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 : PRC Number: ?????? Provider No: Venue: ?????

I.

Initiating/Maintaining peripheral IV infusions

Patient No.
383682 386055

Name of Patient

Age
52 4

Date
12-12-10 12-12-10

Time
5:30 PM 2:00 PM

Kind of infusion
0.9 % Sodium Chloride 5% Dextrose in Lactated Ringers Solution 5% Dextrose in Lactated Ringers Solution

Site
Right Basilic Vein Right Metacarpal vein Left cephalic vein

Type of Cannula
Introcan Gauge 18 Introcan Gauge 24 Introcan Gauge 18

Dose
1 liter x24 hours 1 liter x 16hours

Rate
10-15 gtts/minute 62-63 ugtts/minute

Signature over printed name of certified trainer/preceptor

License No.

669218

36

12-13-10

11:30PM

1 liter x 24hours

10-15 gtts/minute

II.

Administering intravenous drugs

Patient No.
583679 663679 899032

Name of Patient

Age
52 4 39

Date
12-12-12 12-12-12 12-12-12

Time
10:30 PM 4:00 PM 8:00 PM

Drugs Incorporated
Furosemide Ketorolac Cefuroxime

Dose
20mg IV post blood transfusion 15mg IV every 8 hours 750mg IV every 8 hours

Diagnosis
Urinary tract infection rule out nephrolithiasis Close fracture on left supracondylar humerus Abdominal colic, rule out acute appendicitis

Signature over printed name of certified trainer/preceptor

License No.

III.

Administering and maintaining blood and blood components

Patient No.
523679

Name of Patient

Age
52

Date
12-12-12

Time
6:15 PM

Volume/blood/type/components/rate
450 packed red blood cells, type B+, 38-39 gtts/minute

IV insertion
Right Basilic Vein

Type of Cannula
Introcan Guage 18

Diagnosis
Urinary Tract Infection rule our nephrolithiasis

Signature over printed name of certified trainer/preceptor

License No.

Submitted By:___________________________ (Signature over printed name)

Date Submitted:__________________________ Received by:______________________

Approved by:_______________________________________
Director of Nursing Services (Signature over printed name)