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 lines 0 1 2
Portacath 0 1 2
Groshong 0 1 2
Hickman 0 1 2
IVAC Pumps 0 1 2
IMED Pumps 0 1 2
Syringe Pumps 0 1 2
Drawing blood from central line 0 1 2
Drawing venous blood 0 1 2
ADMINISTRATION OF BLOOD & PRODUCTS
Autotransfusion 0 1 2
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
Assessment 0 1 2
Ausculation (rate, rhythm, volume) 0 1 2
CVP readings 0 1 2
Defibrillation/cardioversion 0 1 2
Doppler 0 1 2
EKG interpretation 0 1 2
Heart sounds/murmurs 0 1 2
CARDOVASCULAR -
CARDIAC Equipment & Procedures
Assist with insertion & set-up Arterial line 0 1 2
Assist with insertion & set-up Central line 0 1 2
Assist with insertion & set-up Pacemaker 0 1 2
Assist with insertion & set-up Swan-Ganz 0 1 2
Assist with pericardiocentesis 0 1 2
Medications
Adenosine (Adenocard) 0 1 2
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
Lasix (Furosemide) 0 1 2
Lidocaine (Xylocaine) 0 1 2
Nipride (Nitroprusside) 0 1 2
Nitroclycerin (Tridil) 0 1 2
Procainamide (Pronestyl) 0 1 2
Sodium bicarbonate 0 1 2
Thrombolytic therapy 0 1 2
RESPIRATORY
Chest exam & ausculation 0 1 2
Inspiratory/expiratory evaluation 0 1 2
Patient Care
Assist with intubation 0 1 2
Extubation 0 1 2
Measure peak flow 0 1 2
Chest tubes-measuring output 0 1 2
Chest tubes-insertion/setup 0 1 2
Chest tubes-removal 0 1 2
Aspiration 0 1 2
Collection of sputum specimen 0 1 2
COPD 0 1 2
Hemopneumothorax 0 1 2
Laryngospasm 0 1 2
Pneumonia 0 1 2
Pulmonary edema 0 1 2
Pulmonary embolism 0 1 2
Tension pneumothorax 0 1 2
Thoracentesis-Assist 0 1 2
RESPIRATORY - Patient Care (CONT)
Tuberculosis 0 1 2
Suction-endotracheal 0 1 2
Suction-nasopharyngeal 0 1 2
Suction-tracheostomy 0 1 2
Ventilator Care
Monitoring and maintenance 0 1 2
Pressure alarms 0 1 2
Oxygen Therapy
Ambu bag and mask 0 1 2
External CPAP 0 1 2
Face mask 0 1 2
Inhalers 0 1 2
Nasal cannula 0 1 2
Nebulizer 0 1 2
Non-rebreather mask 0 1 2
Portable oxygen tanks 0 1 2
T-piece 0 1 2
Trach collar 0 1 2
Blood Gases
Arterial line 0 1 2
Femoral artery 0 1 2
Radial artery 0 1 2
Interpretation of gases 0 1 2
Pulse oximetry 0 1 2
Medications
Aminophylline (Theophylline) 0 1 2
Bronkosol (Isoetharine hydrochloride) 0 1 2
Epinephrine (Adrenaline) 0 1 2
Isuprel (Isoproterenol hydrochloride) 0 1 2
Steriods 0 1 2
Terbutaline 0 1 2
NEUROLOGICAL
Assessment-Neurological Status 0 1 2
Assist with Lumbar puncture 0 1 2
Glasgow coma scale 0 1 2
Level of consciousness 0 1 2
Reflex/motor deficits 0 1 2
Visual or communication deficits 0 1 2
NEUROLOGICAL ASSESSMENT -
Increased ICP Management
Intracranial monitoring 0 1 2
Medications 0 1 2
Positioning 0 1 2
Regulation of ICP 0 1 2
Temperature control 0 1 2
Ventilation 0 1 2
Patient Care
Basal skull fracture 0 1 2
Closed head injury 0 1 2
CVA/TIA 0 1 2
DT’s 0 1 2
Encephalitis 0 1 2
Internalized VP shunts 0 1 2
Meningitis 0 1 2
Neuromuscular disease 0 1 2
Overdose 0 1 2
Seizures 0 1 2
Spinal cord injury 0 1 2
Medications
Decadron (Dexamethasone) 0 1 2
Dilantin (Phenytoin) 0 1 2
Mannitol (Osmitrol) 0 1 2
Phenobarbital 0 1 2
Solu-Medrol (Methylprednisolone
sodium succinate) 0 1 2
GASTROINTESTINAL
Assessment-abdominal/bowel sounds 0 1 2
Fluid balance
Nutritional status 0 1 2
Interpretation of blood chemistry 0 1 2
Equipment & Procedures
Insertion of nasogastric tube 0 1 2
Salem sump to suction 0 1 2
Saline lavage 0 1 2
Patient Care
Abdominal trauma 0 1 2
Bowel obstruction 0 1 2
GI bleeding 0 1 2
Hepatitis 0 1 2
GASTROINTESTINAL - GI Medications
Antiemetics 0 1 2
Antispasmodic 0 1 2
Charcoal 0 1 2
Ipecac 0 1 2
RENAL/GENITOURINARY
Assessment of fluid balance 0 1 2
Interpretation of lab results 0 1 2
Interpretation of BUN & creatinine 0 1 2
Interpretation of electrolytes 0 1 2
Collection of urine specimens 0 1 2
Insertion & care of foley catheter-female 0 1 2
Insertion & care of foley catheter-male 0 1 2
Patient Care
Acute renal failure 0 1 2
Peritoneal dialysis 0 1 2
Renal trauma 0 1 2
Urinary tract infectiton 0 1 2
METABOLIC/ENDOCRINE
Signs & symptoms of diabetic coma 0 1 2
Signs & symptoms of insulin reaction 0 1 2
Blood glucose monitoring
Interpretation of lab results-glucose 0 1 2
Electronic measuring devise 0 1 2
Performing finger stick 0 1 2
Patient Care
Diabetic ketoacidosis 0 1 2
Insulin 0 1 2
Oral hypoglycemics 0 1 2
ORTHOPEDICS
Circulation checks 0 1 2
Gait 0 1 2
Range of motion 0 1 2
Skin 0 1 2
Equipment & Procedures
Assist with cast placement 0 1 2
Support devices 0 1 2
Cane/crutches 0 1 2
Sling 0 1 2
Transfer boards 0 1 2
ORTHOPEDICS - Patient Care
Ankle brace 0 1 2
Ankle splint 0 1 2
Assist with closed fracture/dislocation
reduction 0 1 2
Cast 0 1 2
Knee immoblizer 0 1 2
Pinned fractures 0 1 2
Wrist splint 0 1 2
WOUND & SKIN MANAGEMENT
Application of steri strips 0 1 2
Assist with staples 0 1 2
Set-up and assist with sutures 0 1 2
Culdocentesis tray 0 1 2
Staple and suture removal 0 1 2
EENT
Set-up fluorescent/Woods lamp exam 0 1 2
Visual acuity 0 1 2
Equipment & Procedures
Application of eye patch 0 1 2
Ear irrigation 0 1 2
Morgan lens irrigation 0 1 2
Nasal packing 0 1 2
Removal of contact lens 0 1 2
TRAUMA/SHOCK
Champion trauma score 0 1 2
Poison index 0 1 2
Triage 0 1 2
Equipment & Procedures
Air transport of trauma patient 0 1 2
Application of mast suit 0 1 2
Ground transport 0 1 2
Patient Care
Bites, animal 0 1 2
Bites, human 0 1 2
Bites, venomous snake 0 1 2
Bites, venomous spider 0 1 2
Burns
Rule of nines 0 1 2
First degree 0 1 2
Second degree 0 1 2
Third degree 0 1 2
Dehydration 0 1 2
TRAUMA/SHOCK - Burns (CONT)
Electrocution 0 1 2
Gunshot/stab wound 0 1 2
Hazardous material exposure 0 1 2
Heat exhaustion/stroke 0 1 2
Hypothermia 0 1 2
Major trauma 0 1 2
Minor trauma 0 1 2
Radiation exposure 0 1 2
Shock Treatment
Anaphylactic 0 1 2
Cardiogenic 0 1 2
Hypovolemic 0 1 2
Neurogenic 0 1 2
Septic 0 1 2
Traumatic amputation 0 1 2
INFECTIOUS DISEASES
Interpretation of lab values 0 1 2
Fever management 0 1 2
Isolation 0 1 2
Care of the patient with AIDS 0 1 2
PAIN MANAGEMENT
Assessment of pain level 0 1 2
Epidural anesthesia/analgesia 0 1 2
IV conscious sedation 0 1 2
PEDIATRICS
Child abuse/recognition/reporting 0 1 2
Calculating emergency drug doses 0 1 2
Obtain consent to treat 0 1 2
Pediatric cardiopulmonary arrest 0 1 2
PEDIATRICS - Patient Care
Epiglottitis 0 1 2
Near drowning 0 1 2
Overdose/poison ingestion 0 1 2
Status asthmaticus 0 1 2
Status epilepticus 0 1 2
OB/GYN
Assist with pelvic exam 0 1 2
Equipment & Procedures
Pelvic tray 0 1 2
Rape kit 0 1 2
Reporting acts of violence 0 1 2
Patient Care
Abruptio placenta 0 1 2
DIC 0 1 2
Hemorrhage 0 1 2
Placenta previa 0 1 2
Precipitous delivery 0 1 2
Preeclampsia/eclampsia 0 1 2
Spontaneous abortion 0 1 2
PSYCHIATRIC
Crisis intervention 0 1 2
Upholding patient rights 0 1 2
Suicidal patient 0 1 2
Suicide precautions 0 1 2
MISCELLANEOUS
AMA procedures 0 1 2
Disaster protocols 0 1 2
Patient in restraints 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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