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ILOILO MISSION HOSPITAL

Name of Hospital Offering I.V. Training


MISSION ROAD, JARO, ILOILO CITY
Address
Accomplished Requirements of:
Name of Registered Nurse:
CRISTEL DOANNE C. PALABRICA, R.N.
Date of I.V. Training Program Attended: August 4, 5, and 6, 2016
Registration Number of Institution Offering the I.V. Training Program: 139

I.

Venue: ILOILO MISSION HOSPITAL, MISSION ROAD, JARO, ILOILO CITY


Province / Region: ILOILO / VI
ANSAP Chapter: ILOILO
P.R.C. Number: 0881931
Expiry Date: June 6, 2019
I.V. Requirements: 3-3-1

Initiating / Maintaining Peripheral I.V. Infusion

Patient
No.

Name of Patient

Age

Date

Time

Kind of Infusion

Site

Datoon, Riyesa A.

16 years old

08/22/16

4:30 PM

D5LR 1 liter x 8 hours

Left Metacarpal Vein

Satana, Leonita G.

81 years old

08/22/16

5:45 PM

PNSS 1 liter x 12 hours

Left Metacarpal Vein

Jasa, Pablo P.

84 years old

08/22/16

7:05 PM

PNSS 1 liter x KVO

Right Metacarpal Vein

II.

Name of Patient

Age

Chiepe, Devine C.

24 years old

Siosan, Reme J.

70 years old

Bebar, Emelita E.

68 years old

Patient
No.
1

Gauge 20
(Venflon)
Gauge 20
(Venflon)
Gauge 18
(Supercath 5)

Dose

Rate

125 cc/hr

41 gtts/min

80 cc/hr

80 mgtts/min

40 cc/hr

40 mgtts/min

Signature over
Printed Name of
Certified
Trainer/Preceptor
Anabelle L. Turga
Anabelle L. Turga
Anabelle L. Turga

License
No./Expiry
Date
AN-002231/
03-02-19
AN-002231/
03-02-19
AN-002231/
03-02-19

Administering Intravenous Drugs

Patient
No.

III.

Type of
Cannula

Date
08/22/1
6
08/22/1
6
08/22/1
6

Time

Drugs Incorporated

10.00 A.M.

Cefazolin (Stancef) 1gm/ vial

12:00 P.M.
2:00 P.M.

Cefazolin (Fonvicol) 1gm/


vial
Ampicillin-Sulbactam
(Unasan) 750mg/ vial

Dose

Diagnosis

1gm IVTT every 8


hours
1 gm IVTT every 6
hours
750 mg IVTT every
8 hours

G2P1 (1011) Pregnancy Uterine


Delivered Term, Cephalic live baby girl
Chronic Subdural Hematoma Secondary
to Fall
Cholecystolithiasis

Signature over Printed


Name of Certified
Trainer/Preceptor
Anabelle L. Turga
Anabelle L. Turga
Anabelle L. Turga

License
No./Expiry
Date
AN-002231/
03-02-19
AN-002231/
03-02-19
AN-002231/
03-02-19

Administering and Maintaining Blood and Blood Components


Name of Patient
Castillon, Fe L.

Age

Date

Time

Volume / Blood Type/


Components/Rate

I.V. Insertion

69 years old

08/23/16

4:15 PM

PNRC No. 0214002-2 64 ml


Type B + Platelet to run as fast
drip (Terumo 20 gtts/ml)

Left Cephalic Vein

Type of
Cannula
Gauge 22
(Venflon)

Diagnosis
Myelodisplastic Syndrome,
Diabetes Mellitus

This is to certify that I had successfully performed the above requirements as countersigned by my witnesses.
Received by: _______________________________________________
Submitted by: CRISTEL DOANNE C. PALABRICA, R.N.
ANSAP
Signature over Printed Name
I.V. Therapy Certification Card No. ____________________________

Approved by:

NORMA L. LOSAES, R.N., M.N.


Director, Nursing Service

Issued by: _____________________________ Date: ______________

Date of Submission: _____________________________

Signature over Printed


Name of Certified
Trainer/Preceptor/R.N.
Anabelle L. Turga

License
No./Expiry
Date
AN-002231/
03-02-19

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