ILOILO MISSION HOSPITAL Name of Hospital Offering I.V.

Training MISSION ROAD, JARO, ILOILO CITY Address Accomplished Requirements of: Name of Registered Nurse: JOHN G. DE LA CRUZ, 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: 0146867 I.V. Requirements: 3-3-2 Expiry Date: DECEMBER 25, 2020

I.
Patient No.
1 2 3

Initiating / Maintaining Peripheral I.V. Infusion

Name of Patient
Fallaria, John P. Fiedacan, Arnulfo Q. Condensada, Liberty D.

Age
48 years old 66 years old 45 years old

Date
10/16/10 10/24/10 10/29/10

Time
8:40 A.M. 10:00 A.M. 1:45 P.M.

Kind of Infusion
D5LR 1 liter x 8 hours PNSS 1 liter x KVO PNSS 1 liter x 12 hours

Site
Left Cephalic Vein Left Metacarpal Vein Left Cephalic Vein

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

Dose
125 cc/hr 10 cc/hr 80 cc/hr

Rate
31 gtts/min 10 mgtts/min 20 gtts/min

Signature over Printed Name of Certified Trainer/Preceptor

Rosemary S. Alfanta, R.N Larry A. Amazona, R.N Rhea B. Maosa, R.N

License No.
002193 06/20/13 002193 06/20/13 002193 06/20/13

II.
Patient No.
1 2 3

Administering Intravenous Drugs

Name of Patient
Falceso, Nakbar L. Ribs, Kyanuo H. Trada, Josep Y.

Age
35 years old 29 years old 29 years old

Date
10/16/10 10/16/10 10/16/10

Time
8:00 A.M. 10:00 A.M. 12:00 P.M.

Drugs Incorporated
Ceftriaxone (Rocephin) 1 g/vial Tramadol (Tramal) 50 mg/ml Cefuroxime (Kefox) 750 mg/vial

Dose
2 g IVTT every 8 hours 50 mg IVTT every 12 hours 750 mg IVTT every 8 hours

Diagnosis
Pyohydronephrotic Left Kidney with Proximal Third Stone and Nephrolithiasis Acute Abdomen secondary to Bladder Injury Acute Abdomen secondary to Bladder Injury

Signature over Printed Name of Certified Trainer/Preceptor

Mary Ann S. Salcedo, R.N Ma. Gina G. Papelera, R.N Rhoda C. Gemarino, R.N

License No.
002193 06/20/13 002193 06/20/13 002193 06/20/13

III.
Patient No.
1 2

Administering and Maintaining Blood and Blood Components

Name of Patient
Carnapper, Toyota J. Cannon, Hewlett P.

Age
68 years old 69 years old

Date
10/29/10 10/30/10

Time
8:00 P.M. 1:00 A.M.

Volume/Blood Type/ Components/Rate

PNRC No. 201015 268 cc Type A+ packed Red Blood Cells x 4 hours, 11 gtts/min (Hospira 10 gtts/ml) PNRC No. 023767 205 cc Type O+ packed Red Blood Cells x 4 hours, 8 gtts/min (Hospira 10 gtts/ml)

I.V. Insertion
Left Cephalic Vein Left Cephalic Vein

Type of Cannula
Gauge 20 (Venflon) Gauge 20 (Venflon)

Diagnosis
Myelodysplastie Syndrome

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

Chona R. David, R.N

License No.
002193 06/20/13 002193 06/20/13

Community Acquired Pneumonia, Moderate Risk, Upper Gastrointestinal Bleeding

Ma. Pia D. Mirador, R.N

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. ____________________________ Issued by: _____________________________ Date: ______________ Submitted by: Approved by: JOHN G. DE LA CRUZ, R.N. Signature over Printed Name NORMA L. LOSAES, R.N., M.N. Director, Nursing Service

Date of Submission: _____________________________