CINS workbook draft 9.1 (adult) 106 Supervised Practice Assessment Record
Flushing a Peripheral Cannula
Instruction: Please tick (√) if performed, cross (X) if not performed, or write N/A if deemed not applicable
Surname Forename Ward / Area / Department Assessment
Sterile towel or Gauze (if required) Gloves
Chlorhexidine 2% in alcohol solution
Plastic tray cleaned with 70% alcohol based solution Syringes, needles, 0.9% normal saline
Checks packaging and expiry dates Transporting Safely transfers equipment to patient Preparing the
patient
Identifies patient and explains procedure Obtains valid consent from patient Encourages questions
Establishes comfort and privacy of patient Hand washing Decontaminates hands
Performs procedure
Opens equipment, maintains Aseptic Non-Touch Technique Put on gloves and apron
Places sterile towel / gauze under port (if applicable) Prepares flushing solution in an aseptic a manner
Cleanses needle free system / port with chloxhexidine 2% in alcohol swab
Flushes lumen (using push / pause technique) with 0.9% normal saline
Clamps lumen if applicable
Disposes of equipment and sharps as per trust policy Patient comfort &
safety
Ensures line is secure and comfortable Explains care of peripheral cannula to patient Infection Control
Disposes of equipment & sharps as per trust policy Maintains aseptic technique throughout
Decontaminates hands as per trust policy Documentation
Documents procedure in patients records Completes VIP Score
Documents any other information in case
Initial of Supervisor:
Initial of Practitioner:
The number of supervised practices may vary between individuals. Further copies can be obtained from your training department if required
CINS workbook draft 9.1 (adult) 107 Final Assessment of Practice
Flushing a Peripheral Cannula
The final assessment must be undertaken by a member of the Learning & Development team, Specialist Nurse Practitioner or person approved by them
Name:
Job Title:
Department:
Organisation:
Assessor’s Name:
Date:
Activity Pass Refer Comments
Correct equipment collected Transporting
Preparing the patient Hand Hygiene
Correct positioning of patient and preparation of environment
Performs procedure correctly and safely (as per policy)
Patient comfort and safety Infection Control
Completes documentation in line with local policy
Outcome:
If Outcome of final assessment is refer Continue supervised practice
Review progress – Re-take final assessment again when ready (final assessment must be done before independent practice can occur)
Organise a 1 month review Date of review:
Practitioner: sign Assessor: sign Date:
CINS workbook draft 9.1 (adult) 108 Supervised Practice Assessment Record
Administration of IV drugs through a Peripheral Cannula
Instruction: Please tick (√) if performed, cross (X) if not performed, or write N/A if deemed not applicable
Continued over the page
Sterile towel or Gauze (if required) Gloves
Plastic tray cleaned with 70% alcohol based solution Appropriate sterile equipment
needles/straw/syringes/giving sets Chlorhexidine 2% in alcohol solution
Antibiotic, additive, infusion, diluents as prescribed
Preparation of drugs
Checks packaging and expiry dates
Checks patient identification on prescription chart and any medication
Checks Right patient, Right Medication, Right Dose, Right Time, Right Route
Checked any critical test results (eg blood results) Checks drug for any possible incompatibility issues Is aware of potential complications of the drug to be administered
Correctly performs calculations for dose and rate Prepares intravenous antibiotics/additives/infusor in an aseptic manner
Transporting Safely transfers equipment to patient
Preparing the patient
Identifies patient and explains procedure Obtains valid consent from patient Encourages questions
Checks for allergies
Check peripheral cannula site
Establishes comfort and privacy of patient Hand washing Decontaminates hands
Performs procedure
Put on gloves and apron
Places towel / gauze under port (if required)
Cleanses needle free system with Chlorhexidine 2% in alcohol solution
Flushes peripheral cannula with 0.9% Sodium Chloride prior to drug administration as per guidelines
Administers intravenous antibiotic/additive/infusor as per hospital policy.
Monitors for any adverse reaction
Flushes with 0.9% Sodium Chloride following drug administration as per policy
Disposes of equipment as per trust policy
CINS workbook draft 9.1 (adult) 109 Continued from over the page
Administration of IV drugs through a Peripheral Cannula
The number of supervised practices may vary between individuals. Further copies can be obtained from your training department if required
Surname Forename Ward / Area / Department
Assessment Dates
Supervisors Name: 1)
2) 3)
Skills Lab
Patient comfort &
safety
Ensures line is secure and comfortable Explains care of peripheral cannula to patient Infection Control
Disposes of equipment as per trust policy
Maintains aseptic non-touch technique throughout Decontaminates hands as per trust policy
Documentation
Documents procedure in patients records Completes VIP Score
Documents any other information in case
Initial of Supervisor:
Initial of Practitioner:
CINS workbook draft 9.1 (adult) 110 Final Assessment of Practice
Administration of IV drugs through a Peripheral Cannula
The final assessment must be undertaken by a member of the Learning & Development team, Specialist Nurse Practitioner or person approved by them
Name:
Job Title:
Department:
Organisation:
Assessor’s Name:
Date:
Activity Pass Refer Comments
Correct equipment collected Transporting
Preparing the patient Hand Hygiene
Correct positioning of patient and preparation of environment
Performs procedure correctly and safely (as per policy)
Patient comfort and safety Infection Control
Completes documentation in line with local policy
Outcome:
If Outcome of final assessment is refer Continue supervised practice
Review progress – Re-take final assessment again when ready (final assessment must be done before independent practice can occur)
Organise a 1 month review Date of review:
Practitioner: sign Assessor: sign Date:
CINS workbook draft 9.1 (adult) 111
CINS workbook draft 9.1 (adult) 112 Supervised Practice Assessment Record
Care and Maintenance of Peripheral Cannula
Instruction: Please tick (√) if performed, cross (X) if not performed, or write N/A if deemed not applicable
Surname Forename Ward / Area / Department
Assessment Dates
Supervisors Name: 1)
2) 3)
Skills Lab Only required if further practice
needed
Correct equipment collected
Sterile pack
Chlorhexidine 2% in alcohol solution Sterile Gloves x 1
Checks packaging and expiry dates Appropriate Dressings
Transporting Safely transfers equipment to patient Preparing the patient
Identifies patient and explains procedure Obtains valid consent from patient Encourages questions
Establishes comfort and privacy of patient
Hand washing Decontaminates hands using the Ayliffe technique as per trust policy
Performs procedure
Observes site using VIP scoring and takes appropriate action
Opens equipment, maintains sterile field
Removes existing dressing in an aseptic manner Places sterile dressing towel as close to peripheral cannula as possible
Cleanses skin covering surrounding peripheral cannula with Chlorhexidine 2% in alcohol solution Applies appropriate dressing
Disposes of equipment as per trust policy Patient comfort &
safety
Ensures line is secure and comfortable Explains care of peripheral cannula to patient Infection Control
Disposes of equipment as per trust policy Maintains aseptic technique throughout Decontaminates hands as per trust policy Documentation
Documents procedure in patients records Completes VIP Score
Documents any other information in case records Initial of Supervisor:
Initial of Practitioner:
The number of supervised practices may vary between individuals. Should you require more practice please use the two end columns
CINS workbook draft 9.1 (adult) 113 Final Assessment of Practice
Care and Maintenance of Peripheral Cannula
The final assessment must be undertaken by a member of the Learning & Development team, Specialist Nurse Practitioner or person approved by them
Name:
Job Title:
Department:
Organisation:
Assessor’s Name:
Date:
Activity Pass Refer Comments
Correct equipment collected Transporting
Preparing the patient Hand Hygiene
Correct positioning of patient and preparation of environment
Performs procedure correctly and safely (as per policy)
Patient comfort and safety Infection Control
Completes documentation in line with local policy
Outcome:
If Outcome of final assessment is refer Continue supervised practice
Review progress – Re-take final assessment again when ready (final assessment must be passed before independent practice can occur)
Organise a 1 month review Date of review:
Practitioner: sign Assessor: sign Date:
CINS workbook draft 9.1 (adult) 114
CINS workbook draft 9.1 (adult) 115