Davao Doctors College, Inc. Gen. Malvar St.
, Davao City Nursing Program
EVALUATION TOOL FOR NRG 204
PREPARING MEDICATION FROM AN AMPULE AND INTRAMUSCULAR AND SUBCUTANEOUS MEDICATION ADMINISTRATION
NAME FINAL RATING: YEAR/SEC
DATE GRP. #
Directions: Each student is to be rated on performance in the return demonstration. Careful evaluation to be taken to compare the jobs and tasks actually
performed by the student nurse with those expected from the full performance of that assignment. Keeping the guidelines in mind, please complete the
Performance Evaluation Tool. Then determine an overall rating, giving weight to various performance categories as appropriate to the particular assignment.
Please indicate remarks in the space provided if needed. Overall rating must be considered with the following standard definition.
PERFORMANCE 70% Clinical Instructors' Rating
GENERAL PREPARATION 5 4 3 2 1
1 Checks the Doctor's order.
Checks the Medication Administration Recored (MAR):
2 Checks the label on the medication carefully against the eMAR to make sure that the correct medication is
being prepared.
3 Follows the three checks for administering medications. Read the label on the medication (1) when it is taken
from the medication cart, (2) before withdrawing the medication, and (3) after withdrawing the medication.
4 Organizes the equipment.
PREPARING MEDICATIONS FROM AMPULES 5 4 3 2 1
5 Performs hand hygiene and observe other appropriate infection prevention procedures.
6 Prepares the medication ampule for drug withdrawal:
Flicks the upper stem of the ampule several times with a fingernail.
Uses an ampule opener or place a piece of sterile gauze or alcohol wipe between your thumb and the ampule
neck or around the ampule neck, and break off the top by bending it toward you to ensure the ampule is broken
away from yourself and away from others.
Places the antiseptic wipe packet over the top of the ampule before breaking off the top.
Disposes of the top of the ampule in the sharps container.
7 Withdraws the medication:
Places the ampule on a flat surface.
Attaches the filter needle/straw to the syringe.
Removes the 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.
With a single-dose ampule, holds the ampule slightly on its side, if necessary, to obtain more than the ordered
amount of medication.
Disposes of the filter needle by placing in a sharps container.
If giving an injection replace the filter needle with a regular needle, tighten the cap at the hub of the needle, and
push solution into the needle, to the prescribed amount.
INTRAMUSCULAR INJECTION
8 Checks the MAR:
9 Checks the label on the medication carefully against the eMAR to make sure that the correct medication is
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Davao Doctors College, Inc. Gen. Malvar St., Davao City Nursing Program
10 Follows the three checks for administering medications. Read the label on the medication (1) when it is taken
from the medication cart, (2) before withdrawing the medication, and (3) after withdrawing the medication.
1 Organizes the equipment.
1
1 Performs hand hygiene and observe other appropriate infection prevention procedures.
2
1 Prepares the medication from the ampule or vial for drug withdrawal.
3
1 Provides for client privacy.
4
1 Prepares the client.
5
1 Prior to performing the procedure, introduces self and verifies the client’s identity using agency protocol.
6
1 Assists the client to a supine, lateral, prone, or sitting position, depending on the chosen site. If the target
7 muscle is the gluteus medius (ventrogluteal site), have the client in the supine position flex the knee(s); in the
lateral position, flex the upper leg; and in the prone position, toe in.
1 Obtain assistance in holding an uncooperative client.
8
1 Explains the purpose of the medication and how it will help, using language that the client can understand.
9 Include relevant information about effects of the medication.
2 Selects, locates, and cleanse the site.
0
2 Select a site free of skin lesions, tenderness, swelling, hardness, or localized inflammation and one that has
1 not been used frequently.
2 If injections are to be frequent, alternate sites. Avoid using the same site twice in a row.
2
2 Locate the exact site for the injection.
3
2 Apply clean gloves.
4
2 Clean the site with an antiseptic swab. Using a circular motion,
5
Transfers and holds the swab between the third and fourth fingers of your nondominant hand in readiness for
needle withdrawal, or position the swab on the client’s skin above the intended site.
2 Prepares the syringe for injection.
6
Remove the needle cover and discard without contaminating the needle.
If using a prefilled unit-dose medication, take caution to avoid dripping medication on the needle prior
to injection. If this does occur, wipe the medication off the needle with a sterile gauze.
2 Injects the medication using the Z-track technique.
7
a. Uses the ulnar side of the nondominant hand to pull the skin approximately 2.5 cm (1 in.) to the side. Under
some circumstances, such as for an emaciated client or an infant, the muscle may be pinched.
b. Holding the syringe between the thumb and forefinger (as if holding a pen), pierce the skin quickly and
smoothly at a 90° angle
c. Holds the barrel of the syringe steady with your nondominant hand and aspirate by pulling back on the
plunger with your dominant hand. Aspirate for 5 to 10 seconds.
If blood appears in the syringe, withdraw the needle, discard the syringe, and prepare a new injection.
If blood does not appear, inject the medication steadily and slowly (approximately 10 sec/ml) while holding the
syringe steady if using the ventrogluteal site.
After injection, wait 10 seconds if using the ventrogluteal site.
2 Withdraws the needle.
8
Withdraws the needle smoothly at the same angle of insertion.
Applies gentle pressure at the site with a dry sponge.
It is not necessary to massage the area at the site of injection.
If bleeding occurs, apply pressure with a dry sterile gauze until it stops.
2 Activates the needle safety device or discard the uncapped needle and attached syringe into the proper
9 receptacle.
3 Removes and discard gloves and perform hand hygiene.
0
3 Documents all relevant information. The time of administration, drug name, dose, route, and the client’s
1 reactions.
3 AssessES the effectiveness of the medication at the time it is expected to act.
2
TOTAL
OTHERS 30% 5 4 3 2 1
1 Maintains body mechanics throughout the performance of the assessment.
2 Observes neatness and orderliness while performing the assessment.
3 Receptive to criticisms.
4 Observes courtesy.
5 Shows calmness and maintains composure while performing the procedure.
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Davao Doctors College, Inc. Gen. Malvar St., Davao City Nursing Program
6 Exercises proper and fluent use of English language.
7 Shows mastery of the procedure.
TOTAL
Comments:
Performance 70%
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Others 30%
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Final Rating
=
Students' Signature CI's Signature
lcm/kms/dts/bbn/01.15.2021
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__________________________ __________________________ Students' Signature CI's Signature
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