3+3+2 ACCOMPLISHED REQUIREMENTS of

3 DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FOR NURSES

Name of Registered Nurse Norelle Jane B. Olarte____________________________________ PRC Number: 0608372__________________________

Name of Hospital offering IV Taining PLTCI-LAT Medical Center____________________________________ Provider No. 168______________________________

Date of IV Training Program Attended July 18-20, 2010____________________________________________ Venue: Governors’s Hotel, Solano, Nueva Vizcaya

I. Initiating/Maintaining Peripheral IV Infusions

Patient Kind of Type of Signature over Printed

No. Name of Patient Age Date Time Infusion Site Cannula Dose Rate name of Certified License No.
Trainer/Preceptor
252 Joaquinn de Leon 6 y/o 08-27-10 3:00pm D5LRs Left metacarpal vein Gauge 24 1L 24 gtss/min 09009563
Lilian Bayad
249 Bhiagy Yron Ric Dulawan 5 y/o 08-24-10 11:45am D5LRs Right metacarpal vein Gauge 24 1L 60 ugtts/min 09009563
Quintos Lilian Bayad
244 Rosario Monica Asuncion 2 y/o 08-25-10 10:10am D5IMB Left metacarpal vein Gauge 24 1L 31 gtts/min 09009563
Camma Lilian Bayad
II. Administering Intravenous Drugs

Patient Signature over Printed

No. Name of Patient Age Date Time Drugs Incorporated Dose Diagnosis name of Certified License No.
Trainer/Preceptor
246 Linda Apolonio Abalos 54 y/o 08-20-10 12nn Ampicillin 1.5g Pneumonia BrCA Stage IV (Pulmo mets) 09009563
Lilian Bayad
240 Amielle Keizha Bacena 1 y/o 08-25-10 8am Paracetamol 100mg Benign Febrile Cnvulsion 09009563
Ecwasen Lilian Bayad
256 Vrienn Ezrah Karl Claril 1 y/o 08-24-10 12nn Cefuroxime 350mg Pneumonia, severe 09009563
Viernes Lilian Bayad
III. Administering and Maintaining Blood and Blood Components

Patient Volume/Blood Type of Signature over Printed

No. Name of Patient Age Date Time Type/Components/Rate IV insertion Cannula Diagnosis Name of Certified License No.
Trainer/Preceptor
252 Joaquinn de Leon 6 y/0 08-23-10 4:45pm 450/Blood Type Left metacarpal Gauge 18 Dengue Hemorrhagic 09009563
“O”/FFP/28 gtts/min vein Fever Stage III Lilian Bayad
250 Merly Padua Sinaban 44 y/o 08-21-10 1:00pm 450/Blood Type Right cephalic Gauge 18 Go Myoma utero r/o 09009563
“A”/Whole Blood/15 vein Adenomyoma, Lilian Bayad
gtts/min Endometriosis

Submitted By; Norelle Jane B. Olarte, RN Date Submitted: September 29, 2010 Received By: ___________________________ Approved By: Luz F. Bartolome RN, MSN, MAN