Está en la página 1de 2

IV THERAPY ACCOMPLISHED REQUIREMENTS FORMAT

Butuan Doctors’ Hospital_ Venue: Butuan Doctors’ College, NEW AVR


Name of Hospital Offering Training 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 PRC No: Expiry
Date:
IV Requirements: 6+6+2
Registration No. of Institution Offering the IV Training Program:
Name of Patient Age Kind of Infusion Given Date/time/Site of IV Insertions/Types of Signature of Witness M.D./IV
Cannula/Dose/Rate/Drug Incorporation Present Trained Preceptor
I. Initiating Maintaining Peripheral IV Infusion
1. Tiempo, Domingo 69 D5 NM 1Liter Nov. 17, 2008/12:00pm/Left Cephalic Vein/Gage-22/ Emmanuel Mantilla, RN
30gtts/min
2. Rodemio, Felix 53 PLR 1liter Nov. 18, 2008/1:20pm/Left Cephalic vein/Gage- Emmanuel Mantilla, RN
22/10cc/hr
3. Aquino, Rolando 69 PNSS 1liter Nov. 20, 2008/8:30am/Left Cephalic venin/Gage- Riadne Fesalboni, RN
22/100cc/hr
4. Torralba, Zephanniah 3 D5 0.3NaCl 500 cc Nov. 20, 2008/11:20am/Left Metacarpal vein/Gage- Riadne Fesalboni, RN
Seith 24/60cc/hr
5. Montero, Justine 1yr5m D5 0.3NaCl 500 cc Nov. 20, 2008/3:20pm/Left Metacarpal vein/Gage- Riadne Fesalboni, RN
os 24/90cc/hr
6. Telen, Josefina 70 D5 NM 1liter Nov. 27, 2008/2:4mpm/Left Metacarpal vein/Gage- Riadne Fesalboni, RN
22/20gtts/min
II. Administering IV Drugs
Drug Incorporation/Dose Date/Time/Diagnosis
1. Carandang, Daryl 24 Tramadol 50mg Nov. 26, 2008/9:40am/Vehicular Accident V/A Joan Siaboc, RN
2. Tan, Andres 76 Pantoloc 4omg Nov. 27, 2008/6am/Epigastric Pain, (+) Amoebiasis Joan Siaboc, RN
3. Llaros, Crizelle 4Cefuroxime (kefox) 500mg Nov. 27, 2008/10am/Pneumonia Joan Siaboc, RN
4. Balatero, Florinda 41 Ranitidine 50mg Nov.27, 2008/10am/Acute Gastritis Joan Siaboc, RN
5. Cubilo, Rolinda 59 Solucortef 100mg Nov.27, 2008/12pm/Cough+Dyspnea Joan Siaboc, RN
6. Gerona, Susan 46Hyoscine Butylbromide ½ Nov. 27, 2008/10am/Acute Gastroenteritis with mild Joan Siaboc, RN
ampule dehydration
III. Administering and Maintaining Blood Components
Blood Date/Time/Site of Insertions/Type of Cannula/Rate
Type/Volume/Component
s
1. Gudelosao, Alex 43 A+/250cc/PRBC Dec. 3, 2008/11am/AV Fistula/Gage-16/30gtts/min Riadne Fesalboni, RN
2. Denurog, Princess Dianne 2 A+/50cc/Platelet Dec. 20, 2008/9pm/Left Metacarpal Vein/G-18/Fast Drip Joan Siaboc, RN
concentrate

This is to certify that I had successfully performed the above requirements as countersigned by my witness.
Received by:_________________ Submitted by: Rickson P.
Rambuyon, RN
ANSAP Signature Over printer Name

IV Therapy Certification Card No. __________________ Approved by: Marianita


Gorme, RN, MN
Director
of Nursing Service

Issued by:______________________________________ Date: ________________________ Date


Submitted:___________________________