Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
ASSESSMENT AND TEACHING
Pre dialysis Nursing Assessment 0 1 2
Patient Teaching 0 1 2
DIALYSIS EQUIPMENT SETUP
Bicarbonate Dialysate 0 1 2
Conductivity Testing 0 1 2
Primer Dialyzer 0 1 2
Machine/Alarm Checks 0 1 2
Initiate Dialysis Treatment 0 1 2
Vascular Access Prep 0 1 2
Dialysis 0 1 2
Fistula/Vein Graft 0 1 2
Collect Appropriate Blood Specimens 0 1 2
ANTICOAGULATION
Regular 0 1 2
Low Dose 0 1 2
No Heparin 0 1 2
MONITOR PATIENT & EQUIPMENT DURING DIALYSIS
Vital Signs 0 1 2
Volume Status 0 1 2
Vascular Access Function 0 1 2
Blood Flow Rate 0 1 2
Arterial and Venous Pressure 0 1 2
Level of consciousness 0 1 2
Subjective Response to Treatment 0 1 2
Anticoagulation 0 1 2
Conductivity 0 1 2
Drip Chamber Levels 0 1 2
Ultra Filtration Calcuation 0 1 2
Operation of Myron L Meter 0 1 2
Recirculation 0 1 2
ADMINISTRATION OF VOLUME EXPANDERS
Blood Transfusions 0 1 2
Albumin 0 1 2
Sequential 0 1 2
Normal Saline 0 1 2
Mannitol 0 1 2
DISCONTINUED DIALYSIS
Return of Blood 0 1 2
Dialysis Catheter 0 1 2
Fistula/Vein Graft 0 1 2
Post Treatment Access Care 0 1 2
DOCUMENTATION
Dialysis Flow Sheet 0 1 2
Lab Flow Sheet 0 1 2
Progressive Note 0 1 2
Machine Maintenance Sheet 0 1 2
ALARM CONDITIONS
Arterial Presssure 0 1 2
Venous Pressure Alarm 0 1 2
Blood Leak Alarm 0 1 2
High Temperature Alarm 0 1 2
Ultra Filtration Alarm 0 1 2
Air/Foam Detector Alarm 0 1 2
Power Failure Alarm 0 1 2
Ultra Filtration Controls Alarms 0 1 2
DIALYSIS COMPLICATIONS
Access Problems 0 1 2
Air Embolus 0 1 2
Blood Leak 0 1 2
Hemolysis 0 1 2
“Code” Situations 0 1 2
Seizures 0 1 2
Pyrogen Reactions 0 1 2
Clotted Dialyzer 0 1 2
Blood Transfusion Reactions 0 1 2
MACHINE TROUBLESHOOTING PROCEDURE
Air Leaks 0 1 2
Fluid Leaks 0 1 2
Blood Pump Failure 0 1 2
EQUIPMENT CLEAN-UP
Vinegar Procedure 0 1 2
Bleach Procedure 0 1 2
Sterilization Procedure 0 1 2
Proper Disposal of Supplies 0 1 2
Clean -Up of OR 0 1 2
OTHER
Blood Glucose Monitoring 0 1 2
YEARS OF EXPERIENCE IN
Pediatrics
Adult
PICU

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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