Formative Intravenous Bolus Medication Administration

Intravenous Bolus Medication Administration
MonthDayYearHourMinutes
What class is the student in?*

ABCEvening
A Shift*
B Shift*
C Shift*
Evening Class*
Who is the Evaluator?*

InstructorA Shift Student EvaluatorB Shift Student EvaluatorC Shift Student EvaluatorEvening Class Student Evaluator
Instructor*
A Shift Student Evaluator*
B Shift Student Evaluator*
C Shift Student Evaluator*
Evening Class Student Evaluator*
Selects, checks, assembles equipment

IV medicationSharps containerAlcohol swabs
Administers Medication

Takes or verbalizes appropriate PPE precautionsConfirms medication orderAsks patient for known allergiesExplains procedure to patientCheck medication for: Right patientCheck medication for: Right medicationCheck medication for: Right dosage/concentrationCheck medication for: Right rateCheck medication for: Right routeCheck medication for: Expiration dateAssembles prefilled syringe correctly and dispels airIdentifies and cleanses most proximal injection site(Y-port or hub)Reconfirms medicationStops IV flowAdministers correct dose at proper push rateDisposes/verbalizes proper disposal of syringe and other material in proper containerTurns IV on and adjusts drip rate to TKO/KVOVerbalizes need to observe patient for desired effect and adverse side effects
Affective

Accepts evaluation and criticism professionallyShows willingness to learnInteracts with simulated patient and other personnel in professional manner
Critical Criteria

Failure to take or verbalize appropriate PPE precautionsContaminates equipment or site without appropriately correcting situationFailure to adequately dispel air resulting in the potential for air embolismInjects improper medication or dosage (wrong medication, incorrect amount, administers at an inappropriate rate)Recaps needle or failure to dispose/verbalize disposal of syringe and other material in proper containerFailure to turn on IV after administering medicationFailure to manage the patient as a competent EMTExhibits unacceptable affect with patient or other personnelUses or orders a dangerous or inappropriate intervention
Evaluator Comments
Was the student successful or unsuccessful in this skill?*

SuccessfulUnsuccessful
Signature*
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