3+3+1 ACCOMPLISHED REQUIREMENTS OF 3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FOR NURSES NAME OF RN: LIZA MAY

CAINAP ELLAGA________________________ NAME OF HOSPITAL OFFERING IV TRAINING: ASMGH_____________ DATE OF IV TRAINING PROGRAM ATTENDED: October 13, 14, 15, 2012 I. INITIATING/MAINTAINING PERIPHERAL IV INFUSIONS PATIENT NAME OF PATIENT AGE DATE NO. 20120174307 CONSUELO ESPINOSA 17 y.o. 10/27/2012 20120132723 ADELFA IBAEZ 66 y.o. 10/27/2012 20120174341 JENELYN ALLO 28 y.o. 10/27/2012 ADMINISTERING INTRAVENOUS DRUGS PATIENT NO. 20120174011 20120173723 20120174040 NAME OF PATIENT AGE DATE TIME DRUGS INCORPORATED Meropenem Amikacin Cefotaxime DOSE DIAGNOSIS Pneumonia, Moderate Risk; Bronchial Asthma in Acute Exacerbation Acute Bacterial Meningitis Neonatal Sepsis Alice P. Miedes SIGNATURE OVER PRINTED NAME OF CERTIFIED TRAINER/PRECEPTOR Alice P. Miedes Alice P. Miedes LICENSE NO. PRC-0138059 IVT-10-012012 PRC-0138059 IVT-10-012012 PRC-0138059 IVT-10-012012 PRC NUMBER: __________________ PROVIDER NO. 230 ______________ VENUE: CINDYS II, SAN JOSE, ANTIQUE

TIME

KIND OF INFUSION D5NSS D5NSS PLR

SITE

TYPE OF CANNULA Gauge 20 Gauge 20 Gauge 18

DOSE

RATE

SIGNATURE OVER PRINTED NAME OF CERTIFIED TRAINER/PRECEPTOR Alice P. Miedes Alice P. Miedes Alice P. Miedes

LICENSE NO. PRC-0138059 IVT-10-012012 PRC-0138059 IVT-10-012012 PRC-0138059 IVT-10-012012

8:39 am 10:45 am 11:35 am

Left Cephalic Vein Right Cephalic Vein Right Cephalic Vein

1 Liter 1 Liter 1 Liter

31-32 gtts/min 9-10 gtts/min 31-32 gtts/min

II.

REXEL JOSH PUNO ROSELYN ALYSSA VIO MICHAELA NICOLE MOSCOSO

2 mos. 1 y.o. 22 days

10/26/2012 10/27/2012 10/27/2012

12:00 pm 8:00 am 10:00 am

150 mgs. 58 mgs. 185 mgs.

III. ADMINISTERING AND MAINTAINING BLOOD AND BLOOD COMPONENTS PATIENT NAME OF PATIENT AGE DATE TIME VOLUME/BLOOD NO. TYPE/COMPONENTS/RATE 2004Type O RH + Packed Red 0017234 DALMACIA MONTERO 79 y.o. 10/26.2012 10:25 pm Blood Cells with Serial No. of 051259 at 20 gtts/min

IV INSERTION Piggyback

TYPE OF CANNULA Gauge 18

DIAGNOSIS UTI; SP Colostomy

SIGNATURE OVER PRINTED NAME OF CERTIFIED TRAINER/PRECEPTOR

LICENSE NO.

Alice P. Miedes

PRC-0138059 IVT-10-012012

SUBMITTED BY: Liza May C. Ellaga

DATE SUBMITTED: October 30, 2012

RECEIVED BY:__________________

APPROVED BY: Maxima G. Marfil, RN Director of Nursing Services