3+3+2 ACCOMPLISHED REQUIREMENTS I VT F O RM 09 s 09

3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES

Name of Registered Nurse: Iony T. Dimaculangan PRC Number : 0651828

Name of Hospital offering I V Training: Mary Mediatrix Medical Center Provider No.: 046
Date of I V Training Program Attended: February 23, 24, 25, 2011 Venue: VLM Hall

I. Initiating/ Maintaining Peripheral IV Infusion

Patient No. Name of Patient Age Date Time Kind of Infusion Site Type of Dose Rate Signature Over Printed Name of License
Cannula Certified Trainer/ Preceptor Number
5714 Rodolfo Hernandez 66 March 3, 2011 9:10am Plain Normal Saline Left Gauge 20 500ml 10 Ma. Victoria Z. Panganiban 09-051764
Solution metacarpal cc/hour
326818-2011 Nemesio Dayanghirang 57 March 3, 2011 10:55am 0.3 Sodium Chloride Left Gauge 20 1000ml 80 Ma. Victoria Z. Panganiban 09-051764
metacarpal cc/hour
37742-2005 Pastor Olan 72 March 3, 2011 3:15pm Plain Normal Saline Left Gauge 20 1000ml 100 Ma. Victoria Z. Panganiban 09-051764
Solution metacarpal cc/hour

II. Administering Intravenous Drugs

Patient No. Name of Patient Age Date Time Drugs Incorporated Dose Diagnosis Signature Over Printed Name of License
Certified Trainer/ Preceptor Number
20082-2005 Canuto Dalawampu 78 March 3, 2011 12:00nn Hydrocortisone 100mg Upper respiratory tract 09-051764
infection, Obstetric airway
disease Ma. Victoria Z. Panganiban
54635-2005 Adoracion Perez 69 March 3, 2011 3:35pm Esomeprasole 40mg Acid peptic disease, Diabetes 09-051764
Milletus type II Ma. Victoria Z. Panganiban
326858-2011 Robinson Iduria 25 March 3, 2011 4:00pm Cefuroxime 750mg To consider Dengue 09-051764
Ma. Victoria Z. Panganiban

III. Administering Maintaining Blood and Blood Components

Patient No. Name of Patient Age Date Time Volume/Blood Type/ IV Insertion Type of Diagnosis Signature Over Printed Name of License
Components/Rate Cannula Certified Trainer/ Preceptor Number
149004-2007 Justa Aloya 49 March 23, 2011 1:00pm 350cc/B positive/Packed Red Right Gauge End stage renal 09-051764
Blood Cell/20gtts/min metacarpal 20 disease Ma. Victoria Z. Panganiban
16079-2005 Gaudencio Saniano 60 March 24, 2011 9:20pm 300cc/B positive/Platelet Right Gauge Myodysplastic 09-051764
Pheresis/33gtts/min metacarpal 20 syndrome Ma. Victoria Z. Panganiban

Submitted by: _Iony T. Dimaculangan RN.____ Date Submitted: ____________ Received by: _______________________ Approved by: Roselle Marie D. Azucena, RN. MAN____
(Signature over Printed Name) Director of Nursing Service
(Signature over Printed Name)