3+3+2 Accomplished Requirements of 3 Day Basic Intravenous Therapy Training Program for Nurses

Name of Registered Nurse: Name of Hospital offering IV Training : Date of IV Training Program Attended FRANZ NANCY A. SAHAGUN Premiere Medical Center September 21-23, 2011 PRC Number: Provider no. : Venue : 178 PMC Auditorium

I. Initiating/Maintaining Peripheral IV Infusions Patient No. 68036 131538 131518 Name of Patient Nancy Andres Gilbert David Gaspar Mary Joyce Santiago Age 46 7 mos. 11 Date 9/26/2011 9/26/2011 9/26/2011 Time 8:00am 9:30am 10:00am Kind of Infusion D5LRS 1L D5 0 .3 Na Cl 500cc D5LRS 1L Site Left metacarpal Vein Left saphenous Vein Left metacarpal Vein Type of Cannula Int. G.22 Int. G.24 Int. G.24 Dose 8 hours 27 hours 8 hours Rate 42 gtts/min
18 mgtts/min

Signature over Printed name of Certified Trainer/Preceptor

License No. 08-015540 08-015540 08-015540

42 gtts/min

II. Administering Intravenous Drugs Patient No. 131539 131512 131539 Name of Patient Andrian Camus Orcino Girlie Mosa Andrian Camus Orcino Age 2 14 2 Date 9/26/2011 9/26/2011 9/26/2011 Time 8:50am 9:00am 9:15am Drug Incorporated Amikacin Vitamin K Cefuroxime Dose 98mg 5mg 325mg Diagnosis Acute Glumerulonephritis Aplastic Anemia Acute Glumerulonephritis Signature over Printed name of Certified Trainer/Preceptor License No. 08-015540 08-15540 08-15540

III. Administering and Maintaining blood and Blood Components Patient No. 108946 Name of Patient Daisy Belmonte Age 49 Date 9/26/2011 Time 10:05am
Volume/Blood Type/Component/Rate

IV Insertion Left Jugular Vein

Type of Cannula IJ

Diagnosis Chronic Kidney Disease

Signature over Printed name of Certified Trainer/Preceptor

License No. 08-015540

280cc/O+/PRBC/FD

Submitted by:________________________________
(Signature over printed name)

Date Submitted:__________________

Received by:________________________

Approved by: CARMELA T. PASCUAL, RN,MAN Director of Nursing Service

(Signature over printed name)

3+3+2 Accomplished 3 Day Basic Intravenous Therapy

Name of Registered Nurse: Name of Hospital offering IV Training : Date of IV Training Program Attended FRANZ NANCY A. SAHAGUN Premiere Medical Center September 21-23, 2011

I. Initiating/Maintaining Peripheral IV Infusions Patient No. 68036 131538 131518 Name of Patient Nancy Andres Gilbert David Gaspar Mary Joyce Santiago Age 46 7 mos. 11 Date 9/26/2011 9/26/2011 9/26/2011 Time 8:00am 9:30am 10:00am

II. Administering Intravenous Drugs Patient No. 131539 131512 131539 Name of Patient Andrian Camus Orcino Girlie Mosa Andrian Camus Orcino Age 2 14 2 Date 9/26/2011 9/26/2011 9/26/2011 Time 8:50am 9:00am 9:15am

III. Administering and Maintaining blood and Blood Components Patient No. 108946 Name of Patient Daisy Belmonte Age 49 Date 9/26/2011 Time 10:05am

Submitted by:________________________________
(Signature over printed name)

Date Submitted:__________________

Received by:_________

3+3+2 Accomplished Requirements of 3 Day Basic Intravenous Therapy Training Program for Nurses
PRC Number: Provider no. : Venue :

Kind of Infusion D5LRS 1L D5 0 .3 Na Cl 500cc D5LRS 1L

Site Left metacarpal Vein Left saphenous Vein Left metacarpal Vein

Type of Cannula Int. G.22 Int. G.24 Int. G.24

Dose 8 hours 27 hours 8 hours

Rate 42 gtts/min 18 mgtts/min 42 gtts/min

Drug Incorporated Amikacin Vitamin K Cefuroxime

Dose 98mg 5mg 325mg

Diagnosis Acute Glumerulonephritis Aplastic Anemia Acute Glumerulonephritis

Volume/Blood Type/Component/Rate

IV Insertion Left Jugular Vein

Type of Cannula IJ

Diagnosis Chronic Kidney Disease

280cc/O+/PRBC/FD

_____________

Received by:________________________

Approved by: CARMELA T. PASCUAL, RN,MAN

178 PMC Auditorium

Signature over Printed name of Certified Trainer/Preceptor

License No. 08-015540 08-015540 08-015540

Signature over Printed name of Certified Trainer/Preceptor

License No. 08-015540 08-15540 08-15540

Signature over Printed name of Certified Trainer/Preceptor

License No. 08-015540

ELA T. PASCUAL, RN,MAN Director of Nursing Service

(Signature over printed name)