Iv Therapy Accomplished Requirements Format
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IV THERAPY ACCOMPLISHED REQUIREMENTS FORMAT Butuan Doctors’ Hospital_ Name of Hospital Offering Training
Venue: Butuan Doctors’ College, NEW AVR Province/Region: Butuan City ANSAP Chapter: Butuan Chapter
J.C. Aquino Street Butuan City Address Accomplished Requirements of: Name of Registered Nurse: Rickson P. Rambuyon Date of IV Training Program Attended: November 13 – 15, 2008 Date: Registration No. of Institution Offering the IV Training Program: Name of Patient Age Kind of Infusion Given I. Initiating Maintaining Peripheral IV Infusion 1. Tiempo, Domingo 69 D5 NM 1Liter 2. Rodemio, Felix
53
PLR 1liter
3. Aquino, Rolando
69
PNSS 1liter
3
D5 0.3NaCl 500 cc
1yr5m os 70
D5 0.3NaCl 500 cc
4. Torralba, Zephanniah Seith 5. Montero, Justine 6. Telen, Josefina
D5 NM 1liter
PRC No:
Expiry
IV Requirements: 6+6+2 Date/time/Site of IV Insertions/Types of Cannula/Dose/Rate/Drug Incorporation Present
Signature of Witness M.D./IV Trained Preceptor
Nov. 17, 2008/12:00pm/Left Cephalic Vein/Gage-22/ 30gtts/min Nov. 18, 2008/1:20pm/Left Cephalic vein/Gage22/10cc/hr Nov. 20, 2008/8:30am/Left Cephalic venin/Gage22/100cc/hr Nov. 20, 2008/11:20am/Left Metacarpal vein/Gage24/60cc/hr Nov. 20, 2008/3:20pm/Left Metacarpal vein/Gage24/90cc/hr Nov. 27, 2008/2:4mpm/Left Metacarpal vein/Gage22/20gtts/min
Emmanuel Mantilla, RN Emmanuel Mantilla, RN Riadne Fesalboni, RN Riadne Fesalboni, RN Riadne Fesalboni, RN Riadne Fesalboni, RN
II. Administering IV Drugs Drug Incorporation/Dose Tramadol 50mg Pantoloc 4omg Cefuroxime (kefox) 500mg Ranitidine 50mg Solucortef 100mg Hyoscine Butylbromide ½ ampule III. Administering and Maintaining Blood Components Blood Type/Volume/Component s 1. Gudelosao, Alex 43 A+/250cc/PRBC 2. Denurog, Princess Dianne 2 A+/50cc/Platelet 1. 2. 3. 4. 5. 6.
Carandang, Daryl Tan, Andres Llaros, Crizelle Balatero, Florinda Cubilo, Rolinda Gerona, Susan
24 76 4 41 59 46
Date/Time/Diagnosis Nov. 26, 2008/9:40am/Vehicular Accident V/A Nov. 27, 2008/6am/Epigastric Pain, (+) Amoebiasis Nov. 27, 2008/10am/Pneumonia Nov.27, 2008/10am/Acute Gastritis Nov.27, 2008/12pm/Cough+Dyspnea Nov. 27, 2008/10am/Acute Gastroenteritis with mild dehydration
Joan Joan Joan Joan Joan Joan
Siaboc, Siaboc, Siaboc, Siaboc, Siaboc, Siaboc,
RN RN RN RN RN RN
Date/Time/Site of Insertions/Type of Cannula/Rate Dec. 3, 2008/11am/AV Fistula/Gage-16/30gtts/min Dec. 20, 2008/9pm/Left Metacarpal Vein/G-18/Fast Drip
Riadne Fesalboni, RN Joan Siaboc, RN
concentrate This is to certify that I had successfully performed the above requirements as countersigned by my witness. Received by:_________________ Rambuyon, RN ANSAP
Submitted by: Rickson P. Signature Over printer Name
IV Therapy Certification Card No. __________________ Gorme, RN, MN
Approved
Marianita Director
of Nursing Service
Issued by:______________________________________ Submitted:___________________________
by:
Date: ________________________
Date
Venue: Butuan Doctors’ College, NEW AVR Province/Region: Butuan City ANSAP Chapter: Butuan Chapter
J.C. Aquino Street Butuan City Address Accomplished Requirements of: Name of Registered Nurse: Rickson P. Rambuyon Date of IV Training Program Attended: November 13 – 15, 2008 Date: Registration No. of Institution Offering the IV Training Program: Name of Patient Age Kind of Infusion Given I. Initiating Maintaining Peripheral IV Infusion 1. Tiempo, Domingo 69 D5 NM 1Liter 2. Rodemio, Felix
53
PLR 1liter
3. Aquino, Rolando
69
PNSS 1liter
3
D5 0.3NaCl 500 cc
1yr5m os 70
D5 0.3NaCl 500 cc
4. Torralba, Zephanniah Seith 5. Montero, Justine 6. Telen, Josefina
D5 NM 1liter
PRC No:
Expiry
IV Requirements: 6+6+2 Date/time/Site of IV Insertions/Types of Cannula/Dose/Rate/Drug Incorporation Present
Signature of Witness M.D./IV Trained Preceptor
Nov. 17, 2008/12:00pm/Left Cephalic Vein/Gage-22/ 30gtts/min Nov. 18, 2008/1:20pm/Left Cephalic vein/Gage22/10cc/hr Nov. 20, 2008/8:30am/Left Cephalic venin/Gage22/100cc/hr Nov. 20, 2008/11:20am/Left Metacarpal vein/Gage24/60cc/hr Nov. 20, 2008/3:20pm/Left Metacarpal vein/Gage24/90cc/hr Nov. 27, 2008/2:4mpm/Left Metacarpal vein/Gage22/20gtts/min
Emmanuel Mantilla, RN Emmanuel Mantilla, RN Riadne Fesalboni, RN Riadne Fesalboni, RN Riadne Fesalboni, RN Riadne Fesalboni, RN
II. Administering IV Drugs Drug Incorporation/Dose Tramadol 50mg Pantoloc 4omg Cefuroxime (kefox) 500mg Ranitidine 50mg Solucortef 100mg Hyoscine Butylbromide ½ ampule III. Administering and Maintaining Blood Components Blood Type/Volume/Component s 1. Gudelosao, Alex 43 A+/250cc/PRBC 2. Denurog, Princess Dianne 2 A+/50cc/Platelet 1. 2. 3. 4. 5. 6.
Carandang, Daryl Tan, Andres Llaros, Crizelle Balatero, Florinda Cubilo, Rolinda Gerona, Susan
24 76 4 41 59 46
Date/Time/Diagnosis Nov. 26, 2008/9:40am/Vehicular Accident V/A Nov. 27, 2008/6am/Epigastric Pain, (+) Amoebiasis Nov. 27, 2008/10am/Pneumonia Nov.27, 2008/10am/Acute Gastritis Nov.27, 2008/12pm/Cough+Dyspnea Nov. 27, 2008/10am/Acute Gastroenteritis with mild dehydration
Joan Joan Joan Joan Joan Joan
Siaboc, Siaboc, Siaboc, Siaboc, Siaboc, Siaboc,
RN RN RN RN RN RN
Date/Time/Site of Insertions/Type of Cannula/Rate Dec. 3, 2008/11am/AV Fistula/Gage-16/30gtts/min Dec. 20, 2008/9pm/Left Metacarpal Vein/G-18/Fast Drip
Riadne Fesalboni, RN Joan Siaboc, RN
concentrate This is to certify that I had successfully performed the above requirements as countersigned by my witness. Received by:_________________ Rambuyon, RN ANSAP
Submitted by: Rickson P. Signature Over printer Name
IV Therapy Certification Card No. __________________ Gorme, RN, MN
Approved
Marianita Director
of Nursing Service
Issued by:______________________________________ Submitted:___________________________
by:
Date: ________________________
Date
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