3+3+2 ACCOMPLISHED REQUIREMENTS of

3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES

Name of Registered Nurse: ANNE SHERINE CALALANG ERJAS PRC No.: 0639941_________
Name of Hospital offering I V Training: Unciano Medical Center Provider No.: 022__________
Date of I V Training Program Attended: October 15, 16, 17, 2010 Venue: Unciano Medical Center (Antipolo)

I. Initiating/ Maintaining Peripheral IV Infusions

Patient Name of Patient Age Date Time Kind of Site Type of Dose Rate Signature over Printed name of License
No. Infusion Cannula Certified Trainer/Preceptor No.
0050312 Kris Deyta Ragasa 21 10/18/10 3:34 PM D5LR Left Metacarpal Introcan 1Liter 41 drops
Vein Gauge 22 per
minute
0050314 Elizabeth Fortes 62 10/18/10 10:00 D5W Left Metacarpal Introcan ½ 15 drops
Gojar PM Vein Gauge 22 Liter per
minute
0050368 Rebella Altamirano 39 10/28/10 11:50 D5LR Left Cephalic Introcan 1 Liter 41 drops
Cortez PM Vein Gauge 20 per
minute

II. Administering Intravenous Drugs

Patient Name of Patient Age Date Time Drugs Dose Diagnosis Signature over Printed name of License
No. Incorporated Certified Trainer/Preceptor No.

0050246 Teresita Gomez Beltran 62 10/18/10 6:00 PM Imipenem 2g per Intestinal Perforation: Status post
soluset Exploratory Laparotomy
ER/OPD Enrilo Alfonso Lopez 50 10/18/10 7:04 PM Epinephrine 1 mg per Myocardial Infarction
IV push
0050213 Maria Elena Olivay 43 10/18/10 10:30 Paracetamol 300 mg per Cervical Cancer
PM IV push

III. Administering and Maintaining Blood and Blood Components

Patient Name of Patient Age Date Tim Volume/Blood Type/ IV Type of Diagnosis Signature over Printed name of License
No. e Components/Rate Insertion Cannula Certified Trainer/Preceptor No.
0050246 Teresita Gomez 62 10/28/10 12:00 50 mL 25% /Type O/ Right Introcan Intestinal Perforation:
Beltran PM Human Albumin/ Metacarpal Gauge Status post
25 cc/hr vein 20 Exploratory
Laparotomy
0050246 Teresita Gomez 62 11/5/10 1:00 300 mL/ Type O/ Right Introcan Intestinal Perforation:
Beltran PM Packed Red Blood Metacarpal Gauge Status post
Cells/ 30 drops per vein 20 Exploratory
minute Laparotomy

Submitted by: Anne Sherine C. Erjas Date Submitted:__________ Received by:__________________ Approved by: _______________________
(Signature over Printed Name) Director of Nursing Service
( Signature over printed name)