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 PRC Number Provider No. Venue 0773184 RUN Bldg., Pawa, Tabaco City

JAIME B. BERCES MEMORIAL HOSPITAL March 9-11, 2013

I. Initiating/Maintaining Peripheral IV Infusions Patient No. 1303375 13030367 13030370 II. Administering Intravenous Drugs Patient No. 13030365 13030352 13030344 Name of Patient Age 3yo 3yo 84yo Date 3/11/2013 3/11/2013 3/11/2013 Time Drugs Incorporated Dose 200 mg 50 mg 40 mg Diagnosis Intestinal Parasitism
AGE with Moderate Dehydration, Intestinal Parasitism, Malnutrition Signature over Printed Name of Certified Trainer/Preceptor JENNIFER LERIDA, RN JENNIFER LERIDA, RN JENNIFER LERIDA, RN

Name of Patient

Age 60yo 36yo 50yo

Date 3/11/2013 3/11/2013 3/11/2013

Time

Kind of Infusion

Site
Left cephalic vein
Right metacarpal vein

Type of Cannula

Dose 1 Liter 1 Liter 1 Liter

Rate 20 gtts/min 20 gtts/min 20 gtts/min

Signature over Printed Name of Certified Trainer/Preceptor JENNIFER LERIDA, RN JENNIFER LERIDA, RN JENNIFER LERIDA, RN

License No. 11-023742 11-023742 11-023742

5:00 PM Plain Lactated Ringers 6:30 PM Dextrose 0.9 Sodium Chloride 7:00 PM Dextrose 0.9 Sodium Chloride

Gauge 22 Gauge 22 Gauge 22

Left cephalic vein

License No. 11-023742 11-023742 11-023742

6:30 PM Ampicillin (Polypen) 7:30 PM Amikacin (Kamin) 8:30 PM Omeprazole (Cezole)

Hypertension Stage 2, Anorexia

III. Administering and Maintaining Blood and Blood Components Patient No. 13030354 Submitted by: (Signature over Printed Name) Name of Patient Age Date Time 9:00 PM Volume/Blood Type/ Components/Rate 1 unit/B+/PRBC 20gtts/min IV Insertion
Right cephalic vein

Type of Cannula

Diagnosis
DM, Diabetic Foot (L) , Non-heaing S/P below knee amputation, CKD, Anemia

Signature over Printed Name of Certified Trainer/Preceptor

License No. 11-023743

48yo 3/11/2013

Gauge 18

ROSIE B. PARANO

Date submitted:

Received by:

Approved by:

LETICIA M. CARILLO, MAN, RN Director of Nursing Services (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 JENNILYN B. AGUILAR JAIME B. BERCES MEMORIAL HOSPITAL OCTOBER 1, 2 & 3, 2001 PRC Number Provider No. Venue 0321152 RUN Bldg., Pawa, Tabaco City

I. Initiating/Maintaining Peripheral IV Infusions Patient No. Name of Patient Age 1 72

4 MOS

Date 10/29/2011

Time 9:00 AM

Kind of Infusion D5 IMB D5 NR D5 0.3 NaCl

Site
Left metacarpal vein

Type of Cannula

Dose 500 cc 1 Liter 500 cc

Rate
12 microdrops/min

11-10-1380 BOLANTE, ANGEL 11-10-1386 BRONDIAL, LILIA 11-10-1393 ARIZAPA, JOHN CRISTOFF II. Administering Intravenous Drugs Patient No. Name of Patient

gauge 24 gauge 22 gauge 24

10/29/2011 10:00 AM 10/29/2011 4 MOS

Left cephalic vein Left cephalic vein

30 drops/min
40 microdrops/min

Age 1
4 MOS

Date 10/29/2011

Time 1:00 PM

Drugs Incorporated RANITIDINE CEFUROXIME FUROSEMIDE

Dose 10 mg 250 mg 20 mg

Diagnosis PNEUMONIA PNEUMONIA

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

11-10-1390 CEDRO, LOURD ZIOW 11-10-1393 ARIZAPA, JOHN CRISTOFF 11-10-1392 CORTADO, JIMMY

10/29/2011 11:00 AM 10/29/2011 11:00 AM

78

III. Administering and Maintaining Blood and Blood Components Patient No. Name of Patient Age 64 Date 10/28/2011 Time 3:40 PM Volume/Blood Type/ Components/Rate 500cc/AB/PACKED RBC 20-21 DROPS/MIN 10/27/2011 IV Insertion
Left cephalic vein

Type of Cannula

Diagnosis END STAGE RENAL DISEASE Approved by:

11-101385 ARIOLA, ROMEO Submitted by:

gauge 18

SARAH JANE V. ANONUEVO, RN (Signature over Printed Name)

Date submitted:

Received by:

awa, Tabaco City

Signature over Printed Name of Certified Trainer/Preceptor

License No. 09-004632 09-004633 09-004634

MARK JAMES S. ANDAYOG MARK JAMES S. ANDAYOG MARK JAMES S. ANDAYOG

Signature over Printed Name of Certified Trainer/Preceptor

License No. 09-004632 09-004634 09-004633

MARK JAMES S. ANDAYOG MARK JAMES S. ANDAYOG MARK JAMES S. ANDAYOG

Signature over Printed Name of Certified Trainer/Preceptor

License No. 09-004634

MARK JAMES S. ANDAYOG

LETICIA M. CARILLO, MAN, RN Director of Nursing Services (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 JE JAIME B. BERCES MEMORIAL HOSPITAL OCTOBER 1, 2 & 3, 2001 PRC Number Provider No. Venue 0631819 RUN Bldg., Pawa, Tabaco City

I. Initiating/Maintaining Peripheral IV Infusions Patient No. Name of Patient Age 66 72 2 Date 10/4/2011 10/5/2011 10/5/2011 Time 4:30 AM 3:30 AM 4:30 AM Kind of Infusion D5 0.9 % NaCl D5 NM D5 0.3 NaCl Site
Left cephalic vein Left cephalic vein
Left metacarpal vein

Type of Cannula

Dose 1 Liter 1 Liter 500 cc

Rate 20 drops/min 20 drops/min

50 microdrops/min

11-10-1271 CARMONA, DIONISIA G. 11-10-1273 BUATIS, JAIME 11-10-1279 BORBON, JASMINE B. II. Administering Intravenous Drugs Patient No. Name of Patient

gauge 22 gauge 22 gauge 24

Age 20 64 1

Date

Time

Drugs Incorporated CEFUROXIME DEXAMETHASONE AMPICILLIN

Dose 750 mg 50 mg 250 mg

Diagnosis ACUTE APPENDICITIS

HYPOKALEMIA T/C STROKE IN EVOLUTION ACUTE RESPIRATORY INFECTION R/O UTI

11-10-1278 SUMUGOD, ROMMELAINE 11-10-1276 ORBITA, VERONICA 11-10-1274 BIRUELA, JHONA REN

10/5/2011 12:00 AM 10/5/2011 10/4/2011 6:00 AM 6:00 AM

III. Administering and Maintaining Blood and Blood Components Patient No. Name of Patient Age Volume/Blood Type/ Components/Rate 500cc/B+/PACKED RBC 74 10/4/2011 12:00 AM 20-21 DROPS/MIN Date Time Date submitted: 10/27/2011 IV Insertion
Right cephalic vein

Type of Cannula

Diagnosis
ANEMIA - NUTRITIONAL STATUS
POST BT ELECTROLYTE IMBALANCE

11-10-1263 BITARA, HERMINIO Submitted by:

gauge 18

SARAH JANE V. ANONUEVO, RN (Signature over Printed Name)

Received by:

Approved by:

awa, Tabaco City

Signature over Printed Name of Certified Trainer/Preceptor

License No. 09-004632 09-004633 09-004634

MARK JAMES S. ANDAYOG MARK JAMES S. ANDAYOG MARK JAMES S. ANDAYOG

Signature over Printed Name of Certified Trainer/Preceptor

License No. 09-004632 09-004634 09-004633

MARK JAMES S. ANDAYOG MARK JAMES S. ANDAYOG MARK JAMES S. ANDAYOG

Signature over Printed Name of Certified Trainer/Preceptor

License No. 09-004634

MARK JAMES S. ANDAYOG

LETICIA M. CARILLO, MAN, RN Director of Nursing Services (Signature over Printed Name)