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Name of Student : ______________________________________________________ Rating : ________________
Year and Section : ______________________________________________________ Date : ________________
PERFORMANCE CHECKLIST for ADMINISTERING ORAL MEDICATION
Materials/Equipment Needed:
Client’s MAR / Chart Medicine card Towellette
Dispensing system (if available) Medication cups/spoon Medication tray Drinking glass of water
Prescribed medicine Pill crusher/cutter Drinking straw
Procedure 5 4 3 2 1 Remarks
Preparatory phase
1. Check the MAR or the Client’s Chart
Check for the drug name, dosage, frequency, route of administration, and expiration
date
If the MAR is unclear or pertinent information is missing compare the record with the
doctor’s prescription
Report any discrepancies to the charge nurse or follow hospital protocol
2. Know the reason why the client is receiving the medication, drug classification,
contraindication, dosage range, side effects, and nursing consideration for
administering the medication
3. Verify client’s ability to take medication orally. Determine whether the client can
swallow, is NPO, is nauseated or vomiting
4. Organize the materials/supplies
At the medication room, arrange the materials/supplies needed at the medication cart/
tray
Prepare medication card as necessary
Prepare the medication for one client at a time
To prepare the medication
5. Perform hand hygiene and observe other appropriate infection prevention procedures
6. Obtain the appropriate medicine
If available, unlock the dispensing system or take the appropriate medicine from the
shelf, drawer, or refrigerator. The medicine may be dispensed in a bottle, box, or unit-
dose package
Check the expiration date of the medicine, it should have clear, legible labels
7. Calculate the medication dosage accurately if needed or
prepare the correct amount of medication for the required dose
Recheck prepared medicine and container with the MAR again
9. To prepare for tablet or capsule
If using a stock container pour the required number of tablet or capsule into the bottle
cap and transfer to a medication cup without touching the tablet or capsule
Scored tablets may be broken to obtain desired dosage. If necessary, using gloved
hands or with a pill-cutting/splitting device. Check for hospital’s policy on how to
discard unused portion of the medicine
Place packaged unit-dose capsule or tablet directly into the medicine cap without
opening until it is administered to the client.
For clients with difficulty in swallowing, tablets may be crushed into a powder using a
mortar and pestle or by being placed between two paper medication cups and ground
with a blunt object, then mixed in a small amount of applesauce or custard
9. To prepare for liquid medication
Thoroughly mix or shake bottle of the medicine before pouring.
Unscrew cap from the medicine bottle and place the cap upside down on the counter
top.
Hold the bottle and pour liquid medicine with the label towards the palm of the hand
and pours the medicine away from the label
Fill the medication cup to the desired amount of medicine in any of the following
manner:
a) placing the cup on a flat surface at eye level and fills the desired level using the
bottom of the meniscus,
b) holds the cup at eye level pointing thumb nail to desired amount,
c) use of a sterile syringe without a needle on it, or a dropper when giving a small
amount of liquid medicine of less than 5 ml
Before capping the bottle, Wipe lip of bottle with paper towel
To administer medication to client
13. Place the prepared medicine on the medication cart/or on the medication tray with the
medicine card
14. Take the medicine to the client considering hospital’s protocol
15. Before entering client’s room, check room number. When on client’s room, compare
name on bedside with that of the medicine card
16. Provide for client’s privacy
17. Prepare client
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Introduce self and verify clients identity
Assist the client to a sitting position or if not possible to a side-lying position
19. Explain the purpose of the medication and how it will help, using language that the
client can understand
20. In administering tablet or capsule
Allow client to hold the tablet or medication cup
If the client is unable to hold the cup, use the cup to introduce the medication into the
client’s mouth
If an older adult has difficulty swallowing, ask the client to place the tablet/capsule on
the tongue before taking the water
21. For liquid medication
Place a napkin or a towelette under the client’s chin.
Administer medicine using a spoon, or a medication cup.
22. Give a glass of water or other liquid, and straw if needed, to help the client swallow
the medicine
23. Remain with the client until the medicine has been swallowed or dissolved.
24. Assist the client into a comfortable position after taking the
medicine.
21. Document medication given
22. Disposes all supplies appropriately
23. Replenishes stocks at the medication room
24. Clean the work area and perform hand hygiene
25. Observe client for any adverse effect of medication.
Total Score = 170
Raw Score/Total Score x 50 + 50 = Rating
Performance Checklist prepared by : Lucilyn C. Ebuenga, RN.MN & Rafmarc D. Genorga, RN.MAN
Reference: Berman, Audrey; Snyder, Shirlee J. and Frandsen, Geralyn (2018). Kozier & Erb’s
Fundamentals of Nursing: Concepts, Process and Practice 10th ed. Volume 2, Pearson Educational Limited
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Name of Student : _______________________________________________ Rating : ________________
Year and Section : _______________________________________________ Date : ________________
PERFORMANCE CHECKLIST for ADMINISTERING PARENTERAL MEDICATION
Materials/Equipment Needed:
Client’s MAR / Chart Sterile pick-up forcep
Hypodermic tray/injection tray lined with sterile towel Syringe & needle
Antiseptic swab (cotton balls with alcohol & dry cotton balls) Clean gloves
Medication prescribed in an ampule and vial Waste container
Medicine card Sharps’ receptacle
Procedure 5 4 3 2 1 Remarks
Preparatory phase
1. Check the MAR or the Client’s Chart
Check for the drug name, dosage, frequency, route of administration, and expiration date
Follow the three checks for administering medication:
o when it is taken from the medication cart
o before withdrawing
o after withdrawing the medication
2. Organize the materials/supplies
At the medication room, arrange the materials/supplies needed at the medication cart/tray
Select appropriate syringe and needle size
Calculate dosage accurately and prepare prescribed injection correctly
Prepare medication card correctly as necessary
3. Perform hand hygiene and observe other infection prevention procedures
To prepare injection
1. Preparing medication from a vial
Mix the solution, if necessary by rotating the vial between the palms of the hands, not by
shaking
Remove the protective cap, or clean the rubber cap with an antiseptic swab by rubbing in a
circular motion
Withdraw the medication:
o Hold the syringe and ensure that the needle is firmly attached to it
o Remove the cap from the needle, then draw up into the syringe the amount of
air equal to the volume of the medication to be withdrawn
o Carefully insert the needle into the upright vial through the center of the rubber
cap, maintaining the sterility of the needle
o Inject the air into the vial, keeping the bevel of the needle above the surface of
the medication
o Withdraw the prescribed amount of medication using either of the ff. methods:
Hold the vial down (with the base lower than the top) move the needle tip so that
it is below the fluid level and withdraw the medication, avoid drawing the last
drops of the vial, or invert the vial, ensure the needle tip is below the fluid level,
and gradually withdraw the medication
Hold the syringe and vial at eye level to determine that the correct dosage of drug is drawn
into the syringe. Eject air remaining at the top of the syringe into the vial.
When the correct volume of medication is obtained, withdraw needle from the vial and
replace the cap over the needle using the scoop method, thus maintaining sterility
Before administering injection replace needle
2. Preparing medication from an ampule
Flick the upper stem of the ampule several times with a fingernail
Use an ampule opener or place a piece of sterile gauze between your thumb and the
ampule neck or around the ampule neck, and break off the top by bending it towards you to
ensure the ampule is broken away from you. Dispose of the top of the ampule in the
sharps container
Withdraw the medication:
o Place the ampule on a clean flat surface
o Grasp the syringe, remove the cap and insert the needle into the center of the
ampule. Do not touch the rim of the ampule with the needle tip
o Hold the ampule slightly on its side, and obtain the necessary amount of
medication
o Dispose of the needle on the sharps container
o Before administering injection, replace needle, tighten the cap at the hub of the
needle and push solution into the needle to the prescribed amount
To administer intradermal medication to client:
9. Place the prepared medicine on the medication cart/or on the medication tray with the
medicine card
10. Take the medicine to the client considering hospital’s protocol
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11. Before entering client’s room, check room number. When on client’s room, compare name
on bedside and client’s ID band with that of the medicine card
12. Provide for client’s privacy
Close door or put bed screen
Put on gown or drape client’s body
13. Prepares client and assist to a comfortable position depending on chosen site for injection
14. Introduces self and verifies the client’s identification
15. Explain the procedure to the client
16. Select, and locates injection site
Inspect skin for bruises, inflammation, edema, masses, tenderness, and sites of previous
injections.
Forearm site should be a hand’s width above wrists or 3-4 fingerwidths below the
antecubital space , on inner aspect of forearm.
17. Cleanses the skin at the site using antiseptic swab in a circular motion starting at the
center and widening the circle outwards, allows area to dry
18. Expels air bubbles from the syringe
19. Grasps the syringe with dominant hand, close to the bulb, holding it between thumb and
forefinger
20. Pull cap from needle and holds the needle almost parallel to the skin surface, with the
bevel of the needle up
21. Administer injection
With non-dominant hand, stretch skin over site with forefinger and thumb
Insert needle slowly at a 5-to-15-degree angle, bevel up through the epidermis into the
dermis
Then advance to no more than ½ inch below the skin. until resistance is felt
Stabilizes the syringe and the needle
Injects the medication carefully and slowly so that it produces a small wheal on the skin
called bleb
Withdraws the needle quickly at the same angle at which it was inserted. If bleeding
occurs, tap with a dry cotton swab
22. Do not massage the injection site
23. Disposes the uncapped needle and syringe in a sharps’ container and the used cotton
swab in an appropriate waste container
24. Reposition and assist the client to a comfortable position
25. Removes and discard gloves as necessary
26. Clean the work area and perform hand hygiene
27. Document procedure and other relevant information
If the procedure is for purpose of testing of allergic reaction: document testing material
given, time, dosage, route, site, and evaluates client’s response to the testing substance
and the condition of the site
If the procedure is for therapeutic purposes: document relevant data
To administer intramuscular medication to client:
Follow steps from 1-12
28. Select, locates injection site:
Select a site free of tenderness, hardness, swelling, scarring, itching, burning, or localized
inflammation
Deltoid site: locate by placing four fingers across the deltoid muscle with the 1 st finger on
the acronion process
29. Cleans the site with an antiseptic swab in a circular motion starting at the center and move
outward about 5 cm. Discard the used swab in an appropriate container.
30. Get another dry cotton swab, holds the swab between the 3rd and 4th fingers of non-
dominant hand in readiness for needle withdrawal, or positions the swab on the client’s
skin above the intended site
31. Allows the skin to dry prior to injecting medication
32. Prepares the syringe for injection, removes the needle cover and discards without
contaminating the needle
33. Prepares to injects the medication using correct technique, use the ulnar side of the
nondominant hand to pull the skin approximately 2.5 cm (1 in) to the side
34. Holding the syringe between thumb and forefinger as if holding a pen, pierce the skin
quickly and smoothly at 90 degree angle, and inserts the needle onto the muscle
35. Checks for back flow of blood by holding the barrel of the syringe steadily with the non-
dominant hand and aspirates by pulling back on the plunger by your non-dominant hand:
if blood appears in the syringe, withdraws the needle, discards the syringe and prepares
another injection
If blood does not appear, injects the medication steadily and slowly while holding the
syringe steadily
36. Withdraws the needle smoothly at the same angle of insertion
37. Releases gently the skin
38. Applies gentle pressure at the site with a dry cotton swab
39. If bleeding occurs, applies pressure with a dry cotton swab
40. Disposes the uncapped needle and syringe in a sharps’ container and the used cotton
swab in an appropriate waste container
41. Remove gloves as necessary and discard in an appropriate container. Performs hand
hygiene.
42. Document medication given and other relevant information
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43. Assesses the effectiveness of the medication at the time it is expected to act
44. Conducts appropriate follow-up such as desired effect, any adverse reactions or side
effects, local skin or tissue reactions
Total Score = 305
Raw Score/Total Score x 50 + 50 = Rating
Performance Checklist prepared by : Lucilyn C. Ebuenga, RN.MN & Rafmarc D. Genorga, RN.MAN
Reference: Berman, Audrey; Snyder, Shirlee J. and Frandsen, Geralyn (2018). Kozier & Erb’s Fundamentals of Nursing:
Concepts, Process and Practice, 10th ed. Volume 2, Pearson Educational Limited (Published)
Pecson, Jane; Valladolid Esther; Ebuenga, Lucilyn; Manual on Health basic Procedures for Health Allied Students
& Performance Checklist & Record of RLE (Published)
Guasa, Adelia; Binalingbing, Fe; Galan, Nera; RLE Record Book for Midwifery & Nursing Students with Basic Concepts
& Performance Checklist of the Different Health Care Procedures (Unpublished)
Clinical Instructor’s Comments/Feedback:
For Administering Oral Medication
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For Administering Parenteral Medication
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Student’s Signature Clinical Instructor’s Signature
