3+3+2 ACCOMPLISHED REQUIREMENTS FOR

3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FOR NURSES

Name of Registered Nurse: Paula Helena R. Aba PRC Number: 0614984
Name of Hospital Offering IV Training: Maria Reyna Hospital Provider Number: 041
Date of IV Training Program Attended: April 21, 22, 23, 2010 Venue: VIP Hotel, Pacana-Velez Sts., Cagayan de Oro City

I. Initiating/Maintaining Peripheral IV Infusions

Patient Kind of Type of Signature Over Printed Name of
Name of Patient Age Date Time Site Dose Rate License No.
No. Infusion Cannula Certified Trainer/Preceptor
1 Guillermo A. Dablio 60 May 17, 2010 7:55am D50W Right, Cephalic Vein G18 500mL KVO AN-060356
Madonna W. Mendoza, RN, MN
2 Raul Z. Aquino, Sr. 55 May 17, 2010 8:30am D5W Left, Cephalic Vein G18 250 mL KVO AN-060356
Madonna W. Mendoza, RN, MN
3 Manuel M. Balacuit 68 May 17, 2010 1:55pm PNSS Left, Cephalic Vein G22 1 Liter KVO AN-060356
Madonna W. Mendoza, RN, MN

II. Administering Intravenous Drugs

Patient Drugs Signature Over Printed Name of
Name of Patient Age Date Time Dose Diagnosis License No.
No. Incorporated Certified Trainer/Preceptor
1 gm Hydrops at the gallbladder with
1 Loida C. Atabelo 22 May 17, 2010 12:00nn Cefazoline AN-060356
IVTT choledocholithiasis Madonna W. Mendoza, RN, MN
50mg Hydrops at the gallbladder with
2 Loida C. Atabelo 22 May 17, 2010 12:00nn Tramadol AN-060356
IV choledocholithiasis Madonna W. Mendoza, RN, MN
Hydrocortisone 100mg
3 Fidel M. Saa 70 May 17, 2010 12:00nn Liver Cirrhosis AN-060356
Sodium Succinate /2ml Madonna W. Mendoza, RN, MN

III. Administering and Maintaining Blood and Blood Components

Patient Volume/Blood IV Type of Signature Over Printer Name of
Name of Patient Age Date Time Diagnosis License No.
No. Type/Components/Rate Insertion Cannula Certified Trainer/Preceptor
Right,
298mL; “O” +; Packed RBC; ESRD 2⁰ to
1 Edchalico C. Ermita 74 May 17, 2010 8:00am Cephalic G18 AN-060356
30 gtts/min nephropathy
Vein Madonna W. Mendoza, RN, MN
Right,
300mL; “O” +; Packed RBC; End-Stage
2 Jamel H. Mimbantas 70 May 18, 2010 2:20pm Cephalic G18 Renal Disease
AN-060356
30 gtts/min
Vein Madonna W. Mendoza, RN, MN

Submitted by: ___Paula Helena R. Aba, RN___ Date Submitted: June 3, 2010
(Signature Over Printed Name)

Received by: _______________________________ Approved by: _______________________ __

(Signature Over Printed Name) Director of Nursing Service