3 + 3 + 1 ACCOMPLISHED REQUIREMENTS OF 3 DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FOR NURSES

Name of Registered Nurse: Name of Hospital Offering IV Training: Date of IV Training Program Attended:

JOHN HENRY O. VALENCIA

BATAAN GENERAL HOSPITAL November 30, 2012 December 02, 2012

PRC Number: Provider No.: Venue:

0768411 106 Louis Restaurant, City of Balanga, Bataan

I.
Patient No. 31-94-61 19-11-97 19-11-98

Initializing / Maintaining Peripheral IV Infusions

Name of Patient Marissa Tapang Ryuken Macarilay Samuel Quitaleg Age 43 07 57 Date December 14, 2012 December 14, 2012 December 14, 2012 Time 09:10am 10:00am 10:15am Kind of Infusion D5LR D5 0.3NaCl PNSS Site R Metacarpal Vein R Metacarpal Vein L Basilic Vein Type of Cannula g. 22 g. 24 g. 22 Dose 1L 1L 1L Rate 31-32gtts/min 31-32gtts/min 31-32gtts/min Signature Over Printed Name of Certified Trainer/Preceptor/MD, RN Arlene C. Navarro, RN, MAN Arlene C. Navarro, RN, MAN Arlene C. Navarro, RN, MAN License No. 0163411 0163411 0163411

II.
Patient No. 09-56-71 19-11-69 19-11-98 III. Patient No. 19-11-69

Administering Intravenous Drugs

Name of Patient Ruben Opina Jr. Harry Pollojan Samuel Quitaleg Age 36 15 57 Date December 14, 2012 December 14, 2012 December 14, 2012 Time 08:00am 10:40am 11:15am Drug Incorporated Tramadol Diphenhydramine Nicardipine Dose 1cc 1amp 1mg Diagnosis HPN; CRD Anemia HPN; CVA Signature Over Printed Name of Certified Trainer/Preceptor/MD, RN Arlene C. Navarro, RN, MAN Arlene C. Navarro, RN, MAN Arlene C. Navarro, RN, MAN License No. 0163411 0163411 0163411

Administering and Maintaining Blood and Blood Components (2 NURSES IN ONE BLOOD TRANSFUSION ADMINISTRATION)
Name of Patient Harry Pollojan Age 15 Date December 14, 2012 Time 11:10am Volume/Blood Type/Components/Rate 450ml/B+/PRBC/10-15gtts/min IV Insertion Side Drip Type of Diagnosis Cannula g. 18 Anemia Signature Over Printed Name of Certified Trainer/Preceptor/MD, RN Arlene C. Navarro, RN, MAN License No. 0163411

Submitted By: John Henry O. Valencia, RN Date Submitted:

Signature over Printed Name

Received By:

Arlene C. Navarro, RN, MAN

Approved By: Evelyn R. Rubia, RN, Ph.D

Director of Nursing Service (Signature over Printed Name)

3 + 3 + 1 ACCOMPLISHED REQUIREMENTS OF 3 DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FOR NURSES
Name of Registered Nurse: Name of Hospital Offering IV Training: Date of IV Training Program Attended:

MYRA C. BEBIT
BATAAN GENERAL HOSPITAL November 30, 2012 December 02, 2012

PRC Number: Provider No.: Venue:

0700622 106 Louis Restaurant, City of Balanga, Bataan

I.
Patient No. 19-11-99 19-12-00 19-12-01

Initializing / Maintaining Peripheral IV Infusions

Name of Patient Lydia Belen Ricardo Dela Cruz Eyhanna Gigante Age 66 41 3/12 Date December 14, 2012 December 14, 2012 December 14, 2012 Time 11:10am 12:00nn 12:15pm Kind of Infusion D5LR PLR D5IMB Site L Metacarpal Vein R Metacarpal Vein R Metatarsal Vein Type of Cannula g. 22 g. 24 g. 26 Dose 1L 1L 250ml Rate 31-32gtts/min 31-32gtts/min 20-21gtts/min Signature Over Printed Name of Certified Trainer/Preceptor/MD, RN Arlene C. Navarro, RN, MAN Arlene C. Navarro, RN, MAN Arlene C. Navarro, RN, MAN License No. 0163411 0163411 0163411

II.
Patient No. 09-56-71 19-11-69 08-35-68 III. Patient No. 08-37-70

Administering Intravenous Drugs

Name of Patient Ruben Opina Jr. Harry Pollojan Perlita Sebastian Age 36 15 57 Date December 14, 2012 December 14, 2012 December 14, 2012 Time 08:00am 10:40am 11:50am Drug Incorporated Metochlopromide Paracetamol Ceftriaxone Dose 2cc 300mg 1amp Diagnosis HPN; CRD Anemia DM Type 1 Signature Over Printed Name of Certified Trainer/Preceptor/MD, RN Arlene C. Navarro, RN, MAN Arlene C. Navarro, RN, MAN Arlene C. Navarro, RN, MAN License No. 0163411 0163411 0163411

Administering and Maintaining Blood and Blood Components (2 NURSES IN ONE BLOOD TRANSFUSION ADMINISTRATION)
Name of Patient Reynaldo Dela Cruz Age 54 Date December 14, 2012 Time 10:30am Volume/Blood Type/Components/Rate 450ml/O+/PRBC/10-15gtts/min IV Insertion Side Drip Type of Diagnosis Cannula g. 18 Sepsis Signature Over Printed Name of Certified Trainer/Preceptor/MD, RN Arlene C. Navarro, RN, MAN License No. 0163411

Submitted By: Myra C. Bebit, RN

Signature over Printed Name

Date Submitted:

Received By:

Arlene C. Navarro, RN, MAN

Approved By: Evelyn R. Rubia, RN, Ph.D

Director of Nursing Service (Signature over Printed Name)