Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
CARDIAC
Assessment skills 0 1 2
Identification of Arrhythmias 0 1 2
Apical Pulse Rate Rhythm 0 1 2
Holter Monitor 0 1 2
Cardiac Arrest 0 1 2
CPR 0 1 2
Pacemaker 0 1 2
Care of Patient With
Hypertension 0 1 2
Acute MI 0 1 2
CHF 0 1 2
Aneurysm 0 1 2
Pre-post Surgery 0 1 2
Fluid Retention 0 1 2
Patient Teaching for the Following Drugs
Digoxin 0 1 2
Cardizem 0 1 2
Lasix 0 1 2
Dyazide 0 1 2
Coumadin 0 1 2
NTG 0 1 2
Inderal 0 1 2
Potassium Supplements 0 1 2
Diuretics 0 1 2
Antihypertensive Meds 0 1 2
RESPIRATORY
Assessment/Ausculation of Lung Sounds 0 1 2
Identifying Rales, Rhonchi 0 1 2
Principals of Chest Percussion 0 1 2
Establishing an Airway 0 1 2
Oxygen via Nasal Cannula 0 1 2
Face Mask 0 1 2
Ultrasonic Nebulizer 0 1 2
Care of Home Ventilator patients 0 1 2
Care of Patient With
COPD 0 1 2
Tracheostomy 0 1 2
Lung Cancer 0 1 2
Pulmonary Emboli 0 1 2
Patient Teaching for the Following Drugs
Aminophylline 0 1 2
Bronkosol 0 1 2
Brethine 0 1 2
NEUROLOGY
Assessment of Neuro Signs 0 1 2
Seizure Precautions 0 1 2
Traction 0 1 2
Care of Patient With
Seizure activity 0 1 2
Overdose 0 1 2
Spinal Cord Injury 0 1 2
Neuro trauma 0 1 2
Stroke (CVA) 0 1 2
Patient Teaching for the Following Drugs
Dilantin 0 1 2
Decadron 0 1 2
Phenobarbital 0 1 2
Valium 0 1 2
VASCULAR
Assessment of Vascular System 0 1 2
Peripheral Pulses 0 1 2
Fluid Overload 0 1 2
Starting IV’s 0 1 2
Heparin Locks 0 1 2
TPN/Hyperalimentation 0 1 2
Knowledge of Normal Serum Lab Values 0 1 2
Obtaining Venous Blood Samples 0 1 2
Administration of Blood & Blood Products 0 1 2
Infusion Pumps 0 1 2
Hickman/Broviac Catheters 0 1 2
Port-a-caths 0 1 2
Dialysis 0 1 2
Patient Teaching for the following drugs 0 1 2
I.V. Infusions 0 1 2
GASTROINTESTINAL
NG Tube 0 1 2
Gastrostomy Tube 0 1 2
T-Tube 0 1 2
G.I. Bleed 0 1 2
Colostomy Care 0 1 2
Dehiscence 0 1 2
Tube Feedings 0 1 2
GENITOURINARY
Foley Catheter Insertion 0 1 2
Ileostomy 0 1 2
G.U. Irrigations 0 1 2
Nephrostomy Tube 0 1 2
Suprapubic Catheter 0 1 2
Care of Patient With
Shunts and Fistulas 0 1 2
Straight Catherization 0 1 2
Incontinence 0 1 2
GYNECOLOGY
Endometriosis 0 1 2
Self Breast Exam 0 1 2
Mastectomy 0 1 2
Hysterectomy 0 1 2
ORTHOPEDIC
Total Knee Replacement 0 1 2
Bucks Extension 0 1 2
Crutch Walking 0 1 2
Assistive Devices 0 1 2
Total Hip Replacement 0 1 2
Arthroscopy/Arthrotomy 0 1 2
Care of Patient With
Amputation 0 1 2
Trauma 0 1 2
Skeletal Traction 0 1 2
SKIN
Assessment skills 0 1 2
Wound Care (Sterile) 0 1 2
Wound Care (Aseptic) 0 1 2
Irrigation of Wounds 0 1 2
Decubitus Care 0 1 2
Patient Teaching Skills of wound care 0 1 2
OTHER
Oncology 0 1 2
Chemotherapy 0 1 2
Isolation Techniques 0 1 2
Burn Patients 0 1 2
Documentation of skilled care 0 1 2
Medicare 485.486 forms 0 1 2
PATIENT TEACHING SKILLS OF
Diabetic teaching 0 1 2
Insulins 0 1 2
Glucometers 0 1 2
MATERNAL - Child Care
Assessment & care of complicated
pregnancy 0 1 2
Home care of postpartun mother 0 1 2
Healthy baby 0 1 2
NEONATE CARE
Suction 0 1 2
Eye prophylaxis 0 1 2
Collect cord blood samples 0 1 2
NEWBORN CARE
Neonatal Level I 0 1 2
Neonatal Level II 0 1 2
Neonatal Level III 0 1 2
Draw blood from U-Line 0 1 2
Suction with catheter 0 1 2
Cord and circumsion care 0 1 2
Phototherapy 0 1 2
NG Feedings 0 1 2
Administer blood & blood products 0 1 2
Use of Equipment
Cardiac monitors 0 1 2
Apnea monitors 0 1 2
Oxyhood 0 1 2
Ventilators 0 1 2
PEDIATRICS
Calculations of Pedi Dosage 0 1 2
Starting IV Therapy 0 1 2
Scalp veins 0 1 2
Apnea monitor 0 1 2
Cardiac monitor 0 1 2
CPR-Infant/Child 0 1 2
Preparation of Emergency Drugs 0 1 2
Tracheostomy Care & Suctioning 0 1 2
Assist with Lumbar Puncture 0 1 2
Use of oxygen 0 1 2
Use of Croup tents 0 1 2
Use of Ventilators 0 1 2
EQUIPMENT
Bear I 0 1 2
Bear II 0 1 2
Bear V 0 1 2
Bennett 7200 0 1 2
CPAP 0 1 2
Emerson 0 1 2
Engstrom/Erica 0 1 2
EMV 0 1 2
MA-I 0 1 2
MA-II 0 1 2
Monihan 0 1 2
Ohio 560 0 1 2
PEEP 0 1 2
Pressure Pre-Set 0 1 2
Servo 900b 0 1 2
Servo 900c 0 1 2
Servo 900e 0 1 2
Siemens 0 1 2
Hewlett-Packard 0 1 2
Spacelab 0 1 2
Marquette 0 1 2
Mennen 0 1 2
Lifecare 0 1 2
Nihon-Koder 0 1 2
Care of Patient With
Asthma 0 1 2
Bone marrow transplant 0 1 2
Broncho-Pulmonary Dysplasia 0 1 2
Cardiac Surgery 0 1 2
CHF 0 1 2
Cystic Fibrosis 0 1 2
Diabetes Mellitus 0 1 2
Epiglottitis 0 1 2
Failure to thrive 0 1 2
Leukemia 0 1 2
Care of Patient With
Meningitis 0 1 2
Near drowning 0 1 2
Overdose/Poison Ingestion 0 1 2
PDA Ligation 0 1 2
Post Harrington Rod Insertion 0 1 2
RDS 0 1 2
Reye Syndrome 0 1 2
Sickle Cell Disease 0 1 2
Spina Bifida 0 1 2
Tracheoesophogeal Fistula 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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