Southville International School and Colleges

College 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 bottle
8. Open the seal of the IV bottle
aseptically
9. Open IV set aseptically and close clamp
10.Spike the infusate aseptically
11.Fill drip chamber to at least half and
prime the tubing aseptically
12.Remove air bubbles if any and put back
the cover to the distal end of tubing.

(get ready for insertion)

 STEPS CD ID REMARKS

B. CHANGING AN IV INFUSION:
1. Verify doctor’s order and make IV label
2. Explain procedure to patient/SO
3. Assess IV site for any complications
4. 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 procedure
7. Prepare necessary materials. (IV
solution, disinfectant, kidney basin on
IV tray)
8. Check sterility and integrity of solution
9. Place IV label on IV bottle
10.Open and disinfect rubber port of IV
solution to follow
11.Close the clamp or kink tubing and pull
infusate from the runaway IV bottle
aseptically
12.Spike the infusate into the rubber port
of the new IV solution bottle aseptically
13. Regulate flow as ordered.
14.Reassure patient /SO
15.Discard all waste materials according to
hospital policy
16.Document accordingly on patient’s
chart.
C. DISCONTINUING AN IV INFUSION:
1. Verify doctor’s order
2. Explain procedure to patient/SO
3. Assess patient and IV site for any
complications
4. Wash hands before and after procedure
5. 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 tubing
7. 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
 STEPS CD ID REMARKS
if bleeding persists.
13.Place sterile dressing over venipuncture
site and secure with plaster.
14.Reassure patient/SO
15.Discard all used materials according to
hospital policy
16.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 Dean
Southville International School and Colleges
College of Nursing

IVT CHECKLIST

NAME: _______________________________________________
SECTION:________________________

PROCEDURE II: BLOOD TRANSFUSION

STEPS CD ID REMARKS
1. Verify doctor’s order
2. Explain the procedure to patient/SO.
Secure informed consent
3. 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
available
6. Warm blood at room temperature by using
blood warmer or simply wrap blood bag in
towel
7. Countercheck the compatible blood to be
transfused. Double/triple check
crossmatching results, serial number,
 STEPS CD ID REMARKS
expiration date and type of blood
component with another colleague.
8. Monitor patient’s VS and assess for any
untoward s/s
9. Administer premedications as ordered,
usually 30 minutes before transfusion.
10. Wash hands before and after procedure
11.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 units of blood to prevent
sluggish transfusion rate.

18.If blood is consumed, close roller clamp of

BT set
then 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, MAN
Clinical Instructor Level IV Coordinator Dean

Southville International School and Colleges

College 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
 STEPS CD ID REMARKS
the written doctor’s order
2. Observe “10 Rights” when preparing
and administering medications
3. Explain procedure to patient/SO
4. 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
procedure
6. 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 gently
9. 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.

16.Discard sharps and wastes according

to hospital policy
17.Document accordingly

(If the patient has a Heparin –lock device

(Heplock)
 STEPS CD ID REMARKS
1. Do steps 1-5
2. 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
reaction
10.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

B. DRUG INCORPORATION INTO IVF

CONTAINER:
1. Countercheck with written doctor’s
 STEPS CD ID REMARKS
order, make a medication card
2. Observe “10 Rights” when preparing
and administering medication
3. Explain procedure to patient/SO
4. Assess patient, IV site, and verify skin
test result of the drug to be
administered.
5. Wash hands before and after
procedure
6. 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 patient
11.Discard all used devices according to
hospital policy
12.Document accordingly

C. DRUG INCORPORATION INTO

SOLUSET:
1. Countercheck with written doctor’s order
and make medication card
2. Observe “10 Rights” when preparing and
administering medications
3. Explain procedure to patient/SO
4. 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 procedure
6. 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.
 STEPS CD ID REMARKS
(Spike solu-set to new IVF container, prime the
tubing, place an appropriate needle to distal end
of tubing, and connect to the IV main line
through the Y-injection port, secure with tape)

7. Aspirate prepared right drug with correct

dose
8. Add desired IVF diluents into solu-set by
opening the clamp from the bottle then
close the clamp after
9. Disinfect rubber injection port of the
soluset and incorporate the drug. Mix
gently
10.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 reaction
15.Regulate flow rate of main IV fluid
16.Discard all waste according to hospital
policy
17.Document accordingly

TOTAL SCORE: ______________

 Southville International School and Colleges
College of Nursing

IVT CHECKLIST
NAME: _______________________________________________
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 / SO
3. Observe “10 Rights” of medication
administration
4. Wash hands before and after procedure
5. Choose site for IV
6. Apply tourniquet 2-6 inches above
injection site depending on condition of
patient
7. Check for radial pulse below tourniquet
8. 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 hub
14.Release the tourniquet, remove the stylet
while applying digital pressure over the
 STEPS CD ID REMARKS
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
infusion
17.Anchor cannula in place with the use of:
a. Transparent tape (tegaderm) or sterile
dressing over 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 effect
23.Discard all used devices according to
hospital policy
24.Document in the patient’s chart
accordingly

TOTAL SCORE: ________________

Legend:

CD - correctly done
ID - incorrectly done
Prepared by: Reviewed by: Approved by:

Monet Davidson, RN April Apple Gareza, RN Carmel

Villegas, RN, MAN
Clinical Instructor Level IV Coordinator Dean