LYCEUM-NORTHWESTERN UNIVERSITY

College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

I. Major Operations
Type of Supervised by:
No Date of Case Name of Operation Name of Name of
Diagnosis Anesthes Name/Signature of
. Operation No. Patient Performed Surgeon Hospital
ia Qualified C.I.
Pregnancy Uterine
Marjorie Delivery to an alive baby Western
Classical Caesarian Spinal Dr. Victoriano
1 July 8, 2010 182392 Benesen boy Meconium Stain Pangasinan District Mrs. Violeta Gutierrez
Section Anesthesia Rosario
Abaya classical II Gravida 2 Hospital
Parity 2 (2002)
Partial Colonic
Exploratory Western
Violeta Obstruction Secondary to Spinal
2 July 9, 2010 182263 Laparotomy, Hartman’s Dr. Jose Cacho Pangasinan District Mrs. Violeta Gutierrez
Carolino Corilla Rectosigmoid New Anesthesia
Operation Hospital
Growth
Pregnancy Uterine Full
Monette Term Previous Caesarian Western
182633 Low Transverse Spinal
3 July 16, 2010 Bautista Section Delivery to an Dr. Fidelez Ochave Pangasinan District Mrs. Violeta Gutierrez
-R Caesarian Section II Anesthesia
Dacones alive baby boy Gravida 2 Hospital
Parity 2 (2002)
Open Reduction with Western
Ariel Pulusan General
4 July 30, 2010 183195 Mandibular Fracture Internal Fixation, Dr. Ronnie Mamaril Pangasinan District Mrs. Violeta Gutierrez
Dayao Anesthesia
Plating Hospital

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, MA. CONCEPCION H. MIRANDA CRESENCIO C. QUINTO JR. ALMA P. CARRERA MRS. VIRGINIA V. MENDOZA
KIMBERLY M. Chief Nurse Clinical Coordinator Qualified Faculty Dean, College of Nursing
Name of Student Western Pangasinan District Date signed : Western Pangasinan District Date Signed :
(Signature Over Printed Hospital Degree : B.S.N., R.N., Hospital Degree : R.N., M.A.Ed., M.A.N.,
Name) Date signed : M.A.N. Date Signed : Ed.D.
Degree : R.N., M.A.N a). PRC No. : 0292288 Degree : B.S.N., R.N., a) PRC No. : 0042414
a). PRC No. : 0068019 Valid Until : July 18, 2011 M.A.N. Valid Until : April 29, 2011
Valid Until : March 26, 2011 b). PNA No. : 013897 a). PRC No. : 0311104 b) PNA No. : 378
b). PNA No. : 10441 Valid Until : October 31, Valid Until : March 21, 2012 Valid Until : Lifetime
Valid Until : Lifetime 2010 b). PNA No. : 061983 c) ADPCN No. : 190
c). ANSAP No. : 0374 Valid Until : October 31, Valid Until : December 31, 2010
Valid Until : Lifetime 2010
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

I. Major Operations
Type of Supervised by:
No Date of Case Name of Operation Name of Name of
Diagnosis Anesthes Name/Signature of
. Operation No. Patient Performed Surgeon Hospital
ia Qualified C.I.
Open Reduction with
September 18, 11-17- Mercedita Closed Spiral Fracture Spinal Dr. Salvador Eastern Pangasinan
1 Internal Fixation, Mrs. Rosalie Marron
2010 79 Nacion Cinco Femur Left Anesthesia Rodrigo District Hospital
Plating

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, ROSALIA R. MATEO CRESENCIO C. QUINTO JR. JOCELYN G. MACARAEG MRS. VIRGINIA V. MENDOZA
KIMBERLY M. Chief Nurse Clinical Coordinator Qualified Faculty Dean, College of Nursing
Name of Student Eastern Pangasinan District Date signed : Eastern Pangasinan District Date Signed :
(Signature Over Printed Hospital Degree : B.S.N., R.N., Hospital Degree : R.N., M.A.Ed., M.A.N.,
Name) Date signed : M.A.N. Date Signed : Ed.D.
Degree : R.N., M.A.N. a). PRC No. : 0292288 Degree : B.S.N., R.N., a) PRC No. : 0042414
a). PRC No. : 0099313 Valid Until : July 18, 2011 M.A.N. Valid Until : April 29, 2011
Valid Until : September 14, b). PNA No. : 013897 a). PRC No. : 0254320 b) PNA No. : 378
2012 Valid Until : October 31, Valid Until : September 23, Valid Until : Lifetime
b). PNA No. : 12125 2010 2012 c) ADPCN No. : 190
Valid Until : Lifetime b). PNA No. : 018456 Valid Until : December 31, 2010
c). ANSAP No. : 0491 Valid Until : October 31,
Valid Until : Lifetime 2010
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

II. Minor Operations

Supervised by:
No Date of Case Name of Operation Type of
Diagnosis Name of Surgeon Name of Hospital Name/Signature of
. Operation No. Patient Performed Anesthesia
Qualified C.I.
Pregnancy Uterine Full
Term, Cephalic delivered Bilateral Tubal
Sub- Western
182852 Irene Ignacio to an alive baby Ligation Dr. Fedelez
1 July 22, 2010 Arachnoid Pangasinan District Mrs. Violeta Gutierrez
-R Garcia boy( Family Planning Pomeroy Ochave
Block Hospital
Acceptor Gravida 4 Technique
Parity 4 (4004)
Emergency
Western
Euseeff Delia Acute Appendicitis, Appendectomy Spinal
2 July 30, 2010 183167 Dr. Jose Cacho Pangasinan District Mrs. Violeta Gutierrez
Mirante Suppurative Stage Peritoneal Anesthesia
Hospital
Mopping
Final Family Complete
Bilateral Tubal
Bilateral Tubal Ligation Western
Mary Jahl A. Ligation Local
3 July 30, 2010 183174 (Family Planning Dr. Macaraeg Pangasinan District Mrs. Violeta Gutierrez
Rabara Pomeroy Anesthesia
Acceptor Gravida 4 Hospital
Technique
Parity 3 (40030

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, KIMBERLY M. MA. CONCEPCION H. CRESENCIO C. QUINTO JR. ALMA P. CARRERA MRS. VIRGINIA V. MENDOZA
Name of Student MIRANDA Clinical Coordinator Qualified Faculty Dean, College of Nursing
(Signature Over Printed Name) Chief Nurse Date signed : Western Pangasinan District Date Signed :
Western Pangasinan Degree : B.S.N., R.N., Hospital Degree : R.N., M.A.Ed., M.A.N., Ed.D.
District Hospital M.A.N. Date Signed : a) PRC No. : 0042414
Date signed : a). PRC No. : 0292288 Degree : B.S.N., R.N., Valid Until : April 29, 2011
Degree : R.N., M.A.N Valid Until : July 18, 2011 M.A.N. b) PNA No. : 378
a). PRC No. : 0068019 b). PNA No. : 013897 a). PRC No. : 0311104 Valid Until : Lifetime
Valid Until : March 26, Valid Until : October 31, Valid Until : March 21, c) ADPCN No. : 190
2011 2010 2012 Valid Until : December 31, 2010
b). PNA No. : 10441 b). PNA No. : 061983
 Valid Until : Lifetime Valid Until : October 31,
c). ANSAP No. : 0374 2010
Valid Until : Lifetime
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

II. Minor Operations

Supervised by:
No Date of Case Name of Operation Type of
Diagnosis Name of Surgeon Name of Hospital Name/Signature of
. Operation No. Patient Performed Anesthesia
Qualified C.I.
Lacerated Wound 6
January 22, Local Region 1 Medical Mr. Herminigildo
1 29407 Arvin Torio centimeter at Left Suturing Dr. Leo Bautista
2010 Anesthesia Center Bumacod Jr.
Frontal Area
Lacerated Wound 6
January 29, Local Dr. Mayeen Region 1 Medical Mr. Herminigildo
2 49164 Jojo Mercado centimeter Parieto Suturing
2010 Anesthesia Fernandez Center Bumacod Jr.
Occipital at Right Area

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, KIMBERLY M.
Name of Student
(Signature Over Printed Name)
ROSAURO P. CATABAY
OIC - Chief Nurse
Region I Medical Center
Date signed :
Degree : B.S.N.R.N.,
M.AN.
a.) PRC No. : 0157085
Valid Until : October 28,
2010
b.) PNA No. : 12121
Valid Until : Lifetime
c.) ANSAP No. : 0498
Valid Until : Lifetime
CRESENCIO C. QUINTO JR. ALMA G. FAMA MRS. VIRGINIA V. MENDOZA
Clinical Coordinator Dean, College of Nursing
Date signed : Qualified Faculty Date Signed :
Degree : B.S.N., R.N., Region I Medical Center Degree : R.N., M.A.Ed., M.A.N., Ed.D.
M.A.N. Date signed : a) PRC No. : 0042414
a). PRC No. : 0292288 Degree : B.S.N., Valid Until : April 29, 2011
Valid Until : July 18, 2011 R.N.,M.A.N. b) PNA No. : 378
b). PNA No. : 013897 a). PRC No. : 0282241 Valid Until : Lifetime
Valid Until : October 31, Valid Until : January 5, c) ADPCN No. : 190
2010 2013 Valid Until : December 31, 2010
b). PNA No. : 16919
Valid Until : Lifetime
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

II. Minor Operations

Supervised by:
No Date of Case Name of Operation Type of
Diagnosis Name of Surgeon Name of Hospital Name/Signature of
. Operation No. Patient Performed Anesthesia
Qualified C.I.
February 6, Lovely Joy C. Incision and Local Mapandan
1 03854 Abscess Right Foot Dr. Earl Javier Mrs. Grecilda Oclay
2010 De Vera Drainage Anesthesia Community Hospital

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, KIMBERLY M.
Name of Student
(Signature Over Printed Name)
GRACE Z. JOVELLANOS CRESENCIO C. QUINTO JR. JOCELYN G. MACARAEG MRS. VIRGINIA V. MENDOZA
Chief Nurse Clinical Coordinator Qualified Faculty Dean, College of Nursing
Mapandan Community Date signed : Mapandan Community Date Signed :
Hospital Degree : B.S.N., R.N., Hospital Degree : R.N., M.A.Ed., M.A.N., Ed.D.
Date Signed : M.A.N. Date Signed : a) PRC No. : 0042414
Degree : R.N., M.A.N. in a). PRC No. : 0292288 Degree : B.S.N., R.N., Valid Until : April 29, 2011
progress Valid Until : July 18, 2011 M.A.N. b) PNA No. : 378
a) PRC No. : 0064042 b). PNA No. : 013897 a). PRC No. : 0254320 Valid Until : Lifetime
Valid Until : October 31, Valid Until : September 23, c) ADPCN No. : 190
Valid Until : September 2010 2012 Valid Until : December 31, 2010
16, 2011 b). PNA No. : 018456
b) PNA No. : 013853 Valid Until : October 31,
2010
Valid Until : October 31,
2010
c) ANSAP No. : 09-0050

Valid Until : December

31, 2010_
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

II. Minor Operations

Supervised by:
No Date of Case Name of Operation Type of
Diagnosis Name of Surgeon Name of Hospital Name/Signature of
. Operation No. Patient Performed Anesthesia
Qualified C.I.
3-
March 23, Gwen Dela Gravida 1 Parity 0 (0010) Completion Local Dr. Josephine Lingayen District
1 152311 Ms. Marie Kris Santos
2010 Cruz Soriano Abortion Incomplete Curettage Anesthesia Guiang Hospital
0

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, KIMBERLY M. LANI CRUZ CRESENCIO C. QUINTO JR. ALMA P. CARRERA MRS. VIRGINIA V. MENDOZA
Name of Student Chief Nurse Clinical Coordinator Qualified Faculty Dean, College of Nursing
(Signature Over Printed Name) Lingayen District Hospital Date signed : Lingayen District Hospital Date Signed :
Date signed : Degree : B.S.N., R.N., Date Signed : Degree : R.N., M.A.Ed., M.A.N., Ed.D.
a). PRC No. : 0131408 M.A.N. Degree : B.S.N., R.N., a) PRC No. : 0042414
Valid Until : November a). PRC No. : 0292288 M.A.N. Valid Until : April 29, 2011
25, 2010 Valid Until : July 18, 2011 a). PRC No. : 0311104 b) PNA No. : 378
b). PNA No. : 029075 b). PNA No. : 013897 Valid Until : March 21, Valid Until : Lifetime
Valid Until : December Valid Until : October 31, 2012 c) ADPCN No. : 190
31, 2010 2010 b). PNA No. : 061983 Valid Until : December 31, 2010
c). ANSAP No. : Valid Until : October 31,
090082 2010
Valid Until : December
31, 2010
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

III. Actual Deliveries

Time
Supervised by:
No Case Name of of Gender Name of Type of
Diagnosis Age Date of Delivery Name/Signature
. No. Mother Deliver of Baby Hospital Delivery
of Qualified C.I.
y
Pregnancy Uterine Full Term 39
weeks Age of Gestation, Mapandan Normal
Lara Pinto December 22, 12:20
1 02620 Cephalic delivered to an alive 18 Male Community Spontaneous Ms. Jessiel Santorum
Vinluan 2009 am
baby boy Gravida 1 Parity 1 Hospital Delivery
(1001)
Pregnancy Uterine Full Term 39
weeks Age of Gestation, Mapandan Normal
Marilou T. 10:12
2 00294 Cephalic delivered to an alive 19 February 5, 2010 Female Community Spontaneous Mrs. Grecilda Oclay
Poscablo am
baby girl Gravida 1 Parity 1 Hospital Delivery
(1001)

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, KIMBERLY M.
Name of Student
(Signature Over Printed Name)
GRACE Z. JOVELLANOS CRESENCIO C. QUINTO JR. JOCELYN G. MACARAEG MRS. VIRGINIA V. MENDOZA
Chief Nurse Clinical Coordinator Qualified Faculty Dean, College of Nursing
Mapandan Community Date signed : Mapandan Community Date Signed :
Hospital Degree : B.S.N., R.N., Hospital Degree : R.N., M.A.Ed., M.A.N., Ed.D.
Date Signed : M.A.N. Date Signed : a) PRC No. : 0042414
Degree : R.N., M.A.N. in a). PRC No. : 0292288 Degree : B.S.N., R.N., Valid Until : April 29, 2011
progress Valid Until : July 18, 2011 M.A.N. b) PNA No. : 378
a) PRC No. : 0064042 b). PNA No. : 013897 a). PRC No. : 0254320 Valid Until : Lifetime
Valid Until : October 31, Valid Until : September 23, c) ADPCN No. : 190
Valid Until : September 2010 2012 Valid Until : December 31, 2010
16, 2011 b). PNA No. : 018456
b) PNA No. : 013853 Valid Until : October 31,
2010
 Valid Until : October 31,
2010
c) ANSAP No. : 09-0050

Valid Until : December

31, 2010_
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

III. Actual Deliveries

Time
Supervised by:
No Case Name of of Gender Name of Type of
Diagnosis Age Date of Delivery Name/Signature
. No. Mother Deliver of Baby Hospital Delivery
of Qualified C.I.
y
Pregnancy Uterine Full Term,
Nilda De Western Normal
Cephalic delivered to an alive Mrs. Violeta
1 180009 Guzman 40 April 12, 2010 2:10 pm Male Pangasinan Spontaneous
baby boy Gravida 12 Gutierrez
Lacibal District Hospital Delivery
Parity 11 (110111)
Pregnancy Uterine Full Term,
Western Normal
Cephalic delivered to an alive April Corpuz Mrs. Violeta
2 182467 17 July 10, 2010 2:09 pm Male Pangasinan Spontaneous
baby boy Gravida 1 Montemayor Gutierrez
District Hospital Delivery
Parity 1 (1001)
Pregnancy Uterine 36-37 weeks
Ailyn Western Normal
Age of Gestation, Cephalic 11:38 Mrs. Violeta
3 183164 Bagonza 17 July 30, 2010 Female Pangasinan Spontaneous
delivered to alive an baby girl am Gutierrez
Delizo District Hospital Delivery
Gravida 1 Parity 1 (1001)

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, KIMBERLY M. MA. CONCEPCION H. CRESENCIO C. QUINTO JR. ALMA P. CARRERA MRS. VIRGINIA V. MENDOZA
Name of Student MIRANDA Clinical Coordinator Qualified Faculty Dean, College of Nursing
(Signature Over Printed Name) Chief Nurse Date signed : Western Pangasinan District Date Signed :
Western Pangasinan Degree : B.S.N., R.N., Hospital Degree : R.N., M.A.Ed., M.A.N., Ed.D.
District Hospital M.A.N. Date Signed : a) PRC No. : 0042414
Date signed : a). PRC No. : 0292288 Degree : B.S.N., R.N., Valid Until : April 29, 2011
Degree : R.N., M.A.N Valid Until : July 18, 2011 M.A.N. b) PNA No. : 378
a). PRC No. : 0068019 b). PNA No. : 013897 a). PRC No. : 0311104 Valid Until : Lifetime
Valid Until : March 26, Valid Until : October 31, Valid Until : March 21, c) ADPCN No. : 190
2011 2010 2012 Valid Until : December 31, 2010
b). PNA No. : 10441 b). PNA No. : 061983
 Valid Until : Lifetime Valid Until : October 31,
c). ANSAP No. : 0374 2010
Valid Until : Lifetime
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

IV. Assisted Deliveries

Supervised by:
No Case Name of Date of Time of Gender Name of Type of
Diagnosis Age Name/Signature of
. No. Mother Delivery Delivery of Baby Hospital Delivery
Qualified C.I.
Pregnancy Uterine Full Term,
Eastern Normal
10-88- Cephalic delivered to an alive Precy H. September 9,
1 23 10:15 pm Male Pangasinan Spontaneous Mrs. Rosalie Marron
38 baby boy Gravida 1 Parity 1 Ferrer 2010
District Hospital Delivery
(1001)
Pregnancy Uterine Full Term,
Bevilyn Eastern Normal
11-23- Cephalic delivered to an alive September 25,
2 Vicente 34 8:42 pm Male Pangasinan Spontaneous Mrs. Rosalie Marron
13 baby boy Gravida 3 Parity 3 2010
Dilan District Hospital Delivery
(3003)

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, KIMBERLY M.
Name of Student
(Signature Over Printed Name)
ROSALIA R. MATEO CRESENCIO C. QUINTO JR. JOCELYN G. MACARAEG MRS. VIRGINIA V. MENDOZA
Chief Nurse Clinical Coordinator Qualified Faculty Dean, College of Nursing
Eastern Pangasinan Date signed : Eastern Pangasinan District Date Signed :
District Hospital Degree : B.S.N., R.N., Hospital Degree : R.N., M.A.Ed., M.A.N., Ed.D.
Date signed : M.A.N. Date Signed : a) PRC No. : 0042414
Degree : R.N., M.A.N. a). PRC No. : 0292288 Degree : B.S.N., R.N., Valid Until : April 29, 2011
a). PRC No. : 0099313 Valid Until : July 18, 2011 M.A.N. b) PNA No. : 378
Valid Until : September b). PNA No. : 013897 a). PRC No. : 0254320 Valid Until : Lifetime
14, 2012 Valid Until : October 31, Valid Until : September 23, c) ADPCN No. : 190
b). PNA No. : 12125 2010 2012 Valid Until : December 31, 2010
Valid Until : Lifetime b). PNA No. : 018456
c). ANSAP No. : 0491 Valid Until : October 31,
Valid Until : Lifetime 2010
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

IV. Assisted Deliveries

Supervised by:
No Case Name of Date of Time of Gender Name of Type of
Diagnosis Age Name/Signature of
. No. Mother Delivery Delivery of Baby Hospital Delivery
Qualified C.I.
Pregnancy Uterine Full Term,
Magelyn Western Normal
Cephalic delivered to an alive Mrs. Violeta
1 183109 Mendez 20 July 30, 2010 7:59 am Female Pangasinan Spontaneous
baby girl, Pre-eclampsia Gutierrez
Biguas District Hospital Delivery
Gravida 1 Parity 1 (1001)
Pregnancy Uterine Full Term,
Arlyn Western Normal
Cephalic delivered to an alive Mrs. Violeta
2 183226 Abella 33 July 31, 2010 2:20 pm Male Pangasinan Spontaneous
baby boy Gravida 2 Parity 2 Gutierrez
Adanza District Hospital Delivery
(2002)

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, KIMBERLY M.
Name of Student
(Signature Over Printed Name)
MA. CONCEPCION H. CRESENCIO C. QUINTO JR. ALMA P. CARRERA MRS. VIRGINIA V. MENDOZA
MIRANDA Clinical Coordinator Qualified Faculty Dean, College of Nursing
Chief Nurse Date signed : Western Pangasinan District Date Signed :
Western Pangasinan Degree : B.S.N., R.N., Hospital Degree : R.N., M.A.Ed., M.A.N., Ed.D.
District Hospital M.A.N. Date Signed : a) PRC No. : 0042414
Date signed : a). PRC No. : 0292288 Degree : B.S.N., R.N., Valid Until : April 29, 2011
Degree : R.N., M.A.N Valid Until : July 18, 2011 M.A.N. b) PNA No. : 378
a). PRC No. : 0068019 b). PNA No. : 013897 a). PRC No. : 0311104 Valid Until : Lifetime
Valid Until : March 26, Valid Until : October 31, Valid Until : March 21, c) ADPCN No. : 190
2011 2010 2012 Valid Until : December 31, 2010
b). PNA No. : 10441 b). PNA No. : 061983
Valid Until : Lifetime Valid Until : October 31,
c). ANSAP No. : 0374 2010
Valid Until : Lifetime
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

V. Cord Dressing
Supervised by:
No Date Gender of
Case No. Name of Baby Name of Mother Age Name of Hospital Name &Signature of
. Performed Baby
Qualified C.I.
Al Crisostomo Caturo Pangasinan Provincial
1 24-15-54 August 8, 2010 Male Ritchel Caturo Gucal 29 Ms. Maria Jasmin Tugade
Gural Hospital

Pangasinan Provincial
2 24-30-87 August 14, 2010 Arvin Morales Bulatao Male Marivic Ferrer Bulatao 23 Ms. Maria Jasmin Tugade
Hospital

Pangasinan Provincial
3 24-47-08 August 27, 2010 Tonilyn R. Nanñasca Female Merlina R. Nanñasca 39 Ms. Maria Jasmin Tugade
Hospital

Pangasinan Provincial
4 24-97-94 August 28, 2010 Baby Girl De Loyola Female Maribel D. De Loyola 33 Ms. Maria Jasmin Tugade
Hospital

September 3, Romeo Alburo Pangasinan Provincial

5 24-62-18 Male Margie A. Pabillaran 23 Ms. Maria Jasmin Tugade
2010 Pabillaran Hospital

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, KIMBERLY M.
Name of Student
(Signature Over Printed Name)
GLORIA M. ERIVE
Assistant Chief Nurse
Pangasinan Provincial
Hospital
Date signed :
Degree : R.N., M.A.N.
a.) PRC No. : 0082420
Valid Until : December 5,
2010
b.) PNA No. : 11972
Valid Until : Lifetime
c.) ANSAP No. : 0469
Valid Until : Lifetime
CRESENCIO C. QUINTO JR. JODI S. DELA CRUZ MRS. VIRGINIA V. MENDOZA
Clinical Coordinator Qualified Faculty Dean, College of Nursing
Date signed : Pangasinan Provincial Date Signed :
Degree : B.S.N., R.N., Hospital Degree : R.N., M.A.Ed., M.A.N., Ed.D.
M.A.N. Date Signed : a) PRC No. : 0042414
a). PRC No. : 0292288 Degree : B.S.N., R.N., Valid Until : April 29, 2011
Valid Until : July 18, 2011 M.A.N. b) PNA No. : 378
b). PNA No. : 013897 a). PRC No. : 0179039 Valid Until : Lifetime
Valid Until : October 31, Valid Until : February 22, c) ADPCN No. : 190
2010 2012 Valid Until : December 31, 2010
b). PNA No. : 061503
Valid Until : October 31,
2010
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

III. Actual Deliveries

Time
Supervised by:
No Case Name of of Gender Name of Type of
Diagnosis Age Date of Delivery Name/Signature
. No. Mother Deliver of Baby Hospital Delivery
of Qualified C.I.
y
Pregnancy Uterine Full Term 39
weeks Age of Gestation, Mapandan Normal
Lara Pinto December 22, 12:20
1 02620 Cephalic delivered to an alive 18 Male Community Spontaneous Ms. Jessiel Santorum
Vinluan 2009 am
baby boy Gravida 1 Parity 1 Hospital Delivery
(1001)
Pregnancy Uterine Full Term 39
weeks Age of Gestation, Mapandan Normal
Marilou T. 10:12
2 00294 Cephalic delivered to an alive 19 February 5, 2010 Female Community Spontaneous Mrs. Grecilda Oclay
Poscablo am
baby girl Gravida 1 Parity 1 Hospital Delivery
(1001)

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, KIMBERLY M. GRACE Z. JOVELLANOS CRESENCIO C. QUINTO JR. JOCELYN G. MACARAEG MRS. VIRGINIA V. MENDOZA
Name of Student Chief Nurse Clinical Coordinator Qualified Faculty Dean, College of Nursing
(Signature Over Printed Name) Mapandan Community Date signed : Mapandan Community Date Signed :
Hospital Degree : B.S.N., R.N., Hospital Degree : R.N., M.A.Ed., M.A.N., Ed.D.
Date Signed : M.A.N. Date Signed : a) PRC No. : 0042414
Degree : R.N., M.A.N. in a). PRC No. : 0292288 Degree : B.S.N., R.N., Valid Until : April 29, 2011
progress Valid Until : July 18, 2011 M.A.N. b) PNA No. : 378
a) PRC No. : 0064042 b). PNA No. : 013897 a). PRC No. : 0254320 Valid Until : Lifetime
Valid Until : October 31, Valid Until : September 23, c) ADPCN No. : 190
Valid Until : September 2010 2012 Valid Until : December 31, 2010
16, 2011 b). PNA No. : 018456
b) PNA No. : 013853 Valid Until : October 31,
2010
Valid Until : October 31,
2010
c) ANSAP No. : 09-0050

Valid Until : December

31, 2010_
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

III. Actual Deliveries

Time
Supervised by:
No Case Name of of Gender Name of Type of
Diagnosis Age Date of Delivery Name/Signature
. No. Mother Deliver of Baby Hospital Delivery
of Qualified C.I.
y
Pregnancy Uterine Full Term,
Rosie Eastern Normal
Cephalic delivered to an alive September 23,
1 112233 Valenzuela 27 9:00 pm Male Pangasinan Spontaneous Mrs. Rosalie Marron
baby boy Gravida 1 Parity 1 2010
Diga District Hospital Delivery
(1001)

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, KIMBERLY M. ROSALIA R. MATEO CRESENCIO C. QUINTO JR. JOCELYN G. MACARAEG MRS. VIRGINIA V. MENDOZA
Name of Student Chief Nurse Clinical Coordinator Qualified Faculty Dean, College of Nursing
(Signature Over Printed Name) Eastern Pangasinan District Date signed : Eastern Pangasinan District Date Signed :
Hospital Degree : B.S.N., R.N., Hospital Degree : R.N., M.A.Ed., M.A.N., Ed.D.
Date Signed : M.A.N. Date Signed : a) PRC No. : 0042414
Degree : R.N., M.A.N. a). PRC No. : 0292288 Degree : B.S.N., R.N., Valid Until : April 29, 2011
. Valid Until : July 18, 2011 M.A.N. b) PNA No. : 378
a) PRC No. : 0099313 b). PNA No. : 013897 a). PRC No. : 0254320 Valid Until : Lifetime
Valid Until : October 31, Valid Until : September 23, c) ADPCN No. : 190
Valid Until : September 2010 2012 Valid Until : December 31, 2010
14, 2012 b). PNA No. : 018456
b) PNA No. : 12125 Valid Until : October 31,
Valid Until : Lifetime 2010
c) ANSAP No. : 0491
Valid Until : Lifetime
_
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: DE GUZMAN, KIMBERLY M.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): Not Applicable School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

II. Minor Operations

Supervised by:
No Date of Case Name of Operation Type of Name of
Diagnosis Name of Surgeon Name/Signature of
. Operation No. Patient Performed Anesthesia Hospital
Qualified C.I.
Rosie Eastern
September Right Mediolateral Local Dr. Josephine
1 112233 Valenzuela Episiorrhapy Pangasinan Mrs. Rosalie R. Marron
23, 2010 Episiotomy Anesthesia Guiang
Diga District Hospital

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

DE GUZMAN, ROSALIA R. MATEO CRESENCIO C. QUINTO JR. JOCELYN G. MACARAEG MRS. VIRGINIA V. MENDOZA
KIMBERLY M. Chief Nurse Clinical Coordinator Qualified Faculty Dean, College of Nursing
Name of Student Eastern Pangasinan District Date signed : Eastern Pangasinan District Date Signed :
(Signature Over Printed Hospital Degree : B.S.N., R.N., Hospital Degree : R.N., M.A.Ed., M.A.N.,
Name) Date signed : M.A.N. Date Signed : Ed.D.
Degree : R.N., M.A.N. a). PRC No. : 0292288 Degree : B.S.N., R.N., a) PRC No. : 0042414
a). PRC No. : 0099313 Valid Until : July 18, 2011 M.A.N. Valid Until : April 29, 2011
Valid Until : September 14, b). PNA No. : 013897 a). PRC No. : 0254320 b) PNA No. : 378
2012 Valid Until : October 31, Valid Until : September 23, Valid Until : Lifetime
b). PNA No. : 12125 2010 2012 c) ADPCN No. : 190
Valid Until : Lifetime b). PNA No. : 018456 Valid Until : December 31, 2010
c). ANSAP No. : 0491 Valid Until : October 31,
Valid Until : Lifetime 2010