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Sample IVT Training Form

The document summarizes the requirements completed by a nurse in a 3-day basic intravenous therapy training program. It includes details of three patients the nurse initiated and maintained peripheral IV infusions for, including infusion sites, types of cannulas used, doses, and rates. It also provides details of three patients the nurse administered intravenous drugs to, including drugs, doses, diagnoses, and times. Finally, it documents the nurse administering and maintaining blood and blood components for one patient, including volume, blood type, insertion site, cannula type, and diagnosis. The document was submitted and approved, completing the nurse's IV training program requirements.

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Igorot Hector
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© Attribution Non-Commercial (BY-NC)
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Download as DOCX, PDF, TXT or read online on Scribd
258 views1 page

Sample IVT Training Form

The document summarizes the requirements completed by a nurse in a 3-day basic intravenous therapy training program. It includes details of three patients the nurse initiated and maintained peripheral IV infusions for, including infusion sites, types of cannulas used, doses, and rates. It also provides details of three patients the nurse administered intravenous drugs to, including drugs, doses, diagnoses, and times. Finally, it documents the nurse administering and maintaining blood and blood components for one patient, including volume, blood type, insertion site, cannula type, and diagnosis. The document was submitted and approved, completing the nurse's IV training program requirements.

Uploaded by

Igorot Hector
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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3+3+2 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 : PRC Number: ?????? Provider No: Venue: ?????

I.

Initiating/Maintaining peripheral IV infusions


Patient No.
383682 386055

Name of Patient

Age
52 4

Date
12-12-10 12-12-10

Time
5:30 PM 2:00 PM

Kind of infusion
0.9 % Sodium Chloride 5% Dextrose in Lactated Ringers Solution 5% Dextrose in Lactated Ringers Solution

Site
Right Basilic Vein Right Metacarpal vein Left cephalic vein

Type of Cannula
Introcan Gauge 18 Introcan Gauge 24 Introcan Gauge 18

Dose
1 liter x24 hours 1 liter x 16hours

Rate
10-15 gtts/minute 62-63 ugtts/minute

Signature over printed name of certified trainer/preceptor

License No.

669218

36

12-13-10

11:30PM

1 liter x 24hours

10-15 gtts/minute

II.

Administering intravenous drugs


Patient No.
583679 663679 899032

Name of Patient

Age
52 4 39

Date
12-12-12 12-12-12 12-12-12

Time
10:30 PM 4:00 PM 8:00 PM

Drugs Incorporated
Furosemide Ketorolac Cefuroxime

Dose
20mg IV post blood transfusion 15mg IV every 8 hours 750mg IV every 8 hours

Diagnosis
Urinary tract infection rule out nephrolithiasis Close fracture on left supracondylar humerus Abdominal colic, rule out acute appendicitis

Signature over printed name of certified trainer/preceptor

License No.

III.

Administering and maintaining blood and blood components


Patient No.
523679

Name of Patient

Age
52

Date
12-12-12

Time
6:15 PM

Volume/blood/type/components/rate
450 packed red blood cells, type B+, 38-39 gtts/minute

IV insertion
Right Basilic Vein

Type of Cannula
Introcan Guage 18

Diagnosis
Urinary Tract Infection rule our nephrolithiasis

Signature over printed name of certified trainer/preceptor

License No.

Submitted By:___________________________ (Signature over printed name)

Date Submitted:__________________________ Received by:______________________

Approved by:_______________________________________
Director of Nursing Services (Signature over printed name)

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