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3+3+1 ACCOMPLISHED REQUIREMENTS of 3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES Name of Registered Nurse: Mark

Joseph A. Guevarra Name of Hospital offering IV Training: PLTCI-Luis A. Tiam Medical Center Date of IV Training Program Attended: March 6 -8, 2013 I. Patient no. 001 002 003 Initiating/ maintaining Peripheral IV Infusions Name of Age Date Time patient Liam Baltazar Judy Dulinayan Redencio Valdez 4 33 28 04-05-13 04-05-13 04-05-13 7:05pm 6:35pm 4:40pm Kind of infusion PLRS D5LR PNSS Site Left Metacarpal Vein Right Metacarpal Vein Left Metacarpal Vein Type of cannula G24 G22 G22 Dose L 1L 1L PRC Number: 0792834 Provider no. : 168 Venue: PLT Wellness Resort Function Hall rate 55-66 ggts/min Mark John B. Ildefonso, RN 41-42 ggts/min Mark John B. Ildefonso, RN 41-42 ggts/min Mark John B. Ildefonso, RN 09-0099562 09-0099562 09-0099562 Signature over printed name of Certified Trainer/ Preceptor/ M.D., RN License no.

II. Patient no. 001 002 003

Administering intravenous Drugs Name of patient Age Date Teodoro Torio Daphne Balagan Lolita Sapon 34 1 46 04-05-13 04-05-13 04-05-13

Time 10:00am 12:00pm 2:00pm

Drugs incorporated Furosemide Ampicillin Meropenium

dose 80mg IV every 6 hour 250mg IV every 6 hour 1gm IV every 8 hour

diagnosis Chronic Renal Failure

Signature over printed name of Certified Trainer/ Preceptor/ M.D., RN Mark John B. Ildefonso, RN

Licenser no.

09-0099562 09-0099562 09-0099562

CAP/Anemic/Acute lymphoblastic Leukemia AGE with some DHN: Electrolyte imbalance

Mark John B. Ildefonso, RN Mark John B. Ildefonso, RN

III. Patient no. 001

Administering and Maintaining Blood and Blood components (2 Nurses In One Blood Transfusion Administration) Name of Age Date Time Volume/ Blood type/ IV insertion Type of diagnosis patient components/ rate cannula Lolita Sapon 46 04-05-13 7:40-7:50pm 100CC/ O positive/ FFP/ Fast Drip Brachial Veincutdown G20 CAP/Anemic/Acute lymphoblastic Leukemia

Signature over printed name of Certified Trainer/ Preceptor/ M.D., RN Mark John B. Ildefonso, RN

Licenser no.

09-0099562

Submitted by: Mark Joseph A. Guevarra Signature over printed name

Date submitted:________________________ received by: ___________________________approved by:_______________________________ director of nursing services

(signature over printed name)