IV THERAPY ACCOMPLISHED REQUIREMENTS

FORMAT
Bauan Doctors General Hospital Venue: Bauan Doctors General Hospital
Name of Hospital Offering IV Training Province/Region: Batangas/Region IV
Bauan Batangas ANSAP Chapter:
Address
Accomplished Requirements of:
Name of Registered Nurse: PRCNo. ExpirDate:________
Date of IV Training Program Attended: IV Requirements:3+3+2
Registration No. of Institution Offering the IV Training Program:

Name of Patient Age Kind of IV Infusion given Date/Time/Site of IV Insertion Type of Cannula/Dose/Rate/ Signature of Witness
Drug Incorporation present M.D./IV Trained Preceptor

I. Initiating Maintaining Peripheral IV Infusion

Plain Lactated Ringer’s
1. Frendalynne Aclan 33 Solution 10/25/2010 10:34AM Left Metacarpal Vein g20 1 Liter 30gtts/min
Dextrose 5% in Lactated
2. Rence John Paul Catipon 4 Ringer’s Solution 10/26/2010 5:30PM Right Metacarpal Vein g22 500 cc 65mgtts/min

3. Conrado Soriano 67 Plain Normal Saline Solution 10/26/2010 8:55PM Left Metacarpal Vein g22 1 Liter 20mgtts/min

II. Administering IV drugs Drug Incorporated/ Date/Time/Diagnosis

Dose

1. Karen Sunshine Quesea 20 Forgram/1 gram 10/26/2010 4:00PM Systemic Viral Infection T/C Dengue Fever

2. Trinidad Datinguinoo 65 Citicholine/1gm 10/26/2010 4:00PM Cerebrovascular Accident

3. Maricel Delen 21 Omepron/40 mg 10/26/2010 8:00PM Acute Gastritis

III. Administering & Maintaining Blood Components

Blood Type/ Date/Time/Site of IV insertions
Volume/Components Type of Cannula/Rate

1. Leticia Ada 74 “B” Rh+/500cc/PWB 10/26/2010 9:15PM Left Metacarpal Vein g18 30gtts/min

2. Angel Arevalo 77 “O” Rh+/500cc/PRBC 10/27/2010 8:00AM Right Metacarpal Vein g18 30gtts/min

This is to certify that I had successfully performed the above requirements, as countersigned by my witnesses.
Received by: Submitted by: Sheena Marie M. Mendoza, RN
ANSAP Signature over Printed Name of RN

IV Therapy Certification Card No.: Approved by: Mrs. Lolita Magsino, RN, MAN
Director, Nursing Service
Issued by: Date: Date submitted: