Preparing the solution
12. Remove the IV solution bag from the outer plastic covering. Open all other
equipment packages, maintaining sterility of the equipment.
13. Grasp the IV administration set and close the flow clampon the tubing.
Attach an extension set tubing to the administration set if necessary.
14. Remove the protective cap or tear the tab from the tubing insertion port on
the solution container; remove the protective covering from the spike on the
administration tubing. Hold the port carefully and firmly with one hand, the
quickly insert the spike into the port with the other hand
15. Invert the solution container and hang it on the IV pole with the infusion
 Republic of
2 the Philippines

PALAWAN STATE UNIVERSITY

College of Nursing and Health Sciences
Department of Midwifery
2

pump. Compress the drip chamber until it is approximately half full. Remove the
protective cap from the end of the infusion tubing (or extension set,if used);
direct the end of the tubing toward a receptacle. Open the flow clamp on the
tubing and allow the fluid to run through the tubing until all the air has been
removed and the entire length of the tubing is filled with solution;then close the
flow clamp.
16. Attach the solution and tubing to the infusion control device according to the
manufacturer’s instructions. Apply label to the solution container if one has not
already been applied by the pharmacy.
Selecting the insertion Site
17. Place the patient in a comfortable, reclining position,leaving the arm in a
dependent position.place a towel or protective pad under the extremity to be used.
Inspect and palpate the patient’s extremity to identify an appropriate vein. Select the
puncture site. If long-term therapy is anticipated, start with a vein at the most distal site
so that you can move proximally as needed for subsequent IV insertion sites.
18. Put on clean gloves and apply a tourniquet about 6 inches (15 cm) above the
intended puncture site. Ensure that the ends of the tourniquet are positioned away from
the intended insertion site. Check for a radial pulse. If it isn’t present , release the
tourniquet
19. Lightly palpate the vein with the index and middle fingersof your nondominant
hand. Stretch the skin to anchor the vein. If the vein feels hard or ropelike, select
another site.
Inserting the Device and Initiating Therapy
20. Clean the site using the approved antimicrobial agent according to facility policy.
Work in a circular motion outward from the site to a diameter of 2 to 4 inches ( 5 to 10
cm), and allow the agent to dry .
21. Grasp the device . Using the thumb of your nondominant hand ,stretch the skin
below the puncture site. If using a vein in the hand, position the hand in a slightly flexed
position to keep the skin taut. Tell the patient that you are about to insert the device
and that you need him or her remain still.
22. Hold the needle bevel up at 15-to- 30- degree angle, depending on estimated depth
of the vein, and enter the skin parallel to the vein. Decrease the angle of the needle
until almost parallel with the skin, and advance the device into the vein in one motion
either from directly over the vein or from the side. You will feel a sense of release or a
pop as you enter the vein. Check for blood return and then advance the device,
maintaining the device parallel to the skin until the hub is at the insertion site
23. Hold finger pressure over end of catheter while removing needle stylet.
24. Remove the tourniquet quickly . while holding the hubwith your nondominant
hand,attach the end of the infusion tubing to the device.
Applying a Dressing
25. Apply a dressing (most commonly a transparent,semipermeable dressing) to the
site. Alternatively , secure the device with nonallergenic tape
26. Loop any IV tubing on the patient’s extremity and secure with tape
27. Label the dressing with the date and time of insertion;device type,gauge, and
size;and your initial’s
28. Begin the infusion, setting the infusion pump to the prescribe rate flow. Assess the
flow of the solution and infusion control device function. Inspect the site for signs of
infiltration.
Providing Ongoing Care
29. Dispose of all equipment and remove gloves. Perform hand hygiene.
30. Apply site protection device and secure as necessary.
31. Assisst the patient to a comfortable position. Assess the patient’s tolerance of the
procedure.
 Republic of
3 the Philippines

PALAWAN STATE UNIVERSITY

College of Nursing and Health Sciences
Department of Midwifery
3

32. Document the procedure, including the date and time of the venipuncture;device
type,gauge, and length;location of insertion site and appearance;type and flow rate of
the IV solution;patient’s response( including adverse reactions);patient teaching
performed;and patient’s understanding of the teaching.
33. Monitor infusion rate,condition of IV site,and patient complaints,initially
approximately 30 minutes after beginning the infusion and then according to facility
policy. Change dressing, tubing, and solution according to facilty policy.

TOTAL SCORE

Clinical Instructor:

Student’s Name& Signature

 1

(Performs examination according to clinic/agency policies ate

Dat

(Performs examination according to clinic/agency policies and

pro(Performs examination according to clinic/agency policies and
cedure)