NEW ERA UNIVERSITY

College of Nursing

PERFORMANCE EVALUATION TOOL

Administration of IV Medication
Medication Incorporation into Volumetric Chamber

Name: _______________________________ Group No.________ Date: ________Grade:________

DIRECTION: Rate the student’s performance utilizing the scale below:

3 - Demonstrated procedure accurately, correctly stated rationale.

2 - Demonstrated procedure accurately, incomplete rationale stated.
1 – Demonstrated procedure inaccurately, incorrect/no rationale stated.
0 – Not Demonstrated

COMPETENCIES REMARKS
1. States objectives of the procedure.
2. Verifies the written medication card against the physician’s
order.
3. Observes ten (10) R’s when preparing medication.
4. Greets the client and introduces self
5. Identifies client with two identifiers.
6. Explains the procedure and action of medication to the
client significant others.
7. Checks the patency and integrity of the IV site.
8. Verifies the skin test result of the medication.
9. Determines for drug-drug, drug-IV fluid incompatibility.
10. Performs hand hygiene.
11. Prepares the necessary materials for procedure.
12. Checks the present IV fluid for label, level, and presence
of any incorporated medicine.
13. Prepares the right medication.
13.1 Performs triple checking in preparing medication. First check: label checking (medicine
drawer or cabinet)
Second check: Compare label with MAR;
check expiration; and perform
calculations
Third check: After preparing and/or
before administration

This is to ensure accuracy and helps to

13.2 Disinfects injection port of the diluents, vial and ampule.
Aspirates right volume of diluents for the medicine (if
needs to be diluted).
13.3 Removes the air if any.
13.4 Aspirates the right dose.
14. Adds desired IVF diluents into volumetric chamber by opening
the sliding clamp from the bottle then closes the clamp.
15. Disinfects rubber injection port of the volumetric chamber
16. Incorporates the medication and mix gently.
prevent errors.
This deters entry of microorganisms when
the syringe enters.
A decision to dilute a specific medication
was also influenced by a prescriber's order
or by a recommendation from a drug or
device manufacturer, the pharmacy, an IV
drug reference, or a hospital policy.
It may cause air bubbles in the tubing and
cause potential harm to patient.
To prevent adherence to the medication
and to provide the dose that client needs.
This dilutes the medication in a minimal
amount of solution. Reclamping prevents
the continued addition of fluid to the
volume to be mixed in the medication.
Deters entry of m.o. when the syringe
enters the chamber.
This ensures that medication evenly

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 NEW ERA UNIVERSITY
College of Nursing

mixed with the solution.

17. Opens the clamp of the airway at the volumetric chamber.
18. Regulates flow rate of IVF infusion accordingly.
19. Places IV label on volumetric chamber indicating drug
incorporated and flow rate.
20. Observes for signs and symptoms of adverse drug reaction.
21. Discards sharps and other waste according to Health Care
Management (DOH/DENR).
22. Performs hand hygiene.
23. Documents all relevant information.
24. Assesses the effectiveness of the medication.
Airvent allows fluid in the chamber to
flow at a regular rate.
Delivery over 30 to 60 minutes interval is
safe method of administering IV
medication.
This identifies content of the set and
prevent medication error.
To prevent causing harm to the patient
and provide early intervention.
Proper disposal prevent injury.
Hand hygiene prevents the spread of m.o.
Timely documentation helps to ensure
patient safety.
The patient needs to be evaluated for
therapeutic and adverse medication.

Fundamentals of Nursing Checklist Skills Laboratory