West Visayas State University Medical Center VENUE: Conference Room, 5th Floor, ANNEX Bldg.

VENUE: Conference Room, 5th Floor, ANNEX Bldg., WVSU Medical Center
Name of Hospital Offering I.V. Training Province/ Region: ILOILO
E. Lopez Street, Jaro, Iloilo City ANSAP Chapter: ILOILO
Address
Accomplished Requirements of:
Name of Registered Nurse: JAYMON L. NACIONALES PRC Number: O627769 Expiry Date: 11-30-2010
Date of I.V. Training Program Attended: NOVEMBER 4-6, 2010 I.V. Requirements: 3+3+2
Registration No. of Institution Offering the I.V. Training Program: O-39 (ANSAP)

I. Initiating/ Maintaining Peripheral I.V. Infusions

Patient Name of Patient Age Date Time Kind of Site Type Of Cannula Dose Rate Signature over Printed Name of
No. Infusion Certified Trainer/ Preceptor
55-13-10 SOURIBIO, JESON I. 19 Yrs old 12-02-10 11 AM PNSS LEFT METACARPAL VEIN GAUGE 22/ INTROCAN 1 LITER 40 CC/HR
37-07-01 SEPAYA, RITCHEL P. 42 Yrs old 12-02-10 2:35 PM D5NSS LEFT METACARPAL VEIN GAUGE 20/ INTROCAN 1 LITER 40CC/HR MONA LISA J. CABRERA R.N
12-213 MASALIHIT, CHARRY J. 30 Yrs old 12-03-10 10:10AM PNSS RIGHT METACRAPAL VEIN GSUGE 20/ INTROCAN 1 LITER 125 CC/HR License No: o31538

II. Administering Intra venous Drugs

Patient Name of Patient Age Date Time Drugs Incorporated Dose Diagnosis Signature over Printed Name of
No. Certified Trainer/ Preceptor
55-12-68 BARRIDO, VIRGIE L. 60 Yrs old 12-01-10 8 AM CEFAZOLIN 1 GRAM T/C RECTOSIGMOID MALIGNANCY
55-13-36 DEPAMAYLO, FREMA P. 8 Yrs old 12-01-10 10 AM RANITIDINE HYDROCHLORIDE 20 MG T/C APPENDICITIS
55-14-26 SARAYNO, JACONIMA S. 53 Yrs old 12-01-10 10:30 AM VITAMIN K 10 MG T/C BILIARY OBSTRUCTION SECONDARY TO MONA LISA J. CABRERA R.N.
CHOLEDOCHOLIATHIAIS License No: o31538

III. Administering and Maintaining Blood and Blood Components

Patient Name of Patient Age Date Time Volume/Blood/Co IV Insertion Type of Cannula Diagnosis Signature over Printed Name
No. mponents/Rate of Certified Trainer/ Preceptor
55-02-06 SALGADO, 71 Yrs old 12-04-10 11:10 AM 300CC PRBC O+/ LEFT CEPHALIC VEIN GAUGE CHF CLASS II SECONDARY TO IHD
ROGELIO R. 20 gtts/ minute 20/INTROCAN AORTIC INSUFFICIENCY
55-14-88 DIVINAGRACIA, 83 Yrs old 12-04-10 5:30 PM 226 PRBC O+/ 20 LEFT METACARPAL GAUGE CAP HR on TOP OF BA IN MONA LISA J. CABRERA R.N.
ANUNCIACION D. gtts/minute VEIN 20/INTROCAN EXXACERBATION License No: o31538
This is to certify that I had successfully performed the above requirements, as counter signed by the witnesses.

Received by: _______________________________________________________ Submitted by: JAYMON L. NACIONALES RN.

ANSAP Signature over Printed Name of RN

I.V. Therapy Certification Card No._____________________________________ Approved by: VIRGINIA J. GUBATANGA, RN., MAN
Issued by: __________________________Date:__________________________ Asst. Hosp. director for Nursing Services
Date of Submission: _________________________________________