3+3+2 ACCOMPLISHED REQUIREMENTS OF

3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FOR NURSES

Name of Registered Nurse: Aban, Anna Mae A. PRC Number: 900224495 __________________________
Name of Hospital offering IV Training: Saint Joseph Southern Bukidnon Hospital Provider No.: 064 ________________________________
Date of IV Training Program Attended: Auguts 20-22, 2010 __ Venue: Saint Joseph Southern Bukidnon Hospital- Conference Room______

I. Initiating / Maintaining Peripheral IV Infusions

Signature over printed License No.
Patient Name of Age Date Time Kind of Infusion Site Type of Dose Rate Name of
No. Patient Cannula Trainer/Preceptor
Right arm
1 Guigayoma, 56y.o 10/30/201 8:15am 0.9% Sodium Chloride metacarpal IV Catheter 1000 ml 120 cc/hr
Arsenia 0 vein Gauge 22
Left arm IV Catheter
2 Akut, Sophia 10 mos. 10/30/201 4:00 pm D5 Dextrose in 0.9% metacarpal Guage 26 500 ml 30 cc/hr
Angela 0 Sodium Chloride vein
Right arm IV Catheter
3 Dagulo, Simeona 87y.o 10/30/201 4:15pm 0.9% Sodium Chloride cephalic vein Guage 22 1000 ml 100 cc/hr
0

II. Administering Intravenous Drug

Signature over Printed License
Patient Name of Age Date Time Drugs Incorporated Dose Diagnosis Name of No.
No. Patient Trainer/Preceptor
250mg IVTT q AGE w/ some dehydration; Oral
1 Amarga, Jeraldeyn 10 mos. 10/30/2010 12:00nn Ampicillin 6 hrs. ANST(-) dehydration therapy failure
375mg IVTT q Hypokalemia, UTI; Intestinal
2 Abalde, Phoebe 3y.o 10/30/2010 12:00nn Ampicillin 6 hrs. ANST(-) amoebiasis
250mg IVTT q
3 Jurolan, Jasper 1y.o 10/30/2010 12:00nn Ceftazidime 8 hrs. ANST(-) Bacterial Pneumonia

III. Administering and maintaining Blood and Blood Components

IV Signature over Printed License
Patient Name of Age Date Time Volume / Blood Type / Insertion Type of Diagnosis Name of No.
No. Patient Components/ Rate Site Cannula Trainer/Preceptor
1 PRBC w/ serial no.
1 Malahay, Emily 56y.o 10/30/201 8:15am 2010-004463; type “o” @ Right arm IV Catheter Ovarian new growth
0 30gtts/min. Guage 18
62y.o 1 PRBC w/ serial no. Adeno carcinoma w/ differentiate;
2 Galisa, Francisca 10/30/201 2:30pm 2009-271077; type “B” @ Left arm IV Catheter uterus statuts post fractural curettage
0 30gtts/min. Guage 18 anemic secondary to chronic blood loss

Submitted by: ANNA MAE A. ABAN Date Submitted: November 3, 2010 Receive Approved by: ________________________________
Signature over printed name Director of Nursing Services
(Signature over printed name)