ILOILO MISSION HOSPITAL

Name of Hospital Offering I.V. Training

MISSION ROAD, JARO, ILOILO CITY
Address
Accomplished Requirements of:
Name of Registered Nurse:
DEMETRIO S. FERRER III, R.N.
Date of I.V. Training Program Attended: October 2, 3, and 4, 2014
Registration Number of Institution Offering the I.V. Training Program: 139

I.

Venue: ILOILO MISSION HOSPITAL, MISSION ROAD, JARO, ILOILO CITY

Province / Region: ILOILO / VI
ANSAP Chapter: ILOILO
P.R.C. Number: 0840432
I.V. Requirements: 3-3-1

Expiry Date: APRIL3,2017

Initiating / Maintaining Peripheral I.V. Infusion

Patient
No.

Name of Patient

Age

Date

Time

Kind of Infusion

Site

Type of
Cannula

Malones, Eugenia S.

54 years old

10/19/14

4:30 P.M.

D5LR 1 liter x 8 hours

Right Metacarpal Vein

Galliner, Ma. Fedielline

O.

23 years old

10/22/14

7:25 A.M.

PNSS 1 liter x 10 hours

Right Metacarpal Vein

Oredina, Carlito T.

61 years old

10/22/14

7:40 A.M.

PNSS 1 liter x 8 hours

Right Cephalic Vein

II.

Gauge 22
(Insyte)
Gauge 20
(Venflon)
Gauge 20
(Venflon)

Dose

Rate

125 cc/hr

31 gtts/min

100 cc/hr

25 mgtts/min

125 cc/hr

31 gtts/min

Signature over Printed

Name of Certified
Trainer/Preceptor

License
No./Expiry
Date

Chona David, R.N.

AN-002202/
03/30/2015
AN-002202/
03/30/2015
AN-002202/
03/30/2015

Signature over Printed

Name of Certified
Trainer/Preceptor

License
No./Expiry
Date

Chona David, R.N.

Chona David, R.N.

Administering Intravenous Drugs

Patient
No.

Name of Patient

Age

Date

Time

Drugs Incorporated

Dose

Diagnosis

Dideles, Angelo E.

73 years old

10/20/14

1:45 P.M.

Furosemide (Furoscan) 20mg/ampule

20 mg IVTT every 8 hours

Anemia secondary to Infection

De Leon, Virgilio G.

73 years old

10/20/14

2: 00 P.M.

Morphine Sulfate 16 mg/ampule

4 mg IVTT every 4 hours

Trigeminal Neuralgia

2:15 P.M.

Hydrocortisone (solucortef) 100

mg/vial

750 mg IVTT every 8 hours

Bronchial Asthma Moderate Severe Exacerbation

III.

Suson, Nick Anthony S.

15 years old

10/20/14

Chona David, R.N.

AN-002202/
03/30/2015
AN-002202/
03/30/2015
AN-002202/
03/30/2015

Signature over Printed

Name of Certified
Trainer/Preceptor/R.N.

License
No./Expiry
Date

Chona David, R.N.

Chona David, R.N.

Administering and Maintaining Blood and Blood Components

Patient
No.
1

Name of Patient
Lizardo, Samuel Maric
P.

Age

23 years old

Date

10/24/14

Time

Volume / Blood Type/

Components/Rate

I.V. Insertion

Type of
Cannula

Diagnosis

11: 50 A.M.

PNRC No. 5000-012227-1 167 cc

Type A+ packed Fresh frozen
Plasma x 1 hour,
28 gtts/min
(Hospira 10 gtts/ml)

Left Cephalic Vein

Gauge 20
(Venflon)

Dengue Hemorrhagic Fever

AN-002202/
03/30/2015
Chona David, R.N.

This is to certify that I had successfully performed the above requirements as countersigned by my witnesses.
Received by: _______________________________________________
ANSAP

Submitted by:

DEMETRIO S. FERRER III, R.N.

Signature over Printed Name

I.V. Therapy Certification Card No. ____________________________

Approved by:

Issued by: _____________________________ Date: ______________

Date of Submission: _____________________________

NORMA L. LOSAES, R.N., M.N.

Director, Nursing Service