3+3+1 ACCOMPLISHED REQUIREMENT of DAYS BASIC IV THERAPY TRAINING PROGRAM for NURSES Name of egistered Nurse: Name of Aospital

l 1ffering IV Training: Date of I V Training Program Attended:

MA% >ATIMA D3#1S SAT1S

SAMP#3 1N#B .S3 the other one ?eloC

$-/-//&)5SPCMC Conferen"e oom

San Pa?lo Colleges Medi"al Center@ San Pa?lo City@ #A+.NA May &/'&*@ &))5

P C Num?er: Pro!ider No: Venue:

I: Initiating / Maintaining Peripheral IV Infusions

Patient No:

Name of Patient

Age &&y/o -(y/o

Date &'&('$) /')-'$) /')*'$)

Time $$:))am (:*)am 0:))pm

Kinds of fusions

Site # Meta"arpal !ein # Meta"arpal Vein Cephali" Vein

Type of Cannula

Dose $# , (hrs $# , $0hrs $# , $&hrs

ate -&gtts/min &$gtts/min (/mgtts/min

Signature o!er Printed Name of Certified Trainer/Pre"eptor

#i"ense No:

$% &% /% Pedia "ase

D*# S D*# S D*# S

+:&) +:&) +:&&

.se &) as drop fa"tor

123NA P% 4ATI 123NA P% 4ATI AN: ))/55/ AN: ))/55/

$&y/o

II%
Patient No:

Administering Intra!enous Drugs

Name of Patient Age y/o y/o y/o Date /')*'$) /')*'$) /')*'$) Time (:))pm 5:))pm $):))pm
Drugs In"orporated Dose

Diagnosis t/" +astritis r/o Cholelithiasis .pper +stro Int% 4leeding

Signature o!er Printed Name of Certified Trainer/Pre"eptor

43 NA D1 A#IMA+N1 7 % 43 NA D1 A#IMA+N1 7 % 43 NA D1 A#IMA+N1 7 %

#i"ense No:
AN: )8'8$$0 AN: )8'8$$0 AN: )8'8$$0

$% &% /%

anitidine *)mg ampule Cefuro9ime 8*)mg !ial anitidine *)mg ampule

$ amp IV 6 $&hrs 8*)mgIV 6 (hrs $ amp IV 6 (hrs

III% Administering : Maintaining 4lood and 4lood Components

Patient No:

Name of Patient

Age y/o

Date /')0'$)

Time (:))am

Volume/4lood Type Components/ ate

IV Insertion

$%
Su?mitted ?y

Type 1 h;<= &*) P 4C ,&$gtts

#Meta"arpal Vein

Type of Cannula +:&)

Diagnosis .+I4

Signature o!er Printed Name of Certified Trainer/Pre"eptor

43 NA D1 A#IMA+N1 7 %

#i"ense No:
AN: )8'8$$0

*))"" >24 , -&gtts

MA% >ATIMA D3#1S SANT1S

Date Su?mitted:

Mar"h $8@ &)$)

e"ei!ed ?y:

Appro!ed ?y:

PROF. CLEOFE A. CABRERA Dire"tor@ Nursing Ser!i"e ;Signature o!er printed Name=

;Signature o!er printed Name=

3+3+1 ACCOMPLISHED REQUIREMENT of DAYS BASIC IV THERAPY TRAINING PROGRAM for NURSES Name of egistered Nurse: Name of Aospital 1ffering IV Training: Date of I V Training Program Attended: 1NNI3 2% D3# I1 San Pa?lo Colleges Medi"al Center@ San Pa?lo City@ #A+.NA >e?ruary &8 ' Mar"h $@ &)$-

P C Num?er: Pro!ider No: Venue:

)(&)(&( $** SPCMC Audio Visual oom

I: Initiating / Maintaining Peripheral IV Infusions

Patient No:

Name of Patient Angeli"a Camille Perpetua Ma"andile >ran"is"o >andialan amil de Al?ay

Age &/y/o 0-y/o /)y/o

Date &'&-'$&'&-'$&'&&'$-

Time $):))am $&:&)pm 8:))pm

Kinds of Infusions

Site # Meta"arpal Vein Meta"arpal Vein # Meta"arpal Vein

Type of Cannula

Dose $# , $&hrs $# , $&hrs $# , $&hrs

ate &(gtts/min (/mgtts/min &(gtts/min

Signature o!er Printed Name of Certified Trainer/Pre"eptor

123NA P% 4ATI 123NA P% 4ATI 123NA P% 4ATI

#i"ense No:
AN: ))/55/ AN: ))/55/ AN: ))/55/

$% &% /%

D*NSS PNSS PNSS

+:&& +:&) +:&)

II%
Patient No:

Administering Intra!enous Drugs

Name of Patient Age /*y/o &&y/o 0/y/o Date &'&-'$&'&-'$&'&-'$Time $&:))pm $):))am -:))pm
Drugs In"orporated Dose

Diagnosis t/" Cere?ro Vas"ular A""ident MPI se" to VA t/" A"ute +astritis r/o .TI

Signature o!er Printed Name of Certified Trainer/Pre"eptor

43 NA D1 A#IMA+N1 7 % 43 NA D1 A#IMA+N1 7 % 43 NA D1 A#IMA+N1 7 %

#i"ense No:
AN: )88$$0 AN: )88$$0 AN: )88$$0

$% &% /%

Marielle Cau?ang +eneth Cadalin Isidro >urio

Citi"holine *))mg ampule anitidine *)mg ampule Pantopra9ole -)mg !ial

$ amp IV 6 0hrs $ amp IV 6 $&hrs $ !ial IV 6 (hrs

III% Administering : Maintaining 4lood and 4lood Components

Patient No:

Name of Patient

Age

Date

Time

Volume/4lood Type Components/ ate

IV Insertion

Type of Cannula

Diagnosis

Signature o!er Printed Name of Certified Trainer/Pre"eptor

43 NA D1 A#IMA+N1 7 %

#i"ense No:
AN: )88$$0

$%
Su?mitted ?y
;Signature o!er printed Name=

Date Su?mitted:

e"ei!ed ?y:

Appro!ed ?y:

PROF. CLEOFE A. CABRERA Dire"tor@ Nursing Ser!i"e ;Signature o!er printed Name=

P 3C3PT1 S ANSAP N.M43 : $% &% 43 NA D1 A#IMA+N1 7 % 123NA P% 4ATI ' ' AN: )88$$0 AN: ))/55/

Complete the details please