54039531 ANSAP IVT Accomplished Requirements Form 3 3 2

3+3+2 AC COMPLISHED R EQUIR EMEN TSof 3-D A YBASIC IN TR A VEN O T H ER A TRA IN IN GPROGR A M for NURSES US PY Name of Registered Nurse: Edward D. Wong Name of Hospital offering I V Training: St. Dominic Medical Center Date of I V Training Program Attended: September 16-18, 2011 I. Initiating/ Maintaining Peripheral IV Infusion s Patient No. Kind of Infusion Type of Cannula Signature over Printed name of Certified Trainer/Preceptor/RN PRC No. 0714828 Provider No.: 080 Venue: St. Dominic College of Asia Name of Patient Age Date Time Site Left Metacarpal Right Metacarpal Left Cephalic Dose Rate License No. 174934 175171 83655 Jeremias, Amitiel P. Say, Magdalena J. Vecino, Rosario P. 3 84 85 9/28/11 12:15pm 9/28/11 1:25 pm 9/28/11 1:40 pm NaCl PNSS PNSS G24 G18 G18 500cc 61-62 gtts/min 1 Liter 40-41 gtts/min 1 Liter 20-21 gtts/min Audrey San Jose, RN Audrey San Jose, RN Audrey San Jose, RN 09-00523 09-00523 09-00523 II. Administering Intravenou s Drugs Patient No. Name of Patient Age Date Time Drug Incorporated Dose Diagnosis Signature over Printed name of Certified Trainer/Preceptor/RN License No. 83611 83611 83600 Legaspi, Anita R. Legaspi, Anita R. Colminar, Ernie D. 75 75 13 CAP t/c Musculoskeletal Strain 9/28/11 8:00 am Furosemide 40 mg CAP t/c Musculoskeletal Strain 9/28/11 9:00 am Cefuroxime 750 mg Benzyl t/c PTB, malnutrition 9/28/11 12:00pm 1 million ‘U’ Penicillin t/c electrolyte imbalance Audrey San Jose, RN Audrey San Jose, RN Audrey San Jose, RN 09-00523 09-00523 09-00523 III. Administering and Maintaining Blood and Blood Components Patient No. Volume/ Blood Type/ Components/ Rate Name of Patient Age Date Time Site of IV Insertion Left Cephalic Diagnosis Hypertensive Nephrosclerosis Signature over Printed name of Certified Trainer/Preceptor/RN License No. 83740 Lilia Macatangay 79 10/17/11 2:40 pm 1 U/ FWB/ B+/ x4 Hours Audrey San Jose, RN 09-00523 Submitted by:____________________Date Submitted:__________Received by:_________________Approved by: Hazel N. Villagracia, RN, MAN, EdD (Signature over Printed Name) ce Director of Nursing Servi (Signature over Printed Name)