Republic of the Philippines
President Ramon Magsaysay State University
Iba, Zambales, Philippines
COLLEGE OF NURSING
PERFORMANCE EVALUATION CHECKLIST
ADMINISTERING AN INTRAMUSCULAR INJECTION
Name: ______________________________________________
Date: ___________________________
Year: ______________ Section: _____________ Group Number: ________________ Rating: ___________________
Direction: Please check the appropriate box below to describe verbalized or demonstrated competence level
using the following criteria:
5
Correctly and independently performs procedure and state rationale
4
Perform procedure and state the rationale with minimal guidance
3
Satisfactorily perform procedure with moderate guidance
2
Procedures incorrectly done without rationale
1
Not performed
Procedure
5
4
3
1.
2.
Assemble equipment and supplies needed.
Check the label on the medication carefully against the MAR to make sure
that the correct medication is being prepared.
3. Follow the three checks for administering medications. Read the label on the
medication:
- When it is taken from the medication cart
- Before withdrawing the medication
- After withdrawing the medication
4. Perform hand hygiene and observe other appropriate infection control
measures.
5. Prepare the medication from the vial or ampule for drug withdrawal.
6. Provide for client privacy.
7. Prepare the client. Introduce self and verify client’s identity.
8. Explain procedure to the client. Include relevant information about effects of
the medication.
9. Assist the client to a supine, lateral, prone, or sitting position depending on
the chosen site.
10. Select a site free of tenderness, harness, swelling, scarring, itching, burning
and localized inflammation. Select a site that has not been used frequently.
11. If injections are to be frequently, alternate sites. Avoid using the same site
twice in a row.
12. Put on clean gloves.
13. As per agency protocol, clean the site with an antiseptic swab. Start at the
center of the site and clean in a widening circle to approximately 5 cm (2
inches). Allow the area to dry thoroughly.
2 of 2
2
1
14. Place and hold a clean swab between the third and fourth fingers of the nondominant hand, or position the swab on the client’s skin above the intended
site.
15. Prepare the syringe for injection. Remove the needle cap while waiting for
the antiseptic to dry. Pull the cap straight off to avoid contaminating the
needle by the outside edge of the cap. Dispose of the needle cap.
16. If using a unit-dose medication, take the caution to avoid dripping
medication on the needle prior to injection. If this does occur, wipe the
medication off the needle with sterile gauze.
17. Inject the medication using a Z-track technique. Use the ulnar side of the
non-dominant hand to pull the skin approximately2.5cm (1in) to the side.
18. Holding the syringe between the thumb and forefinger, pierce the skin
quickly and smoothly at a 90-degree angle and insert the needle into the
muscle.
19. Hold the barrel of the syringe steady with non-dominant hand and aspirate by
pulling back on the plunger with dominant hand. Aspirate for 5-10 seconds.
If blood appears in the syringe, withdraw the needle, discard the syringe and
prepare a new injection.
20. If blood does not appear, inject the medication steadily and slowly while
holding the syringe steady.
21. After injection, wait for 10 seconds.
22. Withdraw the needle smoothly at the same angle of insertion. Release the
skin.
23. Apply gentle pressure at the site with a dry sponge or cotton.
24. If bleeding occurs, apply pressure with a dry sterile gauze until it stops.
25. Discard the uncapped needle and attached syringe into the proper receptacle.
Remove glove and perform hand hygiene.
26. Document the medication given, dosage, time, route and any assessments.
27. Assess the effectiveness of the medication at the time it is expected to act.
TOTAL (135 POINTS)
Actual Points: _______________
Computation:
𝑎𝑐𝑡𝑢𝑎𝑙 𝑝𝑜𝑖𝑛𝑡𝑠
𝑥 60 + 40
𝑇𝑜𝑡𝑎𝑙 𝑠𝑐𝑜𝑟𝑒
Grade: ___________
Remarks:
_______________________________________________________________________________________________
_______________________________________________________________________________
Evaluated by:
Conformer:
_______________________
Clinical Instructor
__________________________
Signature of the Student
Noted by:
Approved by:
Joel D. Federico, RN, MAN
Clinical Coordinator
Celeste A. Orge, PhD., RN
Dean, College of Nursing
2 of 2