OUR LADY OF FATIMA UNIVERSITY

College of Nursing

PROGRAM Bachelor of Science in Nursing STUDENT NAME

YEAR & SECTION

COURSE NCM-101 INSTRUCTOR
DATE

ASSESSMENT RUBRICS FOR RETURN DEMONSTRATION

Write the score on the corresponding box on the following grading criteria:
5-Activity performed accurately with evident ease without supervision
4-Activity performed but needs minimal supervision
3-Activity performed with slight difficulty, needs supervision most of the time
2-Activity performed inaccurately
1-Activity not performed

PROCEDURE : Setting Up an IV Line

EXPECTED OUTCOME: The student should be able to set up an IV line correctly
ASSESSMENT TASK : Return Demonstration

Assessment Dimension (5) (4) (3) (2) (1)

1. Verify the doctor’s order and make an IV label.
2. Observe 10 R’s when preparing and administering IV fluid.
3 Explain the procedure to reassure patient and or significant others, secure
consent if necessary.
4. Do hand hygiene before and after the procedure.
5. Prepare the necessary materials for the procedure.
6. Check for the sterility and integrity of the solution, IV set and other
materials needed.
7. Place the IV label on the IV bottle duly signed by the nurse who prepared
it.
8. Open the seal of the IV infusion aseptically and disinfect rubber port with
cotton balls with alcohol.
9. Open the IV administration set aseptically and close the roller clamp and
spike to infusate container aseptically,
10. Fill in the drip chamber half full.
11. Expel the air bubbles if any and put back the cover to the distal end of
the IV set.
12. Get ready for IV insertion.

SCORE: (_______/60)*100 = ________Target Raw Score: 45 out of 100 If raw score is less than 45, repeat the
demonstration.

______________________________________________________
CI SIGNATURE OVER PRINTED NAME

Prepared by: EVANGELINE F. ORATA RN. RM. MAN Noted by: FRANCIS S. VASQUEZ RN. MAN.
ROSANA P. SUVA RN. MAN. Coordinator
MELANIE S. CAMBEL RN. MAN.

Approved by: LURCELI L. SANTOS RN. MAN

Dean, College of Nursing
 OUR LADY OF FATIMA UNIVERSITY
College of Nursing

PROGRAM Bachelor of Science in Nursing STUDENT NAME

YEAR & SECTION

COURSE NCM-101 INSTRUCTOR
DATE

ASSESSMENT RUBRICS FOR RETURN DEMONSTRATION

Write the score on the corresponding box on the following grading criteria:
5-Activity performed accurately with evident ease without supervision
4-Activity performed but needs minimal supervision
3-Activity performed with slight difficulty, needs supervision most of the time
2-Activity performed inaccurately
1-Activity not performed

PROCEDURE : Setting Up an IV Line

EXPECTED OUTCOME: The student should be able to set up an IV line correctly
ASSESSMENT TASK : Return Demonstration

Assessment Dimension (5) (4) (3) (2) (1)

1. Verify the doctor’s order and make an IV label.
2. Observe 10 R’s when preparing and administering IV fluid.
3 Explain the procedure to reassure patient and or significant others, secure
consent if necessary.
4. Do hand hygiene before and after the procedure.
5. Prepare the necessary materials for the procedure.
6. Check for the sterility and integrity of the solution, IV set and other
materials needed.
7. Place the IV label on the IV bottle duly signed by the nurse who prepared
it.
8. Open the seal of the IV infusion aseptically and disinfect rubber port with
cotton balls with alcohol.
9. Open the IV administration set aseptically and close the roller clamp and
spike to infusate container aseptically,
10. Fill in the drip chamber half full.
11. Expel the air bubbles if any and put back the cover to the distal end of
the IV set.
12. Get ready for IV insertion.

SCORE: (_______/60)*100 = ________Target Raw Score: 45 out of 100 If raw score is less than 45, repeat the
demonstration.

______________________________________________________
CI SIGNATURE OVER PRINTED NAME

Prepared by: EVANGELINE F. ORATA RN. RM. MAN Noted by: FRANCIS S. VASQUEZ RN. MAN.
ROSANA P. SUVA RN. MAN. Coordinator
MELANIE S. CAMBEL RN. MAN.

Approved by: LURCELI L. SANTOS RN. MAN

Dean, College of Nursing
 OUR LADY OF FATIMA UNIVERSITY
College of Nursing

PROGRAM Bachelor of Science in Nursing STUDENT NAME

YEAR & SECTION

COURSE NCM-101 INSTRUCTOR
DATE

ASSESSMENT RUBRICS FOR RETURN DEMONSTRATION

Write the score on the corresponding box on the following grading criteria:
5-Activity performed accurately with evident ease without supervision
4-Activity performed but needs minimal supervision
3-Activity performed with slight difficulty, needs supervision most of the time
2-Activity performed inaccurately
1-Activity not performed

PROCEDURE : Setting Up an IV Line

EXPECTED OUTCOME: The student should be able to set up an IV line correctly
ASSESSMENT TASK : Return Demonstration

Assessment Dimension (5) (4) (3) (2) (1)

1. Verify the doctor’s order and make an IV label.
2. Observe 10 R’s when preparing and administering IV fluid.
3 Explain the procedure to reassure patient and or significant others, secure
consent if necessary.
4. Do hand hygiene before and after the procedure.
5. Prepare the necessary materials for the procedure.
6. Check for the sterility and integrity of the solution, IV set and other
materials needed.
7. Place the IV label on the IV bottle duly signed by the nurse who prepared
it.
8. Open the seal of the IV infusion aseptically and disinfect rubber port with
cotton balls with alcohol.
9. Open the IV administration set aseptically and close the roller clamp and
spike to infusate container aseptically,
10. Fill in the drip chamber half full.
11. Expel the air bubbles if any and put back the cover to the distal end of
the IV set.
12. Get ready for IV insertion.

SCORE: (_______/60)*100 = ________Target Raw Score: 45 out of 100 If raw score is less than 45, repeat the
demonstration.

______________________________________________________
CI SIGNATURE OVER PRINTED NAME

Prepared by: EVANGELINE F. ORATA RN. RM. MAN Noted by: FRANCIS S. VASQUEZ RN. MAN.
ROSANA P. SUVA RN. MAN. Coordinator
MELANIE S. CAMBEL RN. MAN.

Approved by: LURCELI L. SANTOS RN. MAN

Dean, College of Nursing
 OUR LADY OF FATIMA UNIVERSITY
College of Nursing

PROGRAM Bachelor of Science in Nursing STUDENT NAME

YEAR & SECTION

COURSE NCM-101 INSTRUCTOR
DATE

ASSESSMENT RUBRICS FOR RETURN DEMONSTRATION

Write the score on the corresponding box on the following grading criteria:
5-Activity performed accurately with evident ease without supervision
4-Activity performed but needs minimal supervision
3-Activity performed with slight difficulty, needs supervision most of the time
2-Activity performed inaccurately
1-Activity not performed

PROCEDURE : Setting Up an IV Line

EXPECTED OUTCOME: The student should be able to set up an IV line correctly
ASSESSMENT TASK : Return Demonstration

Assessment Dimension (5) (4) (3) (2) (1)

1. Verify the doctor’s order and make an IV label.
2. Observe 10 R’s when preparing and administering IV fluid.
3 Explain the procedure to reassure patient and or significant others, secure
consent if necessary.
4. Do hand hygiene before and after the procedure.
5. Prepare the necessary materials for the procedure.
6. Check for the sterility and integrity of the solution, IV set and other
materials needed.
7. Place the IV label on the IV bottle duly signed by the nurse who prepared
it.
8. Open the seal of the IV infusion aseptically and disinfect rubber port with
cotton balls with alcohol.
9. Open the IV administration set aseptically and close the roller clamp and
spike to infusate container aseptically,
10. Fill in the drip chamber half full.
11. Expel the air bubbles if any and put back the cover to the distal end of
the IV set.
12. Get ready for IV insertion.

SCORE: (_______/60)*100 = ________Target Raw Score: 45 out of 100 If raw score is less than 45, repeat the
demonstration.

______________________________________________________
CI SIGNATURE OVER PRINTED NAME

Prepared by: EVANGELINE F. ORATA RN. RM. MAN Noted by: FRANCIS S. VASQUEZ RN. MAN.
ROSANA P. SUVA RN. MAN. Coordinator
MELANIE S. CAMBEL RN. MAN.

Approved by: LURCELI L. SANTOS RN. MAN

Dean, College of Nursing
 OUR LADY OF FATIMA UNIVERSITY
College of Nursing

PROGRAM Bachelor of Science in Nursing STUDENT NAME

YEAR & SECTION

COURSE NCM-101 INSTRUCTOR
DATE

ASSESSMENT RUBRICS FOR RETURN DEMONSTRATION

Write the score on the corresponding box on the following grading criteria:
5-Activity performed accurately with evident ease without supervision
4-Activity performed but needs minimal supervision
3-Activity performed with slight difficulty, needs supervision most of the time
2-Activity performed inaccurately
1-Activity not performed

PROCEDURE : Setting Up an IV Line

EXPECTED OUTCOME: The student should be able to set up an IV line correctly
ASSESSMENT TASK : Return Demonstration

Assessment Dimension (5) (4) (3) (2) (1)

1. Verify the doctor’s order and make an IV label.
2. Observe 10 R’s when preparing and administering IV fluid.
3 Explain the procedure to reassure patient and or significant others, secure
consent if necessary.
4. Do hand hygiene before and after the procedure.
5. Prepare the necessary materials for the procedure.
6. Check for the sterility and integrity of the solution, IV set and other
materials needed.
7. Place the IV label on the IV bottle duly signed by the nurse who prepared
it.
8. Open the seal of the IV infusion aseptically and disinfect rubber port with
cotton balls with alcohol.
9. Open the IV administration set aseptically and close the roller clamp and
spike to infusate container aseptically,
10. Fill in the drip chamber half full.
11. Expel the air bubbles if any and put back the cover to the distal end of
the IV set.
12. Get ready for IV insertion.

SCORE: (_______/60)*100 = ________Target Raw Score: 45 out of 100 If raw score is less than 45, repeat the
demonstration.

______________________________________________________
CI SIGNATURE OVER PRINTED NAME

Prepared by: EVANGELINE F. ORATA RN. RM. MAN Noted by: FRANCIS S. VASQUEZ RN. MAN.
ROSANA P. SUVA RN. MAN. Coordinator
MELANIE S. CAMBEL RN. MAN.

Approved by: LURCELI L. SANTOS RN. MAN

Dean, College of Nursing
 OUR LADY OF FATIMA UNIVERSITY
College of Nursing

PROGRAM Bachelor of Science in Nursing STUDENT NAME

YEAR & SECTION

COURSE NCM-101 INSTRUCTOR
DATE

ASSESSMENT RUBRICS FOR RETURN DEMONSTRATION

Write the score on the corresponding box on the following grading criteria:
5-Activity performed accurately with evident ease without supervision
4-Activity performed but needs minimal supervision
3-Activity performed with slight difficulty, needs supervision most of the time
2-Activity performed inaccurately
1-Activity not performed

PROCEDURE : Setting Up an IV Line

EXPECTED OUTCOME: The student should be able to set up an IV line correctly
ASSESSMENT TASK : Return Demonstration

Assessment Dimension (5) (4) (3) (2) (1)

1. Verify the doctor’s order and make an IV label.
2. Observe 10 R’s when preparing and administering IV fluid.
3 Explain the procedure to reassure patient and or significant others, secure
consent if necessary.
4. Do hand hygiene before and after the procedure.
5. Prepare the necessary materials for the procedure.
6. Check for the sterility and integrity of the solution, IV set and other
materials needed.
7. Place the IV label on the IV bottle duly signed by the nurse who prepared
it.
8. Open the seal of the IV infusion aseptically and disinfect rubber port with
cotton balls with alcohol.
9. Open the IV administration set aseptically and close the roller clamp and
spike to infusate container aseptically,
10. Fill in the drip chamber half full.
11. Expel the air bubbles if any and put back the cover to the distal end of
the IV set.
12. Get ready for IV insertion.

SCORE: (_______/60)*100 = ________Target Raw Score: 45 out of 100 If raw score is less than 45, repeat the
demonstration.

______________________________________________________
CI SIGNATURE OVER PRINTED NAME

Prepared by: EVANGELINE F. ORATA RN. RM. MAN Noted by: FRANCIS S. VASQUEZ RN. MAN.
ROSANA P. SUVA RN. MAN. Coordinator
MELANIE S. CAMBEL RN. MAN.

Approved by: LURCELI L. SANTOS RN. MAN

Dean, College of Nursing
 OUR LADY OF FATIMA UNIVERSITY
College of Nursing

PROGRAM Bachelor of Science in Nursing STUDENT NAME

YEAR & SECTION

COURSE NCM-101 INSTRUCTOR
DATE

ASSESSMENT RUBRICS FOR RETURN DEMONSTRATION

Write the score on the corresponding box on the following grading criteria:
5-Activity performed accurately with evident ease without supervision
4-Activity performed but needs minimal supervision
3-Activity performed with slight difficulty, needs supervision most of the time
2-Activity performed inaccurately
1-Activity not performed

PROCEDURE : Setting Up an IV Line

EXPECTED OUTCOME: The student should be able to set up an IV line correctly
ASSESSMENT TASK : Return Demonstration

Assessment Dimension (5) (4) (3) (2) (1)

1. Verify the doctor’s order and make an IV label.
2. Observe 10 R’s when preparing and administering IV fluid.
3 Explain the procedure to reassure patient and or significant others, secure
consent if necessary.
4. Do hand hygiene before and after the procedure.
5. Prepare the necessary materials for the procedure.
6. Check for the sterility and integrity of the solution, IV set and other
materials needed.
7. Place the IV label on the IV bottle duly signed by the nurse who prepared
it.
8. Open the seal of the IV infusion aseptically and disinfect rubber port with
cotton balls with alcohol.
9. Open the IV administration set aseptically and close the roller clamp and
spike to infusate container aseptically,
10. Fill in the drip chamber half full.
11. Expel the air bubbles if any and put back the cover to the distal end of
the IV set.
12. Get ready for IV insertion.

SCORE: (_______/60)*100 = ________Target Raw Score: 45 out of 100 If raw score is less than 45, repeat the
demonstration.

______________________________________________________
CI SIGNATURE OVER PRINTED NAME

Prepared by: EVANGELINE F. ORATA RN. RM. MAN Noted by: FRANCIS S. VASQUEZ RN. MAN.
ROSANA P. SUVA RN. MAN. Coordinator
MELANIE S. CAMBEL RN. MAN.

Approved by: LURCELI L. SANTOS RN. MAN

Dean, College of Nursing