3+3+2 ACCOMPLISHED REQUIREMENTS OF

3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FOR NURSES

Name of Registered Nurse: MARIA JOHANNA R. CRAVE PRC Number: 0606446 / Exp Date: 04/12/2013
Name of Hospital offering IV Training: DAVAO MEDICAL CENTER Provider No.: 093-006505
Date of IV Training Program Attended: August 6 – 8, 2010 Venue: DAVAO MEDICAL CENTER

I. INITIATING / MAINTAINING PERIPHERAL IV INFUSIONS

Patient Name of patient Age Date Time Kind of Site Type of Dose Rate Signature over Printed Name of Certified I.V. License No.
No. Infusion Cannula Trainer/Preceptor/MD/RN
1. Sumoroy, Zenaida C. 32 y.o 8-9-10 9:00 am D5LR Left Metacarpal Vein Gauge 18 1 Liter 30 gtts/min Rodel F. Barcoma, RN 09-027435
Lic. No. 0464995
2. Dagoro, Divina L. 26 y.o 8-9-10 10:25 am D5LR Left Metacarpal Vein Gauge 18 1 Liter 30 gtts/min Rodel F. Barcoma, RN 09-027435
Lic. No. 0464995
3. Verola, Estrelita M. 22 y.o 8-9-10 11:05 am D5LR Right Cephalic Vein Gauge 18 1 Liter 30 gtts/min Rodel F. Barcoma, RN 09-027435
Lic. No. 0464995

II. ADMINISTERING INTRAVENOUS DRUGS

Patient Name of patient Age Date Time Kind of Site Type of Dose Rate Signature over Printed Name of Certified I.V. License No.
No. Infusion Cannula Trainer/Preceptor/MD/RN
1. Sacay, Rey R. 757 y.o. 8-9-10 1:55 pm PLR 1L Right Metacarpal Gauge 18 Ranitidine 30 gtts/min Jan Doris Olaivar, RN 08-021271
Vein 50 mg Lic. No. 0485775
2. Limpin, Rey G. 52 y.o 8-9-10 2:15 pm PNSS 1L Right Metacarpal Gauge 20 Clindamycin 30 gtts/min Jan Doris Olaivar, RN 08-021271
Vein 30 mg Lic. No. 0485775
3. Cata, Nancy D. 47 y.o 8-9-10 2:30 pm PLR 1L Right Cephalic Vein Gauge 20 Ketorolac 30 gtts/min Jan Doris Olaivar, RN 08-021271
30 mg Lic. No. 0485775

III. ADMINISTERING / MAINTAINING BLOOD AND BLOOD COMPONENTS

Patient Name of patient Age Date Time Kind of Site Type of Dose Rate Signature over Printed Name of Certified I.V. License No.
No. Infusion Cannula Trainer/Preceptor/MD/RN
1. Landas, Jonathan Jr. 2 y.o 8-11-10 12:10 am Packed RBC Right Metacarpal Vein Gauge 20 150 cc 10 – 15 Chris Adrian A. Perin, RN 08-006429
A. “B+” gtts/min Lic. No. 0393720
2. Completo, Asteria T. 57 y.o 8-11-10 9:35 am Packed RBC Right Cephalic Vein Gauge 20 300 cc 30 gtts/min Dianne Monica P. Abellar, RN 08-012449
“O+” Lic. No. 0475405

Submitted by: CRAVE, Maria Johanna R. Date Submitted: Received by: Approved by: VILMA L. COMODA , R.N., M.A.N.
(Signature over Printed Name) Director of Nursing Services/Chief Nurse
(Signature over Printed Name)