IV Preparation/ Priming/ Administration (with VIP Score) Sample Script
At the Treatment Room:
- Do hand hygiene, Put on apron. You may or may not wear gloves to clean the tray. Do hand hygiene
again after cleaning the tray.
- Get the Kardex/ IV fluid prescription Chart to confirm the order and gather the things around the tray.
(IV Fluid Bag, IV Giving Set, Kidney Basin, 2 pcs of 2% chlorhexidine swab, Box of Gloves because you
need 2 Pairs of Clean Gloves in the Tray, Sharp Bin)
Check the consistency, packaging and expiry dates of all the things that you will be using.
- Do hand hygiene and wear gloves. Remove the packaging of the IV fluid and put it on the IV tray (let it
stand in the kidney basin with Outlet Port pointing upwards), remove the cover of the Outlet Port.
- Remove the packaging of the IV Giving Set. Close the V-track Controller.
- Remove the cover of the Spike and insert the Spike in the Outlet Port slowly making sure that you will
not puncture the IV Fluid bag.
- Hang it on the IV Pole. Fill the drip chamber half full. Prime the tubing onto the Kidney Basin making
sure that there’s no air in the tubing. If there’s excess fluid on the Luer Lock, shake it off and clip it on
the V-track Controller.
- Remove your apron, gloves and do hand hygiene. Proceed to the patient, bringing the IV Pole with the
IV Fluid, Tray and Kardex.
At the patient’s room:
Nurse: Knock on the door. Do hand hygiene and put on apron.
“Hi. I am Mae, your nurse for today.
“How are you? May i know your complete name and date of birth please.?”
Patient: Hi, I am Catherine, my date of birth is on 20/10/1990
Nurse: May I check your ID Band to check your MRN please.
Patient: Sure Nurse
Nurse: I will close the curtain to ensure privacy.
Nurse: Today, I am going to give you IV fluid as per doctor’s order. This will help you to prevent
dehydration. Will that be okay with you? Do you have any allergies?
Patient: Okay nurse, you may proceed. I dont have allergies.
Nurse: (wear gloves) Can I check your IV site?
Sample Questions in Layman's term: Do you feel slight pain on the cannula? Or pain anywhere in your
hand and arms? Did you observe any redness in the cannula site or around this area? Did you observe
any swelling in this area of the cannula or sorrounding area? Did you observe any hardening in the area
of the IV cannula or sorrounding area? Is there any pain along the area of the arm? Did you observe
swelling or pulsation if you touch the part of your arm with swelling? Do you feel warm? Can I get your
temperature to be sure? Thank you.
Then explain to patient if need to contact Medical Team to resite the cannula or consider/initiate
treatment and explain your VIP Score findings to the Assesor.
Assesor then will tell you that the IV cannula have been resited and may proceed now with the IV
Administration.
Nurse: I will proceed with the IV infusion. Do hand Hygiene. Wear apron, gloves. Proceed to scrub the
hub using ANTT. Connect the Luer Lock onto the hub without touching the key parts.
“Now, I am going to open the V-track controller to regulate the IV fluid as per doctor’s order. (Then
Remove the gloves, apron, and do hand hygiene)
I will stay here for 15 mins to observe you for possible adverse reaction.
(Talking to the Assessor: "While waiting, I will complete the Intake and output Fluid Balance Chart,
Accumulative Balance Chart and IV Prescription Chart making sure that the colleague who counter
checked the IV fluid will sign the IV Prescription Chart with my signature first and time IV started)
Removal of IV Fluid from the hub:
-Do hand hygiene, wear gloves and tell patient that you are going to disconnect the IV tubings using
ANTT. Dispose the things as follows:
IV tubings to throw in the sharp bin with red/blue lid (do not cut the spike)
Excess fluid in the IV bag to drain first on the sink and IV bag to throw on clear bag if not infectious, if
infectious - yellow bag.
Hand Hygiene then talk to the patient if she's okay and if she needs anything just ring the call bell and
you will just be in the Nurse Station to complete your documentation.
Tell Assesor that you are going to clean the Tray with gloves on at the Treatment Room and then
remove gloves and do hand washing.
Thank the Assesor(s) before leaving the Station with a Smile 😊
