Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
MEDICATION ADMINISTRATION
PO 0 1 2
Sub q 0 1 2
Rectal 0 1 2
Topical 0 1 2
Drops(i.e. eye, nose, ear) 0 1 2
IM 0 1 2
IV Push 0 1 2
IV Drip 0 1 2
Calculation of dosages 0 1 2
Emergency drugs actions & reactions 0 1 2
IV THERAPY
Start peripheral IV-angio cath 0 1 2
Start peripheral IV-butterfly 0 1 2
Assist with cutdown 0 1 2
Mixing IV’s 0 1 2
Rate calculation 0 1 2
Central Lines 0 1 2
PICC Lines 0 1 2
Broviac 0 1 2
Groshong 0 1 2
Hickman 0 1 2
Portacath 0 1 2
Quinton 0 1 2
IMED Pumps 0 1 2
IVAC Pumps 0 1 2
Syringe Pumps 0 1 2
Drawing blood from central line 0 1 2
Drawing venous blood 0 1 2
Lipids 0 1 2
PPN(peripheral parental nutrition) 0 1 2
ADMINISTRATION OF BLOOD & PRODUCTS
Cryoprecipitate 0 1 2
Packed red blood cells 0 1 2
Plasma/Albumin 0 1 2
Whole Blood 0 1 2
CARDIOVASCULAR
12 lead EKG interpretation 0 1 2
12 lead EKG setup & complete 0 1 2
Assessment 0 1 2
Ausculation (rate, rhythm, volume) 0 1 2
Heart sounds/murmurs 0 1 2
Interpretation of cardiac enzymes/isoenzymes 0 1 2
Interpretation of coagulation studies 0 1 2
Pulses/circulation checks 0 1 2
Arrhythmia interpretation 0 1 2
Lead placement 5 electrode 0 1 2
Lead placement: I, III, V-leads 0 1 2
Lead placement: Lead II & MCL 1 0 1 2
Cardioversion-assist 0 1 2
Cardioversion-perform 0 1 2
Defibrillation-assist 0 1 2
Defibrillation-perform 0 1 2
Doppler 0 1 2
Care of Patient
Abdominal aortic aneurysm repair 0 1 2
Acute MI 0 1 2
Cardiac arrest 0 1 2
Cardiac tamponade 0 1 2
Cardiomyopathy 0 1 2
Congestive Heart Failure 0 1 2
EP study & ablation 0 1 2
Fluid overload 0 1 2
Heart transplant 0 1 2
Immediate post open heart surgery 0 1 2
Infective endocarditis 0 1 2
Myocardial contusion 0 1 2
Pericarditis 0 1 2
Post AICD insertion 0 1 2
Post commissurotomy, valve repair & replacement 0 1 2
Post percutaneous balloon valvuloplasty 0 1 2
Post rotoblade 0 1 2
Post stent placement 0 1 2
Pre/post angioplasty 0 1 2
Pre/post cardiac cath 0 1 2
Assist/Set up Equipment & Procedures
Arterial line 0 1 2
Central line 0 1 2
PA catheter/Swan Ganz insertion 0 1 2
Open chest emergency 0 1 2
Pericardiocentesis 0 1 2
Transesophageal echocardiogram 0 1 2
Ventricular assist device (RVAD or LVAD) 0 1 2
Cardiac Equipment
Intra aortic-balloon pump 0 1 2
Automatic internal cardioverter 0 1 2
Defibrillator 0 1 2
CAVH-D 0 1 2
Pacemaker
External 0 1 2
Permanent 0 1 2
Temporary 0 1 2
Transthoracic (epicardial) 0 1 2
Hemodynamic Monitoring
Cardiac index 0 1 2
Cardiac output 0 1 2
CVP readings 0 1 2
Femoral sheath removal 0 1 2
MAP 0 1 2
PA/Swan-Ganz 0 1 2
PCW pressure 0 1 2
PVR 0 1 2
Radial A-line 0 1 2
SVO2 0 1 2
SVR 0 1 2
Medications
Amiodarone (Cordarone) 0 1 2
Atropine 0 1 2
Bretylium (Bretylol) 0 1 2
Digoxin (Lanoxin) 0 1 2
Diltiazem (Cardizem) 0 1 2
Dobutamine (Dobutrex) 0 1 2
Dopamine (Intropin) 0 1 2
Epinephrine (Adrenalin) 0 1 2
Esmolol (Brevibloc) 0 1 2
Heparin sc, IV drip 0 1 2
Inocor (Amrinone) 0 1 2
Lidocaine (Xylocaine) 0 1 2
Metoprolol (Lopressor) 0 1 2
Nipride (Nitroprusside) 0 1 2
Nitroclycerin (Tridil) 0 1 2
Procainamide (Pronestyl) 0 1 2
Reteplase recombinant (Retavase) 0 1 2
Streptokinase 0 1 2
TPA 0 1 2
Verapamil (Calan, Isoptin, Verelan) 0 1 2
RESPIRATORY
Chest exam & auscultation 0 1 2
Inspiratory/expiratory evaluation 0 1 2
Pleurevac or Thoraclex drainage system 0 1 2
Water seal drainage system 0 1 2
Care of Patient
Airway - establish 0 1 2
ARDS 0 1 2
Aspiration 0 1 2
Assist with extubation 0 1 2
Assist with intubation 0 1 2
Bronchoscopy 0 1 2
Chest trauma 0 1 2
Chest tubes-insertion/setup 0 1 2
Chest tubes-measuring output 0 1 2
Chest tubes-removal Mediastinal 0 1 2
Chest tubes-removal Plueral 0 1 2
Collection of sputum specimen 0 1 2
COPD 0 1 2
Cor pulmonale 0 1 2
Emergency tracheostomy 0 1 2
Laryngospasm 0 1 2
Lobectomy 0 1 2
Lung transplant 0 1 2
Near drowning 0 1 2
Pneumonectomy 0 1 2
Pneumonia 0 1 2
Pulmonary edema/hypertension 0 1 2
Pulmonary embolism 0 1 2
Status asthmaticus 0 1 2
Tension Pneumothorax 0 1 2
Thoracentesis 0 1 2
Thoracotomy 0 1 2
Tuberculosis 0 1 2
RESPIRATORY - Suctioning
Suction-endotracheal 0 1 2
Suction-nasopharyngeal 0 1 2
Suction-oropharyngeal 0 1 2
Suction-tracheostomy 0 1 2
Ventilator Care
External CPAP 0 1 2
High frequency jet ventilation 0 1 2
IMV 0 1 2
PEEP 0 1 2
Pressure support 0 1 2
Weaning modes 0 1 2
Oxygen Therapy
Ambu bag and mask 0 1 2
ET Tube 0 1 2
Face mask 0 1 2
Nasal cannula 0 1 2
Oximetry 0 1 2
Portable oxygen tanks 0 1 2
T-piece 0 1 2
Trach collar 0 1 2
Blood Gases
Obtaining from A-line 0 1 2
Obtaining from femoral artery 0 1 2
Obtaining from radial artery 0 1 2
Interpretation of gases 0 1 2
Blood Chemistry
Interpretation of results 0 1 2
Medications
Alupent (Metaproterenol sulfate) 0 1 2
Aminophylline (Theophylline) 0 1 2
Bronkosol (Isoetharine hydrocholride) 0 1 2
Corticosteriods 0 1 2
Ventolin (Albuterol) 0 1 2
NEUROLOGICAL - Assessment
Neurological status 0 1 2
Cerebellar function 0 1 2
Cranial nerves 0 1 2
Glasgow coma scale 0 1 2
Level of consciousness 0 1 2
Pathological reflexes 0 1 2
Reflex/motor deficits 0 1 2
Visual or communication deficits 0 1 2
Equipment & Procedures
Assist with Lumbar puncture 0 1 2
Halo traction/cervical tongs 0 1 2
Intracranial pressure monitoring 0 1 2
Nerve stimulator 0 1 2
Rotation bed 0 1 2
Seizure precautions 0 1 2
Spinal precautions 0 1 2
Stryker frame 0 1 2
Use of hyper/hypotermia blanket 0 1 2
Care of Patient
Aneurysm 0 1 2
Basal skull fracture 0 1 2
Closed head injury 0 1 2
Coma 0 1 2
CVA/TIA 0 1 2
DT’s 0 1 2
Encephalitis 0 1 2
Internalized VP shunts 0 1 2
Increased ICP 0 1 2
Meningitis 0 1 2
Metastatic tumor/intracranial tumor resection 0 1 2
Multiple sclerosis 0 1 2
Post craniotomy 0 1 2
Spinal cord injury 0 1 2
Ventriculostomy 0 1 2
Medications
Barbiturate induced coma 0 1 2
Decadron (Dexamethasone) 0 1 2
Dilantin (Phenytoin) 0 1 2
Epidural administration 0 1 2
Phenobarbital 0 1 2
Valium (Diazepam) 0 1 2
GASTROINTESTINAL
Assessment-abdominal/bowel sounds 0 1 2
Nutritional status 0 1 2
Interpretation of Blood Chemistry
Serum ammonia 0 1 2
Serum amylase 0 1 2
LFT’s 0 1 2
Equipment & Procedures
Insertion of nasogastric tube 0 1 2
Administratioin of tube feeding-gravity 0 1 2
Administration of tube feeding-pump 0 1 2
Flexible feeding tube (i.e. Dobhoff) 0 1 2
Balloon tamponade (Blakemore) 0 1 2
Salem sump to suction 0 1 2
Saline lavage 0 1 2
Management of
Gastrostomy tube 0 1 2
Jejunostomy tube 0 1 2
T-tube 0 1 2
Care of Patient
Bowel obstruction 0 1 2
Blunt trauma 0 1 2
Colostomy 0 1 2
ERCP 0 1 2
Esophageal bleeding 0 1 2
GI surgery 0 1 2
GI bleeding 0 1 2
Hepatitis 0 1 2
Ileostomy 0 1 2
Inflammatory bowel disease 0 1 2
Liver failure 0 1 2
Liver transplant 0 1 2
Pancreatitis 0 1 2
Paralytic ileus 0 1 2
Penetrating trauma 0 1 2
Medications
AquaMephyton (Vitamin K) 0 1 2
Inderal (Propranolol) 0 1 2
Kayexelate 0 1 2
Lactulose (Cephulac) 0 1 2
Pitressin (Vasopressin) 0 1 2
RENAL/GENITOURINARY
Assessment of fluid & electrolyte balance 0 1 2
Assessment of A-V fistula/shunt 0 1 2
Interpretation of serum electolytes 0 1 2
Interpretation of BUN & creatinine 0 1 2
Equipment & Procedures
Bladder irrigation-continuous 0 1 2
Bladder irrigation-intermittent 0 1 2
Insertion & care of 3 way foley 0 1 2
Insertion & care of foley catheter-female 0 1 2
Insertion & care of foley catheter-male 0 1 2
Supra-pubic catheter 0 1 2
Care of Patient
CAVH dialysis 0 1 2
Hemodialysis 0 1 2
Nephrectomy 0 1 2
Peritoneal dialysis 0 1 2
Renal failure 0 1 2
Renal rejection syndrome 0 1 2
Renal transplant 0 1 2
TURP 0 1 2
Urinary diversion (ileal conduit nephrostomy) 0 1 2
METABOLIC/ENDOCRINE
Insulin administration-IV drip 0 1 2
Insulin pump 0 1 2
Blood glucose monitoring
Interpretation of lab results-glucose 0 1 2
Interpretation of lab results-thyroid levels 0 1 2
Performing finger stick 0 1 2
Visual blood glucose strips 0 1 2
Care of Patient
Addison’s disease 0 1 2
Cushing’s syndrome 0 1 2
Diabetes insipidus 0 1 2
Diabetic ketoacidosis 0 1 2
Drug overdose 0 1 2
Hyperthyoidism (Grave’s disease) 0 1 2
Hypothyroidism 0 1 2
Insulin shock 0 1 2
Thyroidectomy 0 1 2
Thyroid gland disorders 0 1 2
WOUND & SKIN MANAGEMENT
Assessment-skin for impending breakdown 0 1 2
Assessment-stasis ulcers 0 1 2
Assessment-surgical wound healing 0 1 2
Wound & Skin - Equipment & Procedures 0 1 2
Air fluidized, low airloss beds 0 1 2
Sterile dressing changes 0 1 2
Wound care/irrigations 0 1 2
Care of Patient
Burns 0 1 2
Pressure sores 0 1 2
Staged decubitus ulcers 0 1 2
Traumatic wounds 0 1 2
PAIN MANAGEMENT
Assessment of pain level 0 1 2
IV conscious sedation 0 1 2
Patient controlled analgesia (PCA) 0 1 2
MISCELLANEOUS - Care of Patient
Anaphylactic shock 0 1 2
Disseminated intravascular coagulation (DIC) 0 1 2
Hypovolemic shock 0 1 2
Multi-system organ failure 0 1 2
Organ/tissue donation 0 1 2
Patient in restraints 0 1 2
Septic shock 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 (0-30 days) B= Infant (30 days-1 yr) C= Toddler (1-3 yrs) D=Preschool (4-5 yrs) E= School Age (6-12 yrs)
F=Adolescent (13-18 yrs) G= Young Adult (19-39 yrs) H= Middle Adult (40-64 yrs) I = Older Adult (65+ yrs)
A
B
C
D
E
F
G
H
I
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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By checking this box I understand that this is my electronic signature and all the information is correct and true.