IVT FORM 25 OF 26 s 211

3 + 3 + 1 ACCOMPLISHED REQUIREMENTS of
3 DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES
Name of Registered Nurse: Juan Paulo Pescson
PRC Number:
Name of Hospital offering IV Training: Bataan General Hospital
Provider No.:
Date of IV training Program Attended: May 1 3,2015
Venue
I.
Initiating/ Maintaining Peripheral IV Infusions
Patient No. Name of
Age
Date
Time
Patient

Kind of Infusion

Site

Type of
Cannula

Dose

Rate

229928

Junar Java

39

052315

2 pm

PNSS

33 gtts/min

Ramil Konrad
Amianit
Pablo Quinto
Cunanan

051315

3:30pm

D5 0.3 NaCl

500

65mgtts/min

41

051415

3:00pm

D5LR

IV cath
G18
IV cath G
24
IV cath
G22

1L

229952

Metacarpal
Left
Foot Left

1L

33gtts/mis

Date

Time

224013

II. Administering Intravenous Drugs

Patient
Name of
Age
No.
Patient

Metacarpal
Left

Drugs Incorporated

Dose

Diagnosis

Signature over Printed name

of Certified
Trainer/Preceptor/M.D.,RN
Arlene C.Navarro, RN, MAN
Arlene C.Navarro, RN, MAN
Arlene C.Navarro, RN, MAN

III. Administering and Maintaining Blood and Blood Components (2 NURSES IN ONE BLOOD TRANSFUSION ADMINISTRATION)
Patient
Name of
Age
Date
Time
Volume/Blood/Type/Compo IV insertion
Type of
Diagnosis
No.
Patient
nent/Rate
Cannula

14001191
00

Danilo
Enriquez

57

Submitted by: Juan Paulo P. Pecson

05/21/15

5am

PRBC/O+/350ml/ 4hrs

Date Submitted: May 29, 2015

Left
Cephalic

IV Catheter
g 18

Received by: Arlene C.Navarro, RN, MAN

Signature over Printed

name of Certified
Trainer/Preceptor/M.D.,RN
Arlene C.Navarro, RN,
MAN
Arlene C.Navarro, RN,
MAN
Arlene C.Navarro, RN,
MAN

Anemi severe
secondary to
Chronic Kidney
Disease

License
No.

License No.

Signature over Printed

name of Certified
Trainer/Preceptor/M.D.,R
N
Arlene C.Navarro, RN,
MAN

Approved by: Evelyn R. Rubia RN, Ph. D

License
No.

Signature over Printed Name

Director of Nursing Services