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IVT FORM 09 s 09

3+3+2 ACCOMPLISHED REQUIREMENTS of

3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES

Name of Registered Nurse Jomar V. Bañadera _____ PRC Number 0575280___________________________________________

Name of Hospital offering IV Training Calalang General Hospital __________ Provider No. 190________________________________________________

Date of IV Training Program Attended January 21-23, 2010_______________ Venue Multipurpose Hall-CGH 16R Valenzuela St.,
Valenzuela City

I. Initiating/ Maintaining Peripheral IV Infusions

Signature over Printed


Patient Type Of
Name of Patient Age Date Time Kind Of Infusion Site Dose Rate Name of Certified License No.
No. Cannula
Trainer/Preceptor
Left
Pernitez, Maximo Metacarpal 30
100176 Jr. 44 02/03/10 3:15 pm PNSS Vein G 22 #1 1 Liter gtts/min
Left
Vianzon, John Metacarpal
100222 Angelo 13 02/10/10 11:25 pm PLR Vein G 22 #1 1 Liter 40gtts/min
Right
Henson, Increase Metacarpal ½
100212 Fernandez 4 02/11/10 12:20 am PNSS Vein G 24 #1 Liter 60 mL/hr

II. Administering Intravenous Drugs

Signature over Printed


Patient Drugs
Name of Patient Age Date Time Dose Diagnosis Name of Certified License No.
No. Incorporated
Trainer/Preceptor
AGE with some signs of
100158 Doon, Daniella 3 01/29/10 6:00 pm Ampicillin 306 mg Dehydration
Ramos,
100142 Esperanza C. 76 01/29/10 6:00 pm Citicholine 1 gm CVA; HPN II
100162 Isidro, Flohimon 60 01/29/10 10:00 pm Unasyn 750 mg DM Type 2;T/c Pneumonia; UTI

III. Administering and Maintaining Blood and Blood Components

Volume/ Blood Signature over Printed


Patient Type Of
Name of Patient Age Date Time Type/ IV Insertion Diagnosis Name of Certified License No.
No. Cannula
Components/ Rate Trainer/Preceptor
150 mL/Type Right DM Type 2;T/c
O/PRBC/10 Cephalic Chronic Renal
100216 Romero,Arceña 54 02/11/10 12: am gtts/min vein G 19 #1 disease; Anemia
Submitted by: JOMAR VALENCIA BAÑADERA__ Date Submitted: _________________ Received by: ________________________________ Approved by: MARIDEL C. DE LA RAMA RN,MAN.
Signature over Printed Name Director of Nursing Service

(Signature over Printed Name)