Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
PATIENT CARE
Bed Bath 0 1 2
Tub Bath 0 1 2
Shower 0 1 2
Skin Care: Back Rub, Apply Lotion 0 1 2
Decubitus Care 0 1 2
Shampoo 0 1 2
Nail Care 0 1 2
Oral Hygiene 0 1 2
Shaving: Safety/Electric Razor 0 1 2
Dressing - Assisting 0 1 2
Supine/Prone 0 1 2
Dressing - Complete 0 1 2
Perineal Care - Male 0 1 2
Perineal Care - Female 0 1 2
Care of Confused Patient 0 1 2
Care of Suicidal Patient 0 1 2
Care of Combative Patient 0 1 2
Post Mortem Care 0 1 2
ENVIRONMENT
Linen Change - Unoccupied Bed 0 1 2
Linen Change - Occupied Bed 0 1 2
Light Housekeeping 0 1 2
Meal/Snack Preparation 0 1 2
OSHA/JCAHO
Handwashing 0 1 2
Standard Precautions 0 1 2
Isolation Techniques 0 1 2
Patient’s Bill of Rights 0 1 2
TRANSFER/AMBULATION TECHIQUES
Gait Belt 0 1 2
Weight Bearing 0 1 2
Hoyer Lift 0 1 2
2-Person Transfer 0 1 2
Slide Board 0 1 2
Wheelchair 0 1 2
Cain 0 1 2
Walker/Crutches 0 1 2
POSITIONING/TURNING
Fowler’s (Sitting) 0 1 2
Lateral (Side Lying) 0 1 2
Use of Draw Sheet 0 1 2
Range of Motion (ROM) 0 1 2
Up In Chair 0 1 2
Supine/Prone 0 1 2
TAKE AND RECORD VITAL SIGNS
Temperature - Axillary 0 1 2
Temperature - Oral 0 1 2
Temperature - Rectal 0 1 2
Pulse - Radial 0 1 2
Pulse - Apical 0 1 2
Pulse - Brachial 0 1 2
Blood Pressure 0 1 2
Respirations 0 1 2
Height and Weight 0 1 2
NUTRITION/HYDRATION
Encourage Fluids 0 1 2
Assist in Feeding 0 1 2
Feeding Techniques 0 1 2
Measure and Record Input 0 1 2
Measure and Record Output 0 1 2
BOWEL & BLADDER (ELIMINATION)
Bed Pan/Urinal & Fracture Pan 0 1 2
Bedside Commode 0 1 2
Measure and Record Output 0 1 2
Foley Catheter Care 0 1 2
External Catheter Care 0 1 2
Enemas: Tap, H2O, Fleets, Soap Suds 0 1 2
Colostomy Care 0 1 2
MISCELLANEOUS SAFETY DEVICES/EQUIPMENT
Admitting Patients 0 1 2
Discharging Patients 0 1 2
CPR 0 1 2
Choking 0 1 2
Resuscitation 0 1 2
Blood Glucose Monitor 0 1 2
SPECIMEN COLLECTION
Urine 0 1 2
Stool 0 1 2
Sputum 0 1 2
OXYGEN
Flow Rate 0 1 2
Water to Humidifier 0 1 2
Cannula/Mask Placement 0 1 2
OBSERVATION/REPORTING/DOCUMENTATION
Change in Body Function 0 1 2
Change in Behavior 0 1 2
Change in Routines 0 1 2
Charting on Graphics Sheets 0 1 2
Charting on Nurse Notes 0 1 2
SAFETY DEVICES/EQUIPMENT
Padded Side Rails 0 1 2
Use of Restraints 0 1 2
Ace Bandage 0 1 2
Cast Care 0 1 2
Hot / Cold Packs 0 1 2
Bed Scale 0 1 2
CPM / Ortho 0 1 2
Traction 0 1 2

Age Specific Practice Criteria
Please check the appropriate boxes below for each group for which you have experience in providing age-appropriate nursing care.
A=Newborn/Infant(Birth - 1 Year) B= Pediatric/Adolescent(1-18 Yrs) C=Adultt(19-64 Yrs) D=Geriatric(65 + Yrs)
A
B
C
D
Able to adapt care to incorporate normal growth and development.
Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.
Able to ensure a safe environment to reflect needs and alter environment accordingly.
Able to administer medications appropriately and understand different meds, dosages, and possible side effects.
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