3+3+2 ACCOMPLISHED REQUIREMENTS of

3- DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES

Name of Registered Nurse Helen May Mayde Lingayo PRC Number 0619949

Name of Hospital Offering IV Training Notre Dame De Chartres Hospital Provider Number 149

Date Of IV Training Program Attended October 15, 16, 17, 2010 VENUE Pines city Doctor’s Hospital

I. Initiating/ Maintaining Peripheral IV Infusions

Patient Name of Patient AGE Date Time Kind of Site Type of Dose Rate Signature over License No.
No. Infusion Cannula printed Name of
Trainer/Preceptor

1 CLAVIDO, 28 wks December 14, 09:05 AM D10 IMB 500 Right Abbocath 256 cc x 24 11 drops per minute
Baby Girl 2010 ml Metacarpal Gauge 26 hours
Vein

2 GUTTIEREZ, 31 wks December 21, 06:30 PM D5w 500 ml Left Abbocath 80 cc x 12 7 drops per minute
Baby Boy 2010 Metacarpal Gauge 26 hours
Vein

3 CANO, Baby 38 wks December 21, 07:00 PM D5W 500 ml Right Abbocath 75 cc x 12 7 drops per
Boy 2010 Metacarpal Gauge 26 hours minute
Vein
 II. Administering Intravenous Drugs

Patient No. Name of Patient Age Date Time Drugs Incorporated Dose Diagnosis Signature Over Printed License No.
Name of Certified
Trainer/Preceptor

1 SAMIN, Baby Girl 30 wks December 05, 2010
08:00 PM Ampicillin 125 mg LBG Born via LTCS to
25 years old mother
BW-5lbs (2523 kgs)
HC-32 cm, CC-30 cm,
AC-27cm, BL-47 cm,
AS- 8/9 Thickly
Stained Meconium

2 CLAVIDO, Baby Girl 28wks December 14, 2010
09:15 AM Amikacin 24 mg Live Full term female
NB delivered via 1
degree CS for fetal
tachycardia, AS 9/9,
BW-3289 gm, probable
sepsis,
Hyperbilirubinemia

3 CANO, Baby Boy 27 wks December 21, 2010
07:18 PM Gentamycin 23 mg LBG Born via LTCS
BW-666lbs (2523 kgs)
HC-32 cm, CC-31 cm,
AC-28cm, BL-47 cm,
AS- 8/9 Thickly
Stained Meconium

III. Administering and Maintaining Blood and Blood Components

Patient No. Name of Age Date Time Volume/Blood Site of IV Type of Diagnosis Signature Over License No.
Patient Type/Components/Rate Insertion Cannula Printed Name of
Trainer/Preceptor
1 AGUILAR, 19 October 24, 10:00 PM “O” 450 cc Right Abbocath Pneumonia,
Ivan 2010 Cryoprecipitate Cephalic Gauge 21 Dengue
Vein
2 GALEAS, 28 December 12:00 AM “O” 450 cc Right Abbocath Urinary Tract
Iloimarien 11, 2010 Cryoprecipitate Cephalic Gauge 21 Infection,
Vein Dengue

Submitted By: Helen May Mayde Lingayo Date Submitted: Received By: Approved By: .

Director of Nursing Services