IVT Form

3+3+1 ACCOMPLISMENT REQUIREMENTS 3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES
Name of Registered Nurse: DOMINGO, JANICE S. 0696478 Name of Hospital Offering IV Training: BAGUIO GENERAL HOSPITAL and MEDICAL CENTER Date of IV Training Program Attended: December 3-5 2011
I. Initiating Maintaining Peripheral IV Infusion Patient Name of Patient Age Date No. 55473 Torres,Jesie 48 December 28, 2011 Kind of Infusion 0.9% Sodium Chloride Solution Dextrose 5% in Water 0.9% Sodium Chloride Solution Kind of Infusion SulbactamAmpicillin Mannitol Type of Cannula Introcan G20

PRC Number: Provider No.: 028 Venue: BGHMC Auditorium

Signature over Printed name of Certified Trainer/Preceptor Zenaida Riboroso RN,MAN License No. 62560

Time 10am

Site Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein

Dose 1LiterX 16 Hours 500LiterX KVO 1LiterX KVO

Rate 16 drops/minute

445235

Agpawan,Samuel

79

December 28, 2011

1pm

Introcan G22

10 drops/minute

Zenaida Riboroso RN,MAN

62560

043903

Banawan,Francis

54

December 28, 2011

5pm

Introcan G22

10 drops/minute

Zenaida Riboroso RN,MAN

62560

II. Administering Intravenous Drugs Patient Name of Patient Age No. 327324 Tachado,Editha 68

Date December 28, 2011

Time 8am

Site Left Metacarpal Vein Right Metacarpal Vein Right Metacarpal Vein

Type of Cannula Introcan G20

Dose 1.5gm/ml every 8 hours 200ml every 4 hours 2.25gm/ml every 6 hours

Rate 20 drops/minute

Signature over Printed name of Certified Trainer/Preceptor Zenaida Riboroso RN,MAN

License No. 62560

558412

Cirineo,Desiree

39

December 28, 2011

12pm

Introcan G24

31 drops/minute Zenaida Riboroso RN,MAN 20 drops/minute Zenaida Riboroso RN,MAN

62560

593007

Hermenora,Petra

76

December 28, 2011

12pm

Piperacillin+ Tazobactam

Introcan G22

62560

III. Administering and Maintaining Blood and Blood Components Patient Name of Patient Age Date Time No. 485857 Andres, Decela 27 December 28,2011 2pm

Kind of Infusion Type O(+) Fresh Frozen Plasma

Site Left Metacarpal Vein

Type of Cannula Introcan G18

Dose 250ml

Rate 30 drops/minute

Signature over Printed name of Certified Trainer/Preceptor Zenaida Riboroso RN,MAN

License No. 62560

Submitted by: DOMINGO,JANICE S.

Date Submitted: February 22, 2011

Received by: Jovita E. Pajarillo RN, MAN

Approved by: Elena Tampican RN,MAN

IVT Form

3+3+1 ACCOMPLISMENT REQUIREMENTS 3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES
Name of Registered Nurse: DOMINGO, JANICE S. Name of Hospital Offering IV Training: BAGUIO GENERAL HOSPITAL and MEDICAL CENTER Date of IV Training Program Attended: December 3-5 2011
I. Initiating Maintaining Peripheral IV Infusion Patient Name of Patient Age Date No. 55473 Torres,Jesie 48 December 28, 2011 Kind of Infusion 0.9% Sodium Chloride Solution Dextrose 5% in Water 0.9% Sodium Chloride Solution Kind of Infusion SulbactamAmpicillin Mannitol Type of Cannula Introcan G20

PRC Number:0696478 Provider No.: 028 Venue: BGHMC Auditorium

Signature over Printed name of Certified Trainer/Preceptor Zenaida Riboroso RN,MAN 62560 Zenaida Riboroso RN,MAN 62560 Zenaida Riboroso RN,MAN 62560

Time 10am

Site Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein

Dose 1LiterX 16 Hours 500LiterX KVO 1LiterX KVO

Rate 16 drops/minute

445235

Agpawan,Samuel

79

December 28, 2011

1pm

Introcan G22

10 drops/minute

043903

Banawan,Francis

54

December 28, 2011

5pm

Introcan G22

10 drops/minute

II. Administering Intravenous Drugs Patient Name of Patient Age No. 327324 Tachado,Editha 68

Date December 28, 2011

Time 8am

Site Left Metacarpal Vein Right Metacarpal Vein Right Metacarpal Vein

Type of Cannula Introcan G20

Dose 1.5gm/ml every 8 hours 200ml every 4 hours 2.25gm/ml every 6 hours

Rate 20 drops/minute

Signature over Printed name of Certified Trainer/Preceptor Zenaida Riboroso RN,MAN 62560

558412

Cirineo,Desiree

39

December 28, 2011

12pm

Introcan G24

31 drops/minute

Zenaida Riboroso RN,MAN 62560 Zenaida Riboroso RN,MAN 62560

593007

Hermenora,Petra

76

December 28, 2011

12pm

Piperacillin+ Tazobactam

Introcan G22

20 drops/minute

III. Administering and Maintaining Blood and Blood Components Patient Name of Patient Age Date Time No. 485857 Andres, Decela 27 December 28,2011 2pm

Kind of Infusion Type O(+) Fresh Frozen Plasma

Site Left Metacarpal Vein

Type of Cannula Introcan G18

Dose 250ml

Rate 30 drops/minute

Signature over Printed name of Certified Trainer/Preceptor Zenaida Riboroso RN,MAN 62560

Submitted by: DOMINGO,JANICE S.

Date Submitted: February 22, 2011

Received by: Jovita E. Pajarillo RN, MAN

Approved by: Elena Tampican RN,MAN