Republic of the Philippines

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
NURSING DEPARTMENT
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

Performance Evaluation Checklist

NCM 107 Skills 4 (Parenteral Administration of Drugs: Using Medication Ampule and Vial)
Name of Student: ______________________________________
Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ___First Semester ____Second Semester ___ Summer
Inclusive Dates of Clinical Rotation: __________________
Instructor: _____________________________________________

Purposes:
1. To learn how to break and open the neck of an ampule.
2. To aspirate medications from an ampule.

Preparation SCORE REMARKS

ASSESSMENT
1. Assess: 2 1 0
 Allergies to medication
 Specific drug action, side effects,
interactions, route and adverse reaction
 Ordered medication for clarity and
expiration date
 Vital signs and laboratory results
PLANNING
2. Assemble equipment:
 Medication card/MAR
 Medication tray
 Ampule/Vial of sterile medication
 Small square gauze
 Antiseptic swabs/wet cotton balls
 Needle and syringe
 Filter needle
 Sterile water or normal saline, if drug is in
powder form (for vials)
3. Check the medication administration order
(MAR) against the label of the ampule
carefully.
4. Read the label of the medication
(1) WHEN it is taken from the medication
cart
(2) BEFORE withdrawing the medication
(3) AFTER withdrawing the medication
IMPLEMENTATION
Procedure (Ampule)
5. Perform hand hygiene and observe other
infection control procedures.
6. Prepare the medication ampule for the
drug withdrawal.
7. Flick the upper stem of the ampule several
 with a fingernail or shake the ampule
similar to shaking down a mercury
thermometer.
8. Place a piece of sterile gauze between your
thumb and the ampule neck and break off
the top by bending it toward you.
9. Dispose of the top of the ampule in the
sharps container.
10. Withdraw the medication.
11. Using a filter needle, withdraw the
medication, disconnect the regular needle
leaving its cap on and attach the filter
needle to the syringe.
12. Remove cap from the filter needle and
insert the needle into the center of the
ampule. Do not touch the rim of the ampule
with the needle tip or shaft. Withdraw the
amount of drug required for the dosage.
13. Hold the ampule slightly on its side to
obtain all the medication.
14. Replace the filter needle with a regular
needle and tighten the cap at the hub of
the needle before injecting the client.
Procedure (Vial)

15. Prepare the medication vial for the drug

withdrawal.

Mix the solution, if necessary, by rotating

the vial between the palms of the hands,
not by shaking.
16. Remove the protective cap, or clean the
rubber cap of a previously opened vial with
an antiseptic wipe buy rubbing in a circular
motion.
17. Attach a filter needle to draw up premixed
liquid medications. Ensure that the needle
is firmly attached to the syringe.
18. Remove the cap from needle and draw up
into the syringe the amount of air equal to
the volume of the medication to be
withdrawn.
19. Carefully insert the needle into the upright
vial through the center of the rubber cap,
maintaining the sterility of the needle.
20. Inject the air into the vial, keeping the
bevel of the needle above the surface of
the medication.
21. Withdraw the prescribed amount of
medication by inverting the vial at an eye
level and ensuring that the needle tip is
below the fluid and gradually withdraw the
medication.
22. When correct volume of medication is
obtained, withdraw the needle and replace
the cap using the scoop method.
23. Tap the syringe barrel to dislodge any air
bubbles present in the syringe.
24. Replace the filter needle with a regular
needle and cover of the correct gauge and
length before injecting the client.
25. Remove the protective cap, or clean the
rubber cap of a previously opened vial with
an antiseptic wipe buy rubbing in a circular
motion.
EVALUATION
26. Read the label of the medication once
again prior to administration.

Shown to me by:

________________________________
Signature over Printed Name
Clinical Instructor

Shown to me:

________________________________
Signature over Printed Name
Student
 Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

Performance Evaluation Checklist

NCM 107 Skills 4 (Parenteral Administration of Drugs: Intradermal Route)

Name of Student: _______________________________________

Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ___First Semester ____Second Semester ___ Summer
Inclusive Dates of Clinical Rotation: __________________
Instructor: _____________________________________________

Purposes:
1. Used for allergy testing, tuberculosis screening and BCG vaccinations.

Preparation SCORE REMARKS

ASSESSMENT
1. Assess: 2 1 0
 Appearance of injection site
 Specific drug action and expected
response
 Client’s knowledge of drug action and
response
PLANNING
2. Assemble and organize equipment:
 Vial or ampule of the correct medication.
 Filter needle
 Sterile 1-mL syringe
 Dry and wet cotton balls/ antiseptic swabs
 Clean gloves (according to agency
protocol)
 Pen
 Micropore tape
3. Check the medication administration order
(MAR) against the label of the ampule/vial
carefully.
4. Read the label of the medication
(1) WHEN it is taken from the medication
cart
(2) BEFORE withdrawing the medication
(3) AFTER withdrawing the medication
IMPLEMENTATION
Procedure
5. Perform hand hygiene and prepare the
medication from a vial or ampule for drug
withdrawal.
6. Prepare the client.

Check the client’s identification band. Explain

 the procedure to the patient and he/she will
expect. (pain and appearance of a bleb/wheal)
7. Provide for client privacy and don clean
gloves.
8. Select area on the inner aspect of the
forearm that is not heavily pigmented or
covered with hair.
9. Cleanse the site with an alcohol swab by
wiping with a firm circular motion and
moving outward from the injection site.

Allow skin to dry.

10. Remove the needle cap with non-dominant
hand by pulling it straight off.
11. Taut the skin using your non-dominant
hand.
12. Place needle almost flat against the
patient’s skin, bevel side up.
13. Insert the needle into the skin so that the
point of the needle can be seen through
the skin. Insert needle only about 1/8 inch.
14. Stabilize the syringe and needle. Inject the
medication carefully and slowly so that it
produces a small wheal on the skin.
15. Withdraw the needle quickly at the same
angle that it was inserted.
16. Do not massage area after removing
needle.
17. Discard needle and syringe in the
appropriate receptacle. Do not recap.
18. Remove gloves. Perform hand hygiene.
19. Circle the injection site with ink to observe
for redness or induration.
20. Write in a piece of Micropore tape the
medication administered for skin test and
the due time to check for reactions (usually
after 30 minutes).
21. Discard needle and syringe in the
appropriate receptacle. Do not recap.
EVALUATION
22. Document administration of medication,
site, time, dosage, route and nursing
assessments.
23. Observe for possible reaction to the
administered medication.
Shown to me by:

________________________________
Signature over Printed Name
Clinical Instructor

Shown to me:

_______________________________
Signature over Printed Name
Student
 Republic of the Philippines

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
NURSING DEPARTMENT
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

Performance Evaluation Checklist

NCM 107 Skills 3 (Parenteral Administration of Drugs: Intramuscular Route)
Name of Student: _______________________________________
Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ____First Semester ____Second Semester ____Summer
Inclusive Dates of Clinical Rotation: _________________________
Instructor: _____________________________________________

Purposes:
1. To provice a medication that the client requires. If no other advanced routes are available.

Preparation SCORE REMARKS

ASSESSMENT
1. Assess: 2 1 0
 Client allergies to medications
 Specific drug action, side effects, and adverse
reactions
 Client’s knowledge of and learning needs about
the medication
 Tissue integrity of the selected site
 Client’s age and weight, to determine site and
needle size
 Client’s ability or willingness to cooperate
PLANNING
2. Assemble and organize equipment:
 MAR or medication card
 Vial or ampule of the correct medication.
 Syringe and needle of a size appropriate for the
amount of solution to be administered
 Dry and wet cotton balls/ antiseptic swabs
 Clean gloves (according to agency protocol)
 Micropore tape
3. Check the medication administration order
(MAR) against the label of the ampule/vial
carefully.
4. Read the label of the medication
(1) WHEN it is taken from the medication cart
(2) BEFORE withdrawing the medication
(3) AFTER withdrawing the medication
IMPLEMENTATION
5. Perform hand hygiene and observe other
appropriate infection control procedures.
6. Prepare the medication from the ampule or vial
 for drug withdrawal.
7. Provide for client privacy.
8. Prepare the client by introducing self and
verifying client’s identity using agency protocol.

Assist the client assume a position for the site

selected.
 Ventrogluteal- supine position with knee
flexed
 Vastuslateralis- supine or sitting position
 Deltoid- sitting or supine with arm relaxed
 Dorsogluteal- prone with toes pointing
inward or side lying with upper leg flexed
and placed in front of the lower leg
9. Locate site of choice and ensure that the area is
not tender and is free of lumps or nodules. Don
disposable gloves.
10. Clean area thoroughly with antiseptic swab
using a circular motion, start at the center and
move outward about 5cm (2 inches)
11. Remove needle cap by pulling it straight off.
12. Displace skin in a Z-track manner or spread skin
at the site using your non-dominant hand.
13. Hold syringe in your dominant hand between
thumb and forefinger. Pierce the skin quickly
and smoothly at a 90-degree-angle.
14. As soon as the needle is in place, move your
non-dominant hand to hold lower end of
syringe. Slide your dominant hand to the tip of
the barrel.
15. Aspirate by slowly pulling back on plunger to
determine whether the needle is in a blood
vessel. If blood is aspirated, discard needle,
syringe and medication. Prepare a new sterile
set up and inject in another site.
16. If no blood is aspirated, inject solution slowly
(10 seconds per mL of medication)
17. Remove needle slowly and steadily. Release
displaced tissue if Z-tract technique is used.
18. Apply gentle pressure at the site with a dry
cotton ball.
19. Do not recap used needle. Discard needle and
syringe in appropriate receptacle.
20. Remove gloves and perform hand hygiene.
EVALUATION
21. Document administration of medication, site,
time, dosage, route and nursing assessments.
22. Observe for possible reaction to the
administered medication.
Shown to me by:

________________________________
Signature over Printed Name
Clinical Instructor

Shown to me:
_______________________________
Signature over Printed Name
 Student

Republic of the Philippines

TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

Performance Evaluation Checklist

NCM 107 Skills 3 (Administering Ophthalmic Instillations)

Name of Student: _______________________________________

Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ____First Semester ____Second Semester ____Summer
Inclusive Dates of Clinical Rotation: _________________________
Instructor: _____________________________________________
Purposes:
1. To provide an eye medication the client requires (e.g., an antibiotic) to treat an infection or for others
(see specific drug action).

Preparation SCORE REMARKS

ASSESSMENT
1. Assess: 2 1 0
 The appearance of eye and surrounding
structures for lesions, exudate, erythema, or
swelling.
 The location and nature of any discharge,
lacrimation, and swelling of the eyelids or of the
lacrimal gland.
 Client complaints such as itching, burning pain,
blurred vision, and photophobia.
 Client behavior such as squinting, blinking
excessively, frowning, or rubbing the eyes.
Determine:
 If assessment data influence the administration
of the medication..
PLANNING
2. Assemble equipment:
 Dispensing system
 Clean gloves
 Sterile, absorbent sponges soaked in sterile
normal saline
 Medication
 Sterile eye dressing (pad), as needed, and
paper eye tape to secure it
For irrigation, add:
 Irrigating solution (e.g., normal saline) and
irrigating syringe or tubing;
 Dry, sterile absorbent sponges;
 Moisture-resistant towel; and
 Basin (e.g., emesis basin)
3. Check the MAR.
  Check the MAR for the drug name, dosage,
frequency, number of drops, route of
administration, and expiration date for
administering the medication, if appropriate.
 If the MAR is unclear or pertinent information is
missing, compare the MAR with the most recent
primary care provider’s written order.
 Report any discrepancies to the charge nurse or
the primary care provider, as agency policy
dictates.
 Know why the client is receiving the medication,
the drug classification, contraindications, usual
dose range, side effects, and nursing
considerations for administering and evaluating
the intended outcomes of the medication.
4. Read the label of the medication
(1) WHEN it is taken from the medication cart
(2) BEFORE withdrawing the medication
(3) AFTER withdrawing the medication

Check the expiration date

IMPLEMENTATION
5. Introduce self. Explain to the client what you are
going to do, why it is necessary, and how to
client can cooperate.
6. Perform hand hygiene, and observed other
appropriate infection control procedures.
7. Prepare the medication.

If necessary, calculate the medication dosage.

8. Provide for client privacy.
9. Prepare the client.

Assist the client to the comfortable position, either

sitting or lying.
10. Clean the eyelid and the eyelashes.
• Put on clean gloves.
• Use sterile cotton balls moistened with sterile
irrigating solution or sterile normal saline, and wipe
from the inner canthus to the outer canthus.
Administer Opthalmic Medications
11.1 Check the ophthalmic preparation for the name,
a strength, and number of drops, if a liquid is
used. Draw the correct number of drops into the
shaft of the dropper, if a dropper is used, if
ointment is used, discard the first bead.
11.1 Instruct the client to look up to the ceiling. Give
b the client a dry, sterile, absorbent sponge.
11.1 Expose the lower conjuctival sac by placing the
c thumb or fingers of your non-dominant hand on
the client’s cheekbone, just below the eye, and
gently drawing down the skin on the cheek. If the
tissues are edematous, handle the tissues
carefully to avoid damaging them.
11.1 Holding the medication in the dominant hand,
d place your hand on client’s forehead to stabilize
your hand instill the correct number of drops
 onto the outer third of the lower conjuctival sac.
Hold the dropper 1-2 cm (0.4-0.8 inches) above
the sac; or
11.1 Holding the tube above the lower conjunctival
e sac, squeeze 2 cm (0.8 inches) of ointment from
the tube into the lower conjunctival sac from the
inner canthus outward.
11.1 Instruct the client to close eyelids but not to
f squeeze them shut.
11.1 For liquid medications, press firmly or have the
g client press firmly on the nasolacrimal duct for at
least 30 seconds.
Ophthalmic Irrigations
11.2 Place absorbent pads under the head, neck, and
a shoulders. Place an emesis basin next to the eye
to catch drainage.
11.2 Expose the lower conjunctival sac. Or, to irrigate
b in stages, first hold the lower lid down, then hold
the upper lid up. Exert pressure on the bony
prominences of the cheekbone and beneath the
eyebrow when holding the eyelids.
11.2 Fill and hold the eye irrigator about 2.5 cm (1
c inch) above the eye.
11.2 Irrigate the eye, directing the solution onto the
d lower conjunctival sac and from the inner
canthus to the outer canthus.
11.2 Irrigate until the solution leaving the eye is clear
f (no discharge is present), or until all the solution
has been used.
11.2 Instruct the client to close, and move the eyes
g periodically.
12 Clean and dry the eyelids as needed. Wipe the
eyelids gently from the inner to the outer
canthus to collect excess medication.
13 Apply an eye pad, if needed, and secure it with
paper eye tape.
EVALUATION
12. Assess the client’s response.

Assess the character and amount of discharge,

appearance of the canal, discomfort, and so on,
immediately after the instillation, and again when the
medication is expected to act. Inspect the cotton ball
for any drainage.
13. Document all nursing assessments and
interventions relative to the procedure.

Include the name of the drug or irrigating solution,

the strength, the number of drops, if it was a liquid
medication, the time, and the response of the client.
Shown to me by:
________________________________
Signature over Printed Name
Clinical Instructor

Shown to me:
___________________________
Signature over Printed Name
 Student
Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

Performance Evaluation Checklist

NCM 107 Skills 3 (Administration of Oral Forms of Medications)

Name of Student: _______________________________________

Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ____First Semester ____Second Semester ____Summer
Inclusive Dates of Clinical Rotation: _________________________
Instructor: _____________________________________________

Purposes:
1. To provide a medication that has systemic effects or local effects on the gastrointestinal tract or both.

Preparation SCORE REMARKS

ASSESSMENT
1. Assess: 2 1 0
 Allergies to medications.
 Client’s ability to swallow the medication.
 Presence of vomiting or diarrhea that would
interfere with the ability to absorb the medication
 Specific drug action, side effects, interactions,
and adverse reactions.
 Client’s knowledge of and learning needs about
the medication.
 Perform appropriate assessments specific to the
medication
 Determine if the assessment date influences the
administration of the medication.
PLANNING
2. Assemble equipment:
 Dispensing system
 Disposable medication cups: small paper or
plastic cups for tablets and capsules, or waxed
or plastic calibrated medication cups for liquids
 Medication administration record (MAR), or
computer printout
 Pill crusher/cutter
 Straws to administer medications that might
discolor the teeth, or a facilitate the ingestion of
liquid medication for certain clients
 Drinking glass and water or juice
 Applesauce or pudding to use for crushed
medications
3. Check the MAR.
 Check the MAR for the drug name, dosage,
frequency, route of administration, and
expiration date for administering the medication,
 if appropriate.
 If the MAR is unclear or pertinent information is
missing, compare the MAR with the most recent
primary care provider’s written order.
 Report any discrepancies to the charge nurse or
the primary care provider, as agency policy
dictates.
4. Read the label of the medication
(1) WHEN it is taken from the medication cart
(2) BEFORE withdrawing the medication
(3) AFTER withdrawing the medication
IMPLEMENTATION
Procedure (All Medications)
5. Perform hand hygiene, and observe other
appropriate infection control procedures
6. Prepare the medication.
Tablets or Capsules
7.1. Place packaged unit-dose capsules or tablets
a directly into the medicine cup. Do not remove the
medication from the wrapper until at the bedside.
7.1. If using a stock container, pour the required
b number into the bottle cap, then transfer the
medication to the disposable cup without
touching the tablets.
7.1. Keep narcotics and medications that require
c specific assessments-such as pulse
measurements, respiratory rate or depth, or
blood pressure-separate from the others.
7.1. Break scored tablets only, if necessary to obtain
d. the correct dosage. Use a file or cutting device if
needed. Check the agency policy as to whether
unused portions of a medication can be
discarded and, if so, how they are to be
discarded.
7.1. If the client has difficulty swallowing, crush the
e tablets (check to make sure tablets may be
crushed) to a fine powder with a pill crusher, or
between two medication cups. Then mix the
powder with a small amount of soft food such as
applesauce.
Liquid Medication
7.2. Thoroughly mix the medication before pouring.
a Discard any medication that has changed color
or turned cloudy.
7.2. Remove the cap, and place it upside down on the
b countertop.
7.2. Hold the bottle so the label is next to your palm,
c and pour the medication away from the label.
7.2. Place the medication cup at eye level, and fill it
d to the desired level, using the bottom of the
meniscus to align with the container scale.
7.2. Before capping the bottle, wipe the lip with a
e paper towel. .
7.2. When giving small amounts of liquids (<5mL),
f prepare the medication in a sterile syringe
without the needle, or in a specially designed
 oral syringe. Label the syringe with the name of
the medication and the route (PO).
Procedure (All Medications)
8. Place the prepared medication and MAR together
on the medication cart.
9. Recheck the label on the container before
returning the bottle, box or envelope to its
storage place.
10. Avoid leaving prepared medications unattended.
Lock the medication cart before entering the
client’s room.
11. Provide for client privacy.
12. Prepare the client.

Check the client’s identification band.

Assist the client to a sitting position or, if not
possible, to a side-lying position.
If not previously assessed, take the required
assessment measures such as pulse and respiratory
rates or blood pressure.
Explain the purpose of the medication and how it will
help, using language that the client can understand.
Include relevant information about effects.
13. Administer the medication at the correct time.

Take the medication to the client within 30 minutes

before or after the scheduled time.
14. Give the client sufficient water or preferred juice
to swallow the medication. Before using juice,
check for any food and medication
incompatibilities.
15. If the client is unable to hold the pill cup, use it to
introduce the medication into the client’s mouth,
and give only one tablet or capsule at a time.
16. If an order child or adult has difficulty
swallowing, ask the client to place the
medication on the back of the tongue before
taking the water.
17. If the medication has an objectionable taste, ask
the client to suck a few ice chips beforehand, or
give the medication with juice, applesauce, or
bread, if there are no contraindications.
18. If the client says that the medication you are
about to give is different from what the client has
been receiving, do not give the medication
without first checking the original order.
19. Stay with the client until all medications have
been swallowed.
20. Document each medication given.

Record the medication given, dosage, time, any

complaints or assessments of the client, and your
signature.
If medication was refused or omitted, record this fact
on the appropriate record; document the reason,
when possible, and the nurse’s actions, according to
agency policy.
21. Discard used disposable supplies.
EVALUATION
22. Evaluate the effects of the medication.

Return the client when the medication is expected to

take effect to evaluate the effects of the medication
on the client.

Shown to me by:

________________________________
Signature over Printed Name
Clinical Instructor

Shown to me:

________________________________
Signature over Printed Name
Student
 Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

Performance Evaluation Checklist

NCM 107 Skills 3 (Administering Otic Instillations)

Name of Student: Justin Ersnest Llanto

Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ____First Semester ____Second Semester ____Summer
Inclusive Dates of Clinical Rotation: _________________________
Instructor: _____________________________________________
Purposes:
 To soften earwax so that is can be readily removed at a later time
 To provide local therapy to reduce inflammation, destroy infective organisms in the external
ear canal, or both
 To relieve pain

Preparation SCORE REMARKS

ASSESSMENT
1. Assess: 2 1 0
 Appearance of the pinna of the ear and meatus
for signs of redness and abrasions.
 Type and amount of any discharge.

Determine:
If assessment data influence the administration of
the medication.
PLANNING
2. Assemble equipment:
 Dispensing system
 Clean gloves
 Cotton-tipped applicator
 Correct medication bottle with a dropper
 Flexible rubber tip (optional) for the end of the
dropper, which prevents injury from sudden
motion – for example, by a disoriented client
 Cotton fluff
 For irrigation, add:
 Moisture – resistant towel
 Basin (e.g., emesis basin)
 Irrigating solution at the appropriate
temperature, about 500 mL (16 ounces) or as
ordered;
 Container for the irrigating solution
 Syringe
3. Check the MAR.
 Check the MAR for the drug name, dosage,
frequency, number of drops, route of
administration, and expiration date for
 administering the medication, if appropriate.
 If the MAR is unclear or pertinent information is
missing, compare the MAR with the most recent
primary care provider’s written order.
 Report any discrepancies to the charge nurse or
the primary care provider, as agency policy
dictates.
 Know why the client is receiving the medication,
the drug classification, contraindications, usual
dose range, side effects, and nursing
considerations for administering and evaluating
the intended outcomes of the medication.
4. Read the label of the medication
(1) WHEN it is taken from the medication cart
(2) BEFORE withdrawing the medication
(3) AFTER withdrawing the medication

Check the expiration date

IMPLEMENTATION
5. Introduce self. Explain to the client what you are
going to do, why it is necessary, and how to
client can cooperate.

Explain the client might experience a feeling of

fullness, warmth, and, occasionally, discomfort when
the fluid comes in contact with the tympanic
membrane.
6. Perform hand hygiene, and observed other
appropriate infection control procedures.
7. Prepare the medication.

If necessary, calculate the medication dosage.

8. Provide for client privacy.
9. Prepare the client.

Assist the client to a comfortable position for

eardrops, lying with the ear being treated.
10. Clean the pinna of the ear and the meatus of the
ear canal.
• Put on gloves, if infection is suspected.
• Use cotton-tipped applicators and solution to wipe
the pinna and auditory meatus.
Administer Otic Medications
11.1 Warm the medication container in your hand, or
a place it in warm water for a short time.
11.1 Partially fill the ear dropper with medication.
b
11.1 Straighten the auditory canal. Pull the pinna
c upward and backward.
11.1 Instill the correct number of drops along the side
d of the ear canal.
11.1 Press gently but firmly a few times on the tragus
e of the ear.
11.1 Ask the client to remain in the side-lying position
f for about five minutes.
11.1 Insert a small piece of cotton fluff loosely at the
g meatus of the auditory canal for 15-20 minutes.
 Do not press it into the canal.
Otic Irrigations
11.2 Assist the client to a sitting or lying position with
a head turned toward the affected ear.
11.2 Place the moisture resistant towel around the
b client’s shoulder under the ear to be irrigated,
and place the basin under the ear to be irrigated.
11.2 Fill the syringe with solution; or
c Hang up the irrigating container, and run
solution through the tubing and nozzle.
11.2 Straighten the ear canal.
d
11.2 Insert the tip of the syringe into the auditory
f meatus, and direct the solution gently upward
against the top of the canal.
11.2 Continue instilling the fluid until all the solution
g is used or until the canal is cleaned, depending
on the purpose of the irrigation. Take care not to
block the outward flow of the solution with the
syringe.
11.2 Assist the client to a side-lying position on the
h affected side.
11.2 Place a cotton fluff in the auditory meatus to
i absorb the excess fluid.
EVALUATION
12. Assess the client’s response.

Assess the character and amount of discharge,

appearance of the canal, discomfort, and so on,
immediately after the instillation, and again when the
medication is expected to act. Inspect the cotton ball
for any drainage.
13. Document all nursing assessments and
interventions relative to the procedure.

Include the name of the drug or irrigating solution,

the strength, the number of drops, if it was a liquid
medication, the time, and the response of the client.

Shown to me by:

________________________________
Signature over Printed Name
Clinical Instructor

Shown to me:

________________________________
Signature over Printed Name
Student
 Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

Performance Evaluation Checklist

NCM 107 Skills 3 (Parenteral Administration of Drugs: Subcutaneous Route)

Name of Student:
Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ____First Semester ____Second Semester ____Summer
Inclusive Dates of Clinical Rotation: _________________________
Instructor: _____________________________________________

Purposes:
1. To allow slower absorption of medication compared with either IM or IV route

Preparation SCORE REMARKS

ASSESSMENT
1. Assess: 2 1 0
 Appearance of injection site
 Specific drug action and expected response
 Client’s knowledge of drug action and response
PLANNING
2. Assemble and organize equipment:
 Vial or ampule of the correct medication.
 Filter needle
 Sterile 3 mL syringe (#25 gauge needle/smaller
3/8 or 5/8 inch long)
 Dry and wet cotton balls/ antiseptic swabs
 Clean gloves (according to agency protocol)
 Pen
 Micropore tape
3. Check the medication administration order (MAR)
against the label of the ampule/vial carefully.
4. Read the label of the medication
(1) WHEN it is taken from the medication cart
(2) BEFORE withdrawing the medication
(3) AFTER withdrawing the medication
IMPLEMENTATION
Procedure
5. Perform hand hygiene and prepare the
medication from a vial or ampule for drug
withdrawal.
6. Prepare the client.

Check the client’s identification band. Explain the

procedure to the patient and he/she will expect.
(pain)
7. Select the site

Select a site: free of tenderness, hardness, swelling,

scarring, itching, burning, or localized inflammation.
Select a site that has not been used frequently.
8 Don clean gloves

9 Clean the site with antiseptic swab.

Start at the center of the site and clean in a widening

circle to about 5 cm or 2 inches
10 Place and hold a swab between the third and
fourth fingers of a non-dominant hand or position
the swab on the client’s skin above the intended
site.
11 Prepare the syringe for injection

Remove the needle cap by pulling it straight off to

avoid contaminating the needle of the outsides of the
cap
12. Inject the medication.
1
For a 45-degree angle - Grasp the syringe in your
dominant hand holding it between your thumb and
fingers with palm facing to the side or upward.

For a 90-degree angle - Grasp the syringe in your

dominant hand holding it between your thumb and
fingers with palm facing downwards

12. Using the non-dominant hand pinch or spread the

2 skin at the site and insert the needle using the
dominant hand in a firm steady push.

Pinch – if with less adipose tissue

Spread – if the client has more than ½ inch of
adipose
12. When the needle is inserted, move your dominant
3 hand at the end of the syringe and the dominant
hand to the end of the plunger.

Inject the medication by holding the syringe steady

and depressing the plunger with a slow, even
pressure.
12. Embed the needle within the skin for five seconds.
4
13 Remove the needle.

Remove the needle smoothly pulling along the line of

insertion while depressing the skin with the non-
dominant hand.

* if bleeding occurs – apply pressure to the site using

a sterile dry swab or a sterile gauze
14 Dispose of supplies, materials and disposable
equipment used appropriately
15 Remove and dispose of gloves and Perform hand
 hygiene.
EVALUATION
16. Document administration of medication, site,
time, dosage, route and nursing assessments.

17. Observe for possible reaction to the administered

medication and/or effectiveness of medication at
the time it is expected to act.

Shown to me by:

________________________________
Signature over Printed Name
Clinical Instructor

Shown to me:

________________________________
Signature over Printed Name
Student
 Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

Performance Evaluation Checklist

NCM 107 Skills 3 (Parenteral Administration of Drugs: Adding Medications to Intravenous
Fluid Containers)

Name of Student: ______________________________________

Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ____First Semester ____Second Semester ____Summer
Inclusive Dates of Clinical Rotation: _________________________
Instructor: _____________________________________________

Purposes:
1. To provide and maintain constant medication level in the blood
2. To administer well-diluted medication at a continuous and slow rate

Preparation SCORE REMARKS

ASSESSMENT
1. Assess: 2 1 0
 Appearance of injection site
 Specific drug action and expected response
 Client’s knowledge of drug action and response
PLANNING
2. Assemble and organize equipment:
 Vial or ampule of the correct medication.
 Filter needle
 Sterile 5mL/ 10 ml syringe (#20 or #21-gauge
needle 1 to 1 1/2 inch long)
 Dry and wet cotton balls/ antiseptic swabs
 Clean gloves (according to agency protocol)
 Pen
 Micropore tape
 Watch with digital hand or second hand
 Disposable Gloves
3. Check the medication administration order (MAR)
against the label of the ampule/vial carefully.
4. Read the label of the medication
(1) WHEN it is taken from the medication cart
(2) BEFORE withdrawing the medication
(3) AFTER withdrawing the medication
IMPLEMENTATION
Procedure
5. Perform hand hygiene and prepare the
 medication from a vial or ampule for drug
withdrawal.
6. Prepare the client.

Check the client’s identification band. Explain the

procedure to the patient and he/she will expect.
(pain)
ADD MEDICATION TO A NEW IVF
7.1. Locate the injection port and clean the port with
a antiseptic swab
7.1. Remove the needle cap from the syringe, insert
b the needle through the center of the injection
part, and inject the medication into the bag.
7.1. Gently rotate the bag or bottle to mix the
c medication.
7.1. Put on the IV label/tag with name, and dose of
d medication, date, time and nurse’s initials. Attach
it upside down on the bag or bottle.
7.1. Clamp the IV tubing. Spike the IVF and hang the
e IV.
7.1. Regulate the Infusion rate as ordered.
f
ADD MEDICATION EXISTING IVF

7.2. Determine if the IVF solution is sufficient for

a adding medication
7.2. Close the infusion clamp
b
7.2. Wipe the medication part with alcohol or
c disinfectant swab.
7.2. Support and stabilize the bag using the thumb
d and forefinger. Inject the medication.
7.2. Remove the bag from the pole and gently rotate
e. the Fluid.
7.2. Rehang the container and regulate the flow rate.
f
7.2. Put on the IV label/tag with name, and dose of
g medication, date, time and nurse’s initials. Attach
it upside down on the bag or bottle.
8. Dispose all the disposable materials and
equipment used
9. Remove and disposed of gloves. Perform hand
hygiene
EVALUATION
10. Document administration of medication, site,
time, dosage, route and nursing assessments.

11. Observe for possible reaction to the administered

medication and/or effectiveness of medication at
the time it is expected to act.

Shown to me by:

________________________________
Signature over Printed Name
Clinical Instructor

Shown to me:
________________________________
Signature over Printed Name
Student
Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

Performance Evaluation Checklist

NCM 107 Skills 3 (Parenteral Administration of Drugs: Administering IV medications
using IV push)
Name of Student: _______________________________________
Year/Clinical Group: ___________________________________
School Year: ____________________
Term: ____First Semester ____Second Semester ____Summer
Inclusive Dates of Clinical Rotation: _________________________
Instructor: _____________________________________________
Purpose:
1. To achieve immediate and maximum effects of a medication

Preparation SCORE REMARKS

ASSESSMENT
1. Assess: 2 1 0
 Appearance of injection site
 Specific drug action and expected response
 Client’s knowledge of drug action and response
 Take Vital Signs for baseline data if the
medication being administered is potent.
 Determine allergies to medications
 Determine specific drug action, side effects,
normal dosage, and peak action time
 Check Patency of IV
PLANNING
2. Assemble and organize equipment:
Assemble and organize equipment:
 Vial or ampule of the correct medication.
 Vial or ampule of normal saline
 Sterile 5 mL/ 10 ml syringe (#20 or #21-gauge
needle 1 to 1 1/2 inch long) – not needed if using
a needleless system
 Sterile 3ml syringes (for flushing)
 Dry and wet cotton balls/ antiseptic swabs
 Clean gloves (according to agency protocol)
 Pen
 Micropore tape
 Watch with digital hand or second hand
 Disposable Gloves
3. Check the medication administration order (MAR)
against the label of the ampule/vial carefully.

Check and calculate the medication dosage

accurately
4. Read the label of the medication
 (1) WHEN it is taken from the medication cart
(2) BEFORE withdrawing the medication
(3) AFTER withdrawing the medication
IMPLEMENTATION
5. Perform hand hygiene and prepare the
medication from a vial or ampule for drug
withdrawal.
6. Prepare the medication

Prepare 2 syringes each with 1 ml of sterile normal

saline(*Prepare heparin for flushing if indicated by
agency policy)
7. Prepare the client.

Check the client’s identification band. Explain the

procedure to the patient and he/she will expect.
(pain)
IV LOCK
8.1. Clean the injection port with antiseptic swab
a
8.1. Insert the needle of the syringe containing 1ml
b. normal saline from flushing and aspirate for
blood
8.1. Flush with IV saline
c.
Flush the lock with the first syringe which contains
1ml of sterile water by injecting it slowly then remove
the syringe
8.1. Inject the medication slowly at the recommended
d rate of infusion. (use the push-stop-push-stop
technique for Central venous catheters). Remove
the medication and syringe when all the
medication is administered.
8.1. Re-flush IV with saline
e
Repeat injection of 1 ml saline then remove the
syringe. (if heparin is to be used, inject heparin into
the injection port after the last saline flush)
EXISTING IV LINE
8.2. Identify the injection port closest to the client.
a
8.2.b Clean the injection port using a disinfecting swab
8.2. Stop the IV flow by closing the clamp or
c pinching/kinking the tube above the injection
port.
8.2. Connect the Syringe to the IV system
d
>Needle system
- Hold port steady
-Insert the needle of the syringe containing
medication through the center of the port

>Needleless system
- Remove the needle from the syringe
- Inject the medication slowly at the
recommended rate of infusion. (use watch if
necessary)
8.2.e
Release the clamp or tubing
8.2.Withdraw the syringe or the needle. Activate the
f needle safety device. For needleless system
detach the syringe and attach a new sterile cap to
the port.
9 Dispose of disposable materials and equipment
use
10 Remove and disposed of gloves. Perform hand
hygiene
EVALUATION
11. Document administration of medication, site,
time, dosage, route and nursing assessments.
12. Observe for possible reaction to the administered
medication and/or effectiveness of medication at
the time it is expected to act.

Shown to me by:

________________________________
Signature over Printed Name
Clinical Instructor

Shown to me:

________________________________
Signature over Printed Name
Student