ILOILO MISSION HOSPITAL Name of Hospital Offering I.V.

Training MISSION ROAD, JARO, ILOILO CITY Address Accomplished Requirements of: Name of Registered Nurse: IVE MARYROSE A. ESPENIDO, R.N. Date of I.V. Training Program Attended: MARCH 29, 30, and 31, 2011 Registration Number of Institution Offering the I.V. Training Program: 139

Venue: ILOILO MISSION HOSPITAL, MISSION ROAD, JARO, ILOILO CITY Province / Region: ILOILO / VI ANSAP Chapter: ILOILO P.R.C. Number: 0661645 I.V. Requirements: 3-3-2 Expiry Date: JUNE 08, 2013

I.
Patient No.
1 2 3

Initiating / Maintaining Peripheral I.V. Infusion

Name of Patient
Mandigal, Monico Sr. A. Teodosio, Mitchell S. Dreo, Guia L.

Age
80 years old 17 years old 54 years old

Date
05/02/11 05/04/11 05/06/10

Time
10:50 A.M. 01:05 P.M. 4:25 P.M.

Kind of Infusion
PNSS 1 liter x 8 hours D5LR 1 liter x 8 hours D5NSS 1 liter x 8 hours

Site
Left Cephalic Vein Left Metacarpal Vein Left Cephalic Vein

Type of Cannula
Gauge 22 (Insyte) Gauge 22 (Insyte) Gauge 22 (Bio Flon)

Dose
125 cc/hr 100 cc/hr 125 cc/hr

Rate
125 mgtts/min 25 gtts/min 31 gtts/min

Signature over Printed Name of Certified Trainer/Preceptor

Ana V. Jagolina, R.N Ana V. Jagolina, R.N Ana V. Jagolina, R.N

License No.
002226 09/01/13 002226 09/01/13 002226 06/20/13

II.
Patient No.
1 2 3

Administering Intravenous Drugs

Name of Patient
Lopez, Ramon L. Vinson, Eduardo H. Figueroa, Robert Y.

Age
52 years old 49 years old 3 years old

Date
05/04/10 05/04/10 05/04/11

Time
8:00 P.M. 08:00 P.M. 08:00 P.M.

Drugs Incorporated
Piperacillin-Tazobactem (Tazocin) 4.5g/vial Piperacillin-Tazobactem (Tazocin) 4.5g/vial Cefuroxime (Kefox) 750 mg/vial

Dose
2.25 g IVTT every 8 hours 4.5 g IVTT every 8 hours 750 mg IVTT every 8 hours

Diagnosis
Pulmonary Tuberculosis reactivation Community Acquired Pneumonia-Moderate Risk Cerebrovascular Disease Bleed left Basal Ganglia probably cardio embolic, Hypertensive cerebrovascular disease Urinary Tract Infection

Signature over Printed Name of Certified Trainer/Preceptor

Ana V. Jagolina, R.N Ana V. Jagolina, R.N Ana V. Jagolina, R.N

License No.
002226 09/01/13 002226 09/01/13 002226 09/01/13

III.
Patient No.
1 2

Administering and Maintaining Blood and Blood Components

Name of Patient
Ganancial, Roberto M. Custodio, Karen P.

Age
71 years old 25 years old

Date
05/04/11 05/05/11

Time
09:00 P.M. 02:15 A.M.

Volume/Blood Type/ Components/Rate

PNRC No. 322574 236cc Type AB+ packed Red Blood Cells x 4 hours, 9 gtts/min (Hospira 10 gtts/ml) PNRC No. 304783 250 cc Type B+ packed Red Blood Cells x 4 hours, 10 gtts/min (Hospira 10 gtts/ml)

I.V. Insertion
Left Cephalic Vein Left Metacarpal Vein

Type of Cannula
Gauge 18 (Venflon) Gauge 22 (Venflon)

Diagnosis
Upper Gastrointestinal Bleeding probably secondary to Benign Peptic Ulcer Disease Bleeding Hemmorhoids

Signature over Printed Name of Certified Trainer/Preceptor/R.N.

Ana V. Jagolina, R.N Ana V. Jagolina, R.N

License No.
002226 09/01/13 002226 09/01/13

This is to certify that I had successfully performed the above requirements as countersigned by my witnesses. Received by: _______________________________________________ ANSAP I.V. Therapy Certification Card No. ____________________________ Submitted by: Approved by: IVE MARYROSE A. ESPENIDO, R.N. Signature over Printed Name NORMA L. LOSAES, R.N., M.N. Director, Nursing Service

Issued by: _____________________________ Date: ______________

Date of Submission: _____________________________