3+3+2 AC COMPLISHED R EQUIR EMEN TSof 3-D A YBASIC IN TR A VEN O T H ER A TRA IN IN GPROGR A M for NURSES US PY

Name of Registered Nurse: Edward D. Wong Name of Hospital offering I V Training: St. Dominic Medical Center Date of I V Training Program Attended: September 16-18, 2011 I. Initiating/ Maintaining Peripheral IV Infusion s
Patient No. Kind of Infusion Type of Cannula Signature over Printed name of Certified Trainer/Preceptor/RN

PRC No. 0714828 Provider No.: 080 Venue: St. Dominic College of Asia

Name of Patient

Age

Date

Time

Site
Left Metacarpal Right Metacarpal Left Cephalic

Dose

Rate

License No.

174934 175171 83655

Jeremias, Amitiel P. Say, Magdalena J. Vecino, Rosario P.

3 84 85

9/28/11 12:15pm 9/28/11 1:25 pm 9/28/11 1:40 pm

NaCl PNSS PNSS

G24 G18 G18

500cc 61-62 gtts/min 1 Liter 40-41 gtts/min 1 Liter 20-21 gtts/min

Audrey San Jose, RN Audrey San Jose, RN Audrey San Jose, RN

09-00523 09-00523 09-00523

II. Administering Intravenou s Drugs
Patient No. Name of Patient Age Date Time Drug Incorporated

Dose

Diagnosis

Signature over Printed name of Certified Trainer/Preceptor/RN

License No.

83611 83611 83600

Legaspi, Anita R. Legaspi, Anita R. Colminar, Ernie D.

75 75 13

CAP t/c Musculoskeletal Strain 9/28/11 8:00 am Furosemide 40 mg CAP t/c Musculoskeletal Strain 9/28/11 9:00 am Cefuroxime 750 mg Benzyl t/c PTB, malnutrition 9/28/11 12:00pm 1 million ‘U’ Penicillin t/c electrolyte imbalance

Audrey San Jose, RN Audrey San Jose, RN Audrey San Jose, RN

09-00523 09-00523 09-00523

III. Administering and Maintaining Blood and Blood Components
Patient No. Volume/ Blood Type/ Components/ Rate

Name of Patient

Age

Date

Time

Site of IV Insertion Left Cephalic

Diagnosis Hypertensive Nephrosclerosis

Signature over Printed name of Certified Trainer/Preceptor/RN

License No.

83740

Lilia Macatangay

79

10/17/11 2:40 pm

1 U/ FWB/ B+/ x4 Hours

Audrey San Jose, RN

09-00523

Submitted by:____________________Date Submitted:__________Received by:_________________Approved by: Hazel N. Villagracia, RN, MAN, EdD

(Signature over Printed Name) ce Director of Nursing Servi (Signature over Printed Name) .