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., Marulas, Valenzuela City

I. Initiating/ Maintaining Peripheral IV Infusions

Signature over Printed Name

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

II. Administering Intravenous Drugs

Signature over Printed Name

Patient No. Name of Patient Age Date Time Drugs Incorporated Dose Diagnosis of Certified License No.
Trainer/Preceptor
100158 Doon, Daniella 3 01/29/10 6:00 pm Ampicillin 306 mg AGE with some signs of Dehydration    
100142 Ramos, 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

Signature over Printed Name

Volume/ Blood Type/ Type Of
Patient No. Name of Patient Age Date Time IV Insertion Diagnosis of Certified License No.
Components/ Rate Cannula
Trainer/Preceptor
150 mL/Type Right Cephalic DM Type 2;T/c Chronic
100216 Romero,Arceña 54 02/11/10 12: am O/PRBC/10 gtts/min vein G 19 #1 Renal 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)