Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
| AGE OF PATIENTS CARED FOR | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Newborn/Neonate (birth to 30 days) |
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| Infant (1 month to 1 year) |
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| Toddler (1 year to 3 years) |
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| Preschooler (3 years to 5 years) |
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| School Age Child (5 years to 12 years) |
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| Adolescents (12 years to 18 years) |
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| Young Adults (18 years to 39 years) |
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| Middle Adults (39 years to 64 years) |
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| Older Adults (64 years to 79 years) |
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| Elderly Adults (over 79+ years) |
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| GENERAL SKILLS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Care of Patient in Restraints |
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| Automated Med Dispensing Systems |
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| Electronic Documentation |
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| Access/Management of Implanted Ports |
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| Access/Management of Central Lines |
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| Titration of Drips |
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| Administration of Blood/Blood Products |
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| Knowledge of Current IV Therapy Guidelines |
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| Knowledge of Anatomy |
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| Moderate Conscious Sedation |
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| Sedation Reversal Agents |
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| INSERTION OF | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Peripheral IV – Adult |
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| Peripheral IV – Child |
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| Peripheral IV – Neonate |
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| Vein Selection – Peripheral IVs |
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| Interosseous Needles |
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| MIDLINE/PICC LINES | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Midline Catheter Insertion – Adult |
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| Midline Catheter Insertion – Child |
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| Indications for Midline/PICC Placement |
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| Contraindications for Midline/PICC Placement |
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| Vein Selection |
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| Measuring Technique |
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| Catheter and Introducer Device Selection |
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| Correct Tip Placement |
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| Insertion Technique – Basic (Vein) |
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| Insertion Technique – Seldinger |
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| Insertion Technique – Ultrasound |
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| Assist with Insertion in Interventional Radiology |
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| Insertion Site Preparation |
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| Maintaining Sterile Field |
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| Securing Insertion Site Post Placement |
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| X-Ray Assessment for Tip Location |
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| Repositioning After X-Ray |
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| CARE AND MAINTENANCE | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Peripheral IV |
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| Scalp IV |
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| Heparin/Saline Lock |
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| Groshong PICC |
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| Groshong CVL |
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| Hickman/Broviac |
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| Port-a-Cath |
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| Vascath |
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| Multilumen Catheters |
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| Subclavian Line |
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| IJ Line |
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| Femoral Line |
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| Power PICC |
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| Power Port |
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| Dressing Changes |
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| Cap Changes |
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| Flushing Lines (Frequency/Solution) |
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| MEDICATION ADMINISTRATION | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Chemotherapy |
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| Heparin |
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| Streptokinase |
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| TPA (Alteplase) |
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| Lidocaine |
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| TPN/Lipids |
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| Ativan |
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| Valium |
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| Versed |
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| Fentanyl |
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| EQUIPMENT | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| IV Pumps |
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| Needleless Systems |
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| Blood Warmer |
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| PCA Pumps |
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| Pressure Lines |
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| TROUBLESHOOTING/ COMPLICATIONS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Repair PICC |
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| Repair Midline |
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| Air Embolism |
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| Bleeding |
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| Brachial Plexus Injury |
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| Cardiac Arrhythmia |
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| Cardiac Tamponade |
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| Catheter Erosion |
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| Catheter Embolism |
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| Catheter Occlusion |
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| Catheter-Related Sepsis |
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| Endocarditis |
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| Exit Site Infection |
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| Exit Site Necrosis |
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| Extravasation |
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| Hematoma |
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| Laceration of Vessels or Viscus |
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| Myocardial Erosion |
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| Perforation of Vessels or Viscus |
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| Phlebitis |
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| Catheter Tip Malposition or Retraction |
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| Thromboembolism |
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| Venous Thrombosis |
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| Ventricular Thrombosis |
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| Vessel Erosion |
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| Declotting Peripheral Site |
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| Complications from Sedation |
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| DISCONTINUING IV THERAPY | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Peripheral IVs |
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| PICC/Midline |
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| Central Lines |
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