3 Day BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FOR NURSES (3+3+1 Format) 9th Edition Name of Registered Nurse:

APILADO, AVELINA N. Name of Hospital Offering IV Training : ILOCOS TRAINING AND REGIONAL MEDICAL CENTER Date of IV Training Attended: April 13, 14 and 15, 2012 I.
Patient Number
2012-0008609

PRC Number/Expiry Date: ______________ Provider No. 129 Valid until January 9, 2015

Initiating/ Maintaining Peripheral IV Infusions

Name of Patient Mones, Jerome Oreal Sobremonte, Clarita Subido Gapasin, Reynante Hidalgo Age 3 69 34 Date 04-23-2012 04-24-2012 04-24-2012 Time 3:00PM 9:25 AM 12:30 PM Kind of Infusion D5IMB D5LRS D5LRS Site Left Dorsal Foot Right Cephalic Vein Right Dorsal Venous Arch Type of Cannula
Gauge 24

Dose
D5IMB 500cc D5LRS 1LxKVO D5LRS 1Lx8hrs.

Rate
54-55 micro drops/min. 10 drops/min. 31 drops/min.

Signature over Printed Name of Certified Trainer/Preceptor

IV License Number

2003-0001653 2012-0008653

Gauge 20 Gauge 20

II.
Patient Number
2012-0007872

Administering Intravenous Drugs

Dose
40mg

Name of Patient Boado, Carmen Fortez

Age

Date 04-23-2012

Time 10:00 AM

Drugs Incorporated Omeprazole 40mg IV now then every 12hrs. Ampicillin+Sulbactan 1.5g IV every 8hrs Penicillin Sodium 2.5million unit every 6hrs

Diagnosis
Fracture Closed Complete Displaced Intertrochanter Femur Left To Consider Esophageal Mass Mandibular Fracture Body Right Secondary to Vehicular Accident Left Lower Mentum Area

Signature over Printed Name of Certified Trainer/Preceptor

IV License Number

82
2003-0001653 2012-0008646

Sobremonte, Clarita Subido Belad, Joseph Fluentes

04-23-2012
69 28

12:00 PM 3:00PM

1.5g 2.5 million unit

04-23-2012

III.
Patient Number

Administering and Maintaining Blood and Blood Components

Name of Patient Floresca, Emetrio Age 72 Date 04-21-2012 Time 6:45PM Volume/Blood Type Component/Rate/Serial#
450cc/O+/ PRBC/15drops/min./121060

Site
Cephalic Vein Left

Type of Cannula
Gauge 18

Diagnosis
Acute Gastroenteritis with

Signature over Printed Name of Certified Trainer/Preceptor

IV License Number

2001-11846

Submitted by: __APILADO, AVELINA N.__ Name of Participant

Date: April 24, 2012

Received by:_________________________ Approved by: ________________________________ Emilia Zenaida G. Robles, RN, MANc Director, Nursing Services