1 Start 2 Complete

This checklist is to be used to document completion of the clinical phase of the certification course. A Florida licensed Registered Nurse must supervise the clinical experience which demonstrates knowledge and proficiency. Use the attached forms to document an acceptable demonstration of each item as noted. The RN must select agree on each item completed. If the item is not applicable, select "N/A" for that given skill. A brief explanation regarding the N/A should be noted in your overall comments. These items should still be included in the overall discussion for familiarity. A submitted Skills Checklist is treated as an electronic signature from both the LPN and the RN. Once the completed checklist has been submitted, as well as the successfully completed posttest,a certificate of completion will be issued. This proficiency checklist should be maintained by the facility in the LPN’s personnel file. The LPN should also retain a copy of these forms for his/her record.

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AgreeDisagreeN/A
a) Verifies that the prescribed IV therapy matches the physician's order
b) Inspects the IV solution for correct labeling, expiration date, and other required information
c) Gathers and assembles all necessary IV equipment
d) Performs hand hygiene using soap and water or an approved alcohol-based hand sanitizer
e) Verifies the patient's identity
f) Prepares the patient for the IV procedure
g) Follows standard precautions throughout the procedure
h) Prepares the IV tubing and catheter/needle, fills the drip chamber, and removes air from the tubing
i) Applies the tourniquet and uses appropriate techniques to locate and dilate the vein
j) Cleanses the insertion site using an approved antimicrobial solution
k) Maintains sterile technique during IV insertion
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AgreeDisagreeN/A
a) Stabilizes the vein by anchoring it with the thumb and gently stretching the skin downward
b) Removes the needle cap and positions the needle at a 10–15 degree angle with the bevel facing upward
c) Inserts the needle through the skin slightly below the intended vein puncture site
d) Reduces the needle angle and advances the needle until it enters the vein and blood return is observed
e) Advances the needle or catheter cannula into the vein and releases the tourniquet once properly positioned
f) When using an over-the-needle catheter, firmly grasps the catheter hub and withdraws the needle
g) Connects the IV set adapter securely to the catheter or needle hub
h) Opens the flow clamp and verifies that the IV solution flows freely
i) Initiates the IV infusion, secures the insertion site with appropriate tape or dressing, and labels it with the date, catheter size, and initials
j) Adjusts the IV infusion to the prescribed flow rate
k) Documents the procedure, including the date, time, catheter details, solution type and amount, patient tolerance, and signature
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AgreeDisagreeN/A
a) Demonstrates the correct technique for changing IV tubing
b) Demonstrates the correct technique for administering IV medications using the piggyback method
c) Demonstrates how to properly discontinue an IV and document the procedure
d) Demonstrates the correct use of an Electronic Infusion Device (EID)
e) Identifies and demonstrates appropriate troubleshooting procedures for an Electronic Infusion Device (EID)
f) Correctly administers medication or a heparin flush through an intermittent infusion device (INT)
g) Demonstrates the correct procedure for flushing an IV line
h) Explains or demonstrates how to convert an IV catheter to an intermittent infusion device (INT)
i) Identifies at least two signs of phlebitis and two signs of infiltration
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(according to facility's policy and procedures)
AgreeDisagreeN/A
a) Assesses the central venous line (CVL) insertion site for signs of complications
b) Changes the CVL dressing using appropriate sterile technique
c) Changes the CVL cap using appropriate aseptic technique
d) Flushes the CVL using the appropriate technique and solution
e) Administers medications and fluids through the CVL using appropriate procedures
f) Obtains blood samples from the CVL using appropriate procedures
g) Documents all CVL procedures accurately in the appropriate patient record
h) Identifies the appropriate needle type for accessing a vascular access port (VAP)
i) Accesses the vascular access port (VAP) using appropriate sterile technique
j) Obtains blood samples from a vascular access port (VAP) using appropriate procedures
k) Identifies three potential complications associated with central venous lines
l) Describes one or two appropriate remedial measures for each identified complication
m) Identifies two possible insertion sites for a central venous line
n) Identifies two possible insertion sites for a peripherally inserted central catheter (PICC)
o) Identifies at least two signs of inflammation
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AgreeDisagreeN/A
a) Measures and records the patient's temperature before obtaining blood
b) Verifies that the blood product label matches the prescribed order according to agency procedures
c) Assesses the existing IV line, needle size, and insertion site condition
d) Hangs normal saline according to established procedures
e) Flushes the IV needle with normal saline
f) Attaches the administration set, primes the blood filter, and removes air from the tubing
g) Connects the blood administration tubing to the Y-site or follows the agency's approved procedure
h) Regulates the blood infusion rate and explains the expected duration of the transfusion
i) Identifies three signs of a transfusion reaction and explains the appropriate reporting procedures
j) Discontinues the blood transfusion and disposes of tags and tubing according to established procedures
k) Documents the blood transfusion procedure on the appropriate form or flowsheet

Hospital / Facility

I have supervised the listed Florida LPN in the clinical portion of IV Therapy, including managing centrallines, and have completed this checklist with the LPN and have determined that they have completed all areas successfully.

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I hereby certify on this day that I have completed the attached forms

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