3+3+1 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 0773184 RUN Bldg., Pawa, Tabaco City

JAIME B. BERCES MEMORIAL HOSPITAL March 9-11, 2013

I. Initiating/Maintaining Peripheral IV Infusions Patient No. 1303375 13030367 13030370 II. Administering Intravenous Drugs Patient No. 13030365 13030352 13030344 Name of Patient Age 3yo 3yo 84yo Date 3/11/2013 3/11/2013 3/11/2013 Time Drugs Incorporated Dose 200 mg 50 mg 40 mg Diagnosis Intestinal Parasitism
AGE with Moderate Dehydration, Intestinal Parasitism, Malnutrition Signature over Printed Name of Certified Trainer/Preceptor JENNIFER LERIDA, RN JENNIFER LERIDA, RN JENNIFER LERIDA, RN

Name of Patient

Age 60yo 36yo 50yo

Date 3/11/2013 3/11/2013 3/11/2013

Time

Kind of Infusion

Site
Left cephalic vein
Right metacarpal vein

Type of Cannula

Dose 1 Liter 1 Liter 1 Liter

Rate 20 gtts/min 20 gtts/min 20 gtts/min

Signature over Printed Name of Certified Trainer/Preceptor JENNIFER LERIDA, RN JENNIFER LERIDA, RN JENNIFER LERIDA, RN

License No. 11-023742 11-023742 11-023742

5:00 PM Plain Lactated Ringers 6:30 PM Dextrose 0.9 Sodium Chloride 7:00 PM Dextrose 0.9 Sodium Chloride

Gauge 22 Gauge 22 Gauge 22

Left cephalic vein

License No. 11-023742 11-023742 11-023742

6:30 PM Ampicillin (Polypen) 7:30 PM Amikacin (Kamin) 8:30 PM Omeprazole (Cezole)

Hypertension Stage 2, Anorexia

III. Administering and Maintaining Blood and Blood Components Patient No. 13030354 Submitted by: (Signature over Printed Name) Name of Patient Age Date Time 9:00 PM Volume/Blood Type/ Components/Rate 1 unit/B+/PRBC 20gtts/min IV Insertion
Right cephalic vein

Type of Cannula

Diagnosis
DM, Diabetic Foot (L) , Non-heaing S/P below knee amputation, CKD, Anemia

Signature over Printed Name of Certified Trainer/Preceptor

License No. 11-023743

48yo 3/11/2013

Gauge 18

ROSIE B. PARANO

Date submitted:

Received by:

Approved by:

LETICIA M. CARILLO, MAN, RN Director of Nursing Services (Signature over Printed Name)

. Venue 0321152 RUN Bldg. JIMMY 10/29/2011 11:00 AM 10/29/2011 11:00 AM 78 III. Pawa.3 NaCl Site Left metacarpal vein Type of Cannula Dose 500 cc 1 Liter 500 cc Rate 12 microdrops/min 11-10-1380 BOLANTE. Name of Patient Age 1 72 4 MOS Date 10/29/2011 Time 9:00 AM Kind of Infusion D5 IMB D5 NR D5 0.3+3+1 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 JENNILYN B. Tabaco City I. Administering Intravenous Drugs Patient No. ROMEO Submitted by: gauge 18 SARAH JANE V. AGUILAR JAIME B. Administering and Maintaining Blood and Blood Components Patient No. Initiating/Maintaining Peripheral IV Infusions Patient No. LOURD ZIOW 11-10-1393 ARIZAPA. JOHN CRISTOFF 11-10-1392 CORTADO. JOHN CRISTOFF II. 2 & 3. ANONUEVO. RN (Signature over Printed Name) Date submitted: Received by: . 2001 PRC Number Provider No. BERCES MEMORIAL HOSPITAL OCTOBER 1. Name of Patient gauge 24 gauge 22 gauge 24 10/29/2011 10:00 AM 10/29/2011 4 MOS Left cephalic vein Left cephalic vein 30 drops/min 40 microdrops/min Age 1 4 MOS Date 10/29/2011 Time 1:00 PM Drugs Incorporated RANITIDINE CEFUROXIME FUROSEMIDE Dose 10 mg 250 mg 20 mg Diagnosis PNEUMONIA PNEUMONIA CHRONIC OBSTRUCTIVE PULMONARY DISEASE 11-10-1390 CEDRO. Name of Patient Age 64 Date 10/28/2011 Time 3:40 PM Volume/Blood Type/ Components/Rate 500cc/AB/PACKED RBC 20-21 DROPS/MIN 10/27/2011 IV Insertion Left cephalic vein Type of Cannula Diagnosis END STAGE RENAL DISEASE Approved by: 11-101385 ARIOLA. ANGEL 11-10-1386 BRONDIAL. LILIA 11-10-1393 ARIZAPA.

RN Director of Nursing Services (Signature over Printed Name) . CARILLO. ANDAYOG LETICIA M. MAN. ANDAYOG MARK JAMES S. 09-004632 09-004633 09-004634 MARK JAMES S. 09-004634 MARK JAMES S. ANDAYOG Signature over Printed Name of Certified Trainer/Preceptor License No. ANDAYOG Signature over Printed Name of Certified Trainer/Preceptor License No. 09-004632 09-004634 09-004633 MARK JAMES S. Tabaco City Signature over Printed Name of Certified Trainer/Preceptor License No. ANDAYOG MARK JAMES S. ANDAYOG MARK JAMES S. ANDAYOG MARK JAMES S.awa.

Initiating/Maintaining Peripheral IV Infusions Patient No. 2 & 3. Venue 0631819 RUN Bldg. Pawa. Administering Intravenous Drugs Patient No.9 % NaCl D5 NM D5 0. Tabaco City I.. 2001 PRC Number Provider No.3 NaCl Site Left cephalic vein Left cephalic vein Left metacarpal vein Type of Cannula Dose 1 Liter 1 Liter 500 cc Rate 20 drops/min 20 drops/min 50 microdrops/min 11-10-1271 CARMONA. 11-10-1273 BUATIS.NUTRITIONAL STATUS POST BT ELECTROLYTE IMBALANCE 11-10-1263 BITARA. HERMINIO Submitted by: gauge 18 SARAH JANE V. JASMINE B. DIONISIA G. JHONA REN 10/5/2011 12:00 AM 10/5/2011 10/4/2011 6:00 AM 6:00 AM III. ANONUEVO. Name of Patient Age 66 72 2 Date 10/4/2011 10/5/2011 10/5/2011 Time 4:30 AM 3:30 AM 4:30 AM Kind of Infusion D5 0. JAIME 11-10-1279 BORBON. ROMMELAINE 11-10-1276 ORBITA. BERCES MEMORIAL HOSPITAL OCTOBER 1. VERONICA 11-10-1274 BIRUELA.3+3+1 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 JE JAIME B. Administering and Maintaining Blood and Blood Components Patient No. RN (Signature over Printed Name) Received by: Approved by: . Name of Patient Age Volume/Blood Type/ Components/Rate 500cc/B+/PACKED RBC 74 10/4/2011 12:00 AM 20-21 DROPS/MIN Date Time Date submitted: 10/27/2011 IV Insertion Right cephalic vein Type of Cannula Diagnosis ANEMIA . Name of Patient gauge 22 gauge 22 gauge 24 Age 20 64 1 Date Time Drugs Incorporated CEFUROXIME DEXAMETHASONE AMPICILLIN Dose 750 mg 50 mg 250 mg Diagnosis ACUTE APPENDICITIS HYPOKALEMIA T/C STROKE IN EVOLUTION ACUTE RESPIRATORY INFECTION R/O UTI 11-10-1278 SUMUGOD. II.

RN Director of Nursing Services (Signature over Printed Name) . ANDAYOG Signature over Printed Name of Certified Trainer/Preceptor License No. 09-004632 09-004634 09-004633 MARK JAMES S. MAN.awa. ANDAYOG Signature over Printed Name of Certified Trainer/Preceptor License No. 09-004634 MARK JAMES S. ANDAYOG LETICIA M. 09-004632 09-004633 09-004634 MARK JAMES S. ANDAYOG MARK JAMES S. Tabaco City Signature over Printed Name of Certified Trainer/Preceptor License No. CARILLO. ANDAYOG MARK JAMES S. ANDAYOG MARK JAMES S. ANDAYOG MARK JAMES S.

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