N U R S 227 | W e e k 2 S k i l l I n t r a v e n o u s ( I V ) T h e r a p y ( 1 1 5 p o i n t s t o t a l )
Red text suggests failure of skill if incorrectly performed or omitted, per instructor discretion.
General Beginning Steps
1.1 Review client MAR & any pertinent labs/assessment data. (1 point)
1.2 Assess for procedure need (1 point)
1.3 Gather supplies & appropriate disposal of waste. (1 point)
1.4 Introduce yourself to the client. Wash hands (1 point)
1.5 Verify client with 2 identifiers. (1 point)
1.6 Provide client education. (1 point)
1.7 Adjust bed to comfortable working height, assist the client to a comfortable position & ensure client safety (1
point)
Perform hand hygiene and put on appropriate PPE if indicated. (1 Point)
1.8
2.1 Perform medication check. (First check). (1 point)
Remove IV solution from packaging and gently apply pressure to bag while inspecting for tears or leaks.
2.2
Check color, clarity, and expiration date. (1 point)
Priming IV Tubing
Remove primary IV tubing from packaging. (2 points)
2.3 For gravity tubing: Move roller clamp to 1 to 2 inches below drip chamber and close clamp.
For pump tubing: Ensure cassette is closed.
2.4 Perform medication check. (Second check). (1 point)
Remove cover from tubing port on bag. Remove cap insertion spike and insert spike into tubing port of bag,
2.5 maintain aseptic technique. *** If using glass bottle, cleanse rubber stopper before inserting spike. (2
points)
2.6 Hang bag on IV pole and squeeze drip chamber two or three times to fill only at least halfway. (1 point)
For gravity tubing: Loosen cap from end of tubing and open clamp to prime tubing. (4 points)
2.7 For pump tubing: Open cassette by pulling or turning. Follow manufactures instructions to properly prime IV
cassette. Ensure excess fluid/medication is not wasted.
2.8 Check entire length for air bubbles; tap tubing and invert ports to remove air. (2 points)
For gravity tubing: Roll clamp to closed position. For pump tubing: Close cassette to stop the flow of fluid. (3
2.9
points)
2.10 Replace or tighten cap on end of tubing maintain aseptic technique. (1 point)
2.11 Label tubing near drip chamber. (1 point)
3.1
Open short extension tubing and aseptically prime with normal saline. Ensure there are no air bubbles.
Place cap back on distal end of tubing and leave syringe attached to cap. (4 points)
3.2 Place IV tubing within reach and prepare supplies. (1 point)
Preparing saline lock, inserting
catheter & administering
continuous IV fluids
3.3 Place tourniquet on client’s arm. (1 point)
3.4 Inspect hand and arm, palpating and selecting vein. (1 point)
3.5 Release tourniquet. (2 points)
3.6 Cleanse insertion site and allow it to dry. (1 points)
3.7 Reapply tourniquet 5 to 6 inches proximal to the venipuncture site. (3 points)
3.8 Anchor vein by pulling skin taut below insertion site. (3 points)
3.9 Pierce skin with bevel up, stabilize catheter, and pierce vein using approximately a 15 angle. (4 points)
3.10 Confirm blood return. If no return, pull slightly back and re-attempt. (3 points)
Follow the course of the vein, advancing the needle and catheter into the vein until blood returns to the
3.11 lumen of the needle or flashback chamber of the catheter, slightly lower and advance needle into the vein
approx. ¼” to ensure catheter is completely in vein. (4 points)
3.12 Loosen needle from catheter and slightly pull back on needle. (1 point)
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N U R S 227 | W e e k 2 S k i l l I n t r a v e n o u s ( I V ) T h e r a p y ( 1 1 5 p o i n t s t o t a l )
Red text suggests failure of skill if incorrectly performed or omitted, per instructor discretion.
3.13 Advance catheter until hub rests against venipuncture site. (1 point)
3.14 Stabilize catheter, activate safety device, and remove tourniquet. (5 points)
3.17
Stabilize catheter with non-dominant hand. Confirm patency by flushing with 3-5 mL normal saline,
observing for infiltration and leaking. (1 point)
Preparing saline lock, inserting catheter &
administering continuous IV fluids (cont.)
Stabilize catheter with non-dominant hand. Quickly remove protective cap from short extension tubing and
attach it to the catheter, maintaining sterility. (1 point)
Converting IV infusion to saline lock
3.16
4.1 Place supplies near bedside. (1 point)
Discontinuing a peripheral IV catheter
Stabilize catheter with non-dominant hand. Apply pressure above catheter tip. Disconnect catheter from
insertion device and discard in sharps container. (5 points)
3.15
5.1 Move roller clamp on tubing to off position. Gather Supplies (Gauze and tape or bandage). (1 point)
3.18 Secure catheter. Apply transparent dressing over insertion site up to where hub and tubing connect. (1 point)
3.19 Loop tubing next to IV site and secure with tape. (1 point)
3.20 Label dressing as per facility policy. (1 point)
3.21
Perform medication check, set prescribed flow rate. (Third check). (2 points)
Cleanse injection port and attach primed primary IV tubing to Luer-Lok port and set fluid at appropriate rate.
Document according to facility policy (3 points)
3.22
Date and time IV catheter 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
4.2 Assess IV site. (2 points)
4.3
For gravity tubing: Move roller clamp to off position. (1 point)
For pump tubing: Stop pump
4.4 Disconnect primary tubing from extension tubing. (1 point)
4.5
Cleanse injection port, attach 3-mL or 10-mL syringe filled with normal saline to extension tubing maintaining
aseptic technique. (3 points)
4.6 Flush extension tubing with normal saline. Assess site for pain, redness, and swelling. (3 points)
4.7 Move slide clamp on extension tubing to pinch off tubing. (3 points)
4.8 Secure tubing to patient’s arm. (1 points)
5.2 Loosen edges of dressing and tape. (1 point)
5.3 Place gauze pad over IV site. (1 point)
5.4 Keeping catheter parallel to skin, pull it straight back. (3 points)
5.5 Apply pressure c̄ gauze pad to site. Do not apply pressure until catheter is completely removed from vein. (3
points)
5.6 Inspect tip of catheter. (10 points) Must verbalize this for skill re-demo.
5.7 Remove gauze pad. (1 point)
5.8 Assess site. (1 point)
5.9 Apply clean gauze & tape or bandage in place. (1 point)
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N U R S 227 | W e e k 2 S k i l l I n t r a v e n o u s ( I V ) T h e r a p y ( 1 1 5 p o i n t s t o t a l )
Red text suggests failure of skill if incorrectly performed or omitted, per instructor discretion.
5.10 Document according to facility policy (2 points)
Date and time IV infusion was discontinued
⬜ Whether or not IV catheter tip was intact
Condition of IV site
Type of dressing applied (such as pressure dressing)
Amount of fluid infused
Name of person discontinuing IV infusion
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N U R S 227 | W e e k 2 S k i l l I n t r a v e n o u s ( I V ) T h e r a p y ( 1 1 5 p o i n t s t o t a l )
Red text suggests failure of skill if incorrectly performed or omitted, per instructor discretion.
Replacing IV solution (Instructor will demo)
1. Place prepared IV bag and tubing near bedside.
2. Perform medication checks.
3. Remove cover from tubing port on bag.
4. Take empty bag off IV pole and invert it.
5. For gravity tubing: Move roller clamp to off position. For pump tubing: Stop pump
6. Remove spike from bag.
7. Invert new bag and insert spike.
8. Hang new bag on IV pole.
9. Inspect tubing for air bubbles; gently tap to remove them.
10. For large amount of air, cleanse port below air and attach needleless syringe to port, then aspirate air
into syringe, or backprime into pump.
11. Verify that drip chamber is at least half full.
12. For gravity tubing: Adjust roller clamp to set appropriate rate.
For pump tubing: Set pump to appropriate rate and reset volume
Converting a saline lock to an IV infusion (Instructor will demo)
1. Perform medication checks.
2. Move slide clamp on saline lock to pinch off tubing.
3. Remove saline lock adapter.
4. Flush to check for patency.
5. Assess site for pain, redness, and swelling.
6. Remove protective cap from end of primary tubing and attach to extension tubing.
7. Stabilize tubing.
8. Set flow rate.
9. Secure tubing to patient’s arm.
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