College of San Mateo
Nursing 232
IV Piggyback Skills Checklist
Student Name: ________________________ Clinical Group: ___________ Peer Checkoffs: #1 _______ #2_______ #3_______ #4_______
If unsuccessful on the second attempt of passing a skill, the student will receive a Course Notification.
*** The students must be able to demonstrate and perform the correct math calculation required for this check-off. If at any time during the check-off you are unable to do the math the check will be terminated immediately. REMEMBER to speak loud and clear when explaining procedure to the patient (for your instructor to evaluate your understanding of the following criteria).
Procedural Steps First Attempt Second Attempt Third Attempt Fourth Attempt
Pass No
Pass
Pass No Pass Pass
No
Pass
Pass No Pass
1.
2.
Check physician’s orders (by comparing MAR/computer to MD orders).
Verify dosage is in safe range (look it up in your med book)
5.
6.
7.
3.
4.
8.
9.
Perform hand hygiene – wash hands for at least 10-15 seconds OR de-germ.
Select correct medication secondary bag prepared by pharmacy from med cart by completing three checks and consulting medication book for compatibility to MD orders.
Gather equipment, MAR and take to bedside.
Identify yourself.
Verify client’s identification and allergy status via band and questioning client. Minimum of two identifiers.
Compare to MAR/computer.
Explain procedure keeping HIPAA guidelines in mind.
Inform the patient the name of the medication you are administering, the reason for the medication, and any side effects the patient should report to you.
10.
Visually assess IV site for any abnormalities.
11.
Visually check to ensure compatibility with primary infusing solution.

12.
Apply gloves. Attach tubing of administration set to prepared admixture container and close the clamp.
13.
After cleaning port with antiseptic swab for 15 seconds, attach tubing to recessed connection port above backcheck valve.
14.
Using the back-priming method prime the tubing secondary tubing.
15.
Close roller clamp, squeeze drip chamber, and fill half full.
16.
Lower primary IV line.
17.
Open regulator or clamp on mini-bag infusion.
Set rate on the IVP pump to deliver the secondary bag for the correct flow-rate and volume to be infused.
18.
Remove and dispose of gloves.
19.
Perform hand hygiene for at least 10 to 15 seconds OR de-germ.
20.
Document correctly on MAR/computer using actual date and time of video simulation.
21.
State that you will return in 10 minutes to assess client for any adverse reaction, flow of medication, and IV site.
22.
Insure that the call-light is within the patient’s reach prior to leaving the room AND instruct patient to call if experiences any signs and symptoms of adverse reactions such as rash, difficulty breathing, upset stomach, pain at
IV site, etc.
23.
Perform hand hygiene for at least 10 to 15 seconds OR de-germ prior to leaving the room.
ACCESS THE LAB INSTRUCTOR WHEN FINISHED, do not touch IV controller --LEAVE THE IV PUMP ON FOR YOUR
INSTRUCTOR TO VERIFY CORRECT SETTINGS.
References
Elkin, M.K, Perry, A.G., & Potter, P.A. (2011). Nursing interventions and clinical skills (4th ed.). St. Louis: Mosby/Elsevier
Laskowski-Jones, L., & Falkowski, A. (2010). Infusion therapy. In D.D. Ignatavicius & M.L. Workman (Eds.), Medical-surgical nursing: Patient-
centered collaborative care (6 th
ed., pp. 213-240). Philadelphia, PA: Saunders/Elsevier.
Revised 9/21/10 IFS
Revise 10/3/11 TDP