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
Drawing blood from central line 0 1 2
PICC line insertion 0 1 2
PICC line discontinue 0 1 2
Broviac lines 0 1 2
Groshong 0 1 2
Hickman 0 1 2
Portacath 0 1 2
Quinton 0 1 2
IVAC Pumps 0 1 2
IMED Pumps 0 1 2
Syringe Pumps 0 1 2
Drawing venous blood 0 1 2
Lipids 0 1 2
TPN 0 1 2
PPN(peripheral parental nutrition) 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
Assessment (rate, rhythm) 0 1 2
Doppler 0 1 2
Heart sounds/murmurs 0 1 2
Interpretation of coagulation studies 0 1 2
Pulse/circulation checks 0 1 2
Care of Patient
Abdominal aortic bypass 0 1 2
Aneurysm 0 1 2
Angina 0 1 2
Cardiac arrest 0 1 2
Cardiomyopathy 0 1 2
Carotid endarterectomy 0 1 2
Congestive heart failure 0 1 2
Femoral-popliteal bypass 0 1 2
Myocarditis 0 1 2
Open sternal wound 0 1 2
Post acute MI (24-48 hours) 0 1 2
Post angioplasty 0 1 2
Post-cardiac cath 0 1 2
Post-cardiac surgery 0 1 2
Precardiac cath 0 1 2
Sickle cell anemia 0 1 2
Thrombophlebitis 0 1 2
Medications
Oral & IVP antihypertensives 0 1 2
Oral & topical nitrates 0 1 2
Oral anticoagulants 0 1 2
Atropine 0 1 2
Digoxin 0 1 2
Heparin sc, IV drip 0 1 2
Inderal 0 1 2
NTG 0 1 2
Pronestyl 0 1 2
RESPIRATORY - Assessment
Chest exam & ausculation 0 1 2
Chest pain 0 1 2
Cough/secretions/hemoptysis 0 1 2
Inspiratory/expiratory evaluation 0 1 2
Skin-color 0 1 2
RESPIRATORY - Assessment (CONT)
Endotracheal 0 1 2
Nasopharyngeal 0 1 2
Tracheostomy 0 1 2
Oxygen Therapy
Ambu bag and mask 0 1 2
External CPAP 0 1 2
Face mask 0 1 2
Incentive spirometry 0 1 2
Inhalers 0 1 2
Nasal cannula 0 1 2
Oximetry 0 1 2
Portable oxygen tanks 0 1 2
Trach collar 0 1 2
Blood Gases
Interpretation of results 0 1 2
Blood Chemistry
Interpretation of results 0 1 2
Care of Patient
Airway-establish 0 1 2
ARDS 0 1 2
Aspiration 0 1 2
Assist with intubation 0 1 2
Asthma 0 1 2
Bronchoscopy 0 1 2
Chest physiotherapy 0 1 2
Chest tubes-insertion/setup 0 1 2
Chest tubes-measuring output 0 1 2
Chest tubes-removal 0 1 2
Collection of sputum specimen 0 1 2
COPD 0 1 2
Emphysema 0 1 2
Inhalation injuries 0 1 2
IPPB 0 1 2
Lobectomy 0 1 2
Pneumonectomy 0 1 2
Pneumonia 0 1 2
Pneumothorax 0 1 2
Pulmonary edema 0 1 2
Pulmonary embolism 0 1 2
RESPIRATORY - Care of Patient (CONT)
Thoracentesis-assist 0 1 2
Post-op Thoracotomy 0 1 2
Tracheostomy-care/maintenance 0 1 2
Tracheostomy-fresh 0 1 2
Tuberculosis 0 1 2
Medications
Alupent (Metaproterenol sulfate) 0 1 2
Aminophylline (Theopyhlline) 0 1 2
Bronchial inhalers 0 1 2
Bronkosol (Isoetharine hydrochloride) 0 1 2
Steriods 0 1 2
Ventolin (Albuterol) 0 1 2
NEUROLOGICAL - Assessment
Glasgow coma scale 0 1 2
Level of consciousness 0 1 2
Motor function/ROM/strength 0 1 2
Neurological status 0 1 2
Pupil checks 0 1 2
Visual or communications deficits 0 1 2
Equipment & procedures
Assist with Lumbar puncture 0 1 2
Rotation bed 0 1 2
Seizure precautions 0 1 2
Use of hyper/hypothermia blanket 0 1 2
Care of Patient
Alzheimer’s disease 0 1 2
Aneurysm 0 1 2
Closed head injury 0 1 2
Coma 0 1 2
Cranial hemorrhage 0 1 2
CVA/TIA 0 1 2
DT’s 0 1 2
Encephalitis 0 1 2
Head injury/head trauma 0 1 2
Meningitis 0 1 2
Multiple sclerosis 0 1 2
Neuro injury/trauma 0 1 2
Neuro surgery pre & post 0 1 2
Care of Patient (CONT)
Neuromusclar disease 0 1 2
Overdose 0 1 2
Post Craniotomy 0 1 2
Post-op AV shunt 0 1 2
Seizures 0 1 2
Spinal cord injury 0 1 2
Medications
Antidepressants 0 1 2
Carbamazepine (Tegretol) 0 1 2
Clonazepam (Klonopin) 0 1 2
Decadron (Dexamethasone) 0 1 2
Dilantin (Phenytoin) 0 1 2
Nonopiod analgesic 0 1 2
Opiods 0 1 2
Phenobarbital 0 1 2
Solu-Medrol (Methylprednisolone) 0 1 2
Valium (Diazepam) 0 1 2
Versed 0 1 2
GASTROINTESTINAL - Assessment
Assessment - Abdominal/bowel sound 0 1 2
Fluid balance 0 1 2
Nutritional status 0 1 2
Equipment & Procedures
Administration of tube feeding - gravity 0 1 2
Administration of tube feeding - pump 0 1 2
Flexible feeding tube (i.e. Dobhoff) 0 1 2
Guaiac test 0 1 2
Insertion of nasogastric tube 0 1 2
Lavage 0 1 2
Measuring abdominal girth 0 1 2
Salem sump to suction 0 1 2
Throat swab 0 1 2
T-tubes, drains 0 1 2
Management of
Gastrostomy tube 0 1 2
Jejunostomy tube 0 1 2
T-tube 0 1 2
GASTROINTESTINAL - Care of Patient
Bowel obstruction 0 1 2
Colostomy 0 1 2
ERCP 0 1 2
Esophageal bleeding 0 1 2
GI bleeding 0 1 2
GI surgery 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
Ostomy appliances 0 1 2
Ostomy irrigation 0 1 2
Pancreatitis 0 1 2
Paralytic ileus 0 1 2
Whipple procedure 0 1 2
Wound dehiscence 0 1 2
Medications
Antiemetics 0 1 2
Antispasmodic 0 1 2
RENAL/GENITOURINARY - Assessment
Fluid & electrolyte balance 0 1 2
A-V fistula/shunt 0 1 2
Interpretation of chemistries 0 1 2
Interpretation of lab results 0 1 2
Urination 0 1 2
Equipment & Procedures
3-way catheter 0 1 2
Bladder irrigation - continuous 0 1 2
Bladder irrigation - intermittent 0 1 2
Collection of urine specimens, routine, 24 hr 0 1 2
Insertion & care of foley catheter - female 0 1 2
Insertion & care of foley catheter - male 0 1 2
Nephrostomy tube care 0 1 2
Supra-pubic catheter 0 1 2
Care of patient
Cystoscopy 0 1 2
Hemodialysis 0 1 2
Nephrectomy 0 1 2
Peritoneal dialysis 0 1 2
Renal failure 0 1 2
Renal transplant 0 1 2
Renal trauma 0 1 2
Shunts & fistulas 0 1 2
TURP 0 1 2
Urinary diversion/ileal conduit 0 1 2
Urinary tract infection 0 1 2
METABOLIC/ENDOCRINE - Assessment
Signs & symptoms of diabetic coma 0 1 2
Signs & symptoms of insulin reaction 0 1 2
Glucometers 0 1 2
Blood Glucose Monitoring
Interpretation of lab results-glucose 0 1 2
Insulin pumps 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
Diabetes insipidus 0 1 2
Diabetes mellitus 0 1 2
Hyperthroidism (Grave’s disease) 0 1 2
Hypothyroidism 0 1 2
Pancreatitis 0 1 2
Post thyroidectomy 0 1 2
Medications
Antihyperglycemics 0 1 2
Hormone preparations 0 1 2
IM Vasopressin (Pitressin) 0 1 2
Insulin 0 1 2
Steriods-adrenocorticosteriods 0 1 2
GYNECOLOGY - Assessment
Gynecology system 0 1 2
Procedures & Equipment
Ectopic pregnancy 0 1 2
Endometriosis 0 1 2
Hysterectomy 0 1 2
Mastectomy 0 1 2
Repair of cyctocle/rectocele 0 1 2
Tubal ligation 0 1 2
ORTHOPEDICS - Assessment
Circulation checks 0 1 2
Joints-inspection/palpation 0 1 2
Mobility/gait 0 1 2
Positioning 0 1 2
Posture 0 1 2
Transfers 0 1 2
Equipment & Procedures
Continuous passive machine 0 1 2
Crutches-use 0 1 2
Gait training 0 1 2
K-pad 0 1 2
Prosthetics 0 1 2
Range of motion 0 1 2
Splints/immobilizers 0 1 2
Use of assistive devices 0 1 2
Traction
Bryants 0 1 2
Bucks 0 1 2
Halo 0 1 2
Skin/skeletal 0 1 2
Tongs 0 1 2
Care of Patient
Amputation 0 1 2
Arthoscopic surgery 0 1 2
Cast 0 1 2
Cast removal 0 1 2
Cervical collar 0 1 2
Laminectomy 0 1 2
Lumbar brace 0 1 2
Ortho trauma 0 1 2
Osteoporosis 0 1 2
Pinned fractures 0 1 2
Removal of hardware 0 1 2
Rheumatic/arthritic disease 0 1 2
Spika/body cast 0 1 2
Total hip replacement 0 1 2
Total knee replacement 0 1 2
INFECTIOUS DISEASES - Assessment
Effect on body systems 0 1 2
Isolation/standard precautions 0 1 2
Obtaining blood cultures 0 1 2
Obtaining CSF cultures 0 1 2
Obtaining wound cultures 0 1 2
Care of Patient
Abscesses 0 1 2
Bacteremia/septic shock 0 1 2
HIV 0 1 2
MRSA 0 1 2
Parasitic infection 0 1 2
Systemic fungal/richettsial diseases 0 1 2
Viral infection 0 1 2
VRE 0 1 2
Medications
Antibacterial drugs 0 1 2
Antiviral drugs/HIV drugs 0 1 2
Immunizations 0 1 2
Immunoglobulin/antitoxins 0 1 2
WOUND & SKIN MANAGEMENT - Assessment
Skin for impending breakdown 0 1 2
Stasis ulcers 0 1 2
Surgical wound healing 0 1 2
Equipment & Procedures
Air fluidized, low airloss beds 0 1 2
Pressure relief boots/devices 0 1 2
Skin care 0 1 2
Sterile dressing changes 0 1 2
Wound care/irrigations 0 1 2
Wound culture-obtaining 0 1 2
WOUND & SKIN MANAGEMENT -
Care of Patient (CONT)
Burns 0 1 2
Necrotizing fasciitis 0 1 2
Pressure sores 0 1 2
Shingles 0 1 2
Staged decubitus ulcers 0 1 2
Surgical wounds with drain(s) 0 1 2
Traumatic wounds 0 1 2
PAIN MANAGEMENT
Anesthesia/analgesia 0 1 2
Assessment of pain level 0 1 2
Epidural anesthesia/analgesia 0 1 2
IV conscious sedation 0 1 2
Narcotic analgesia 0 1 2
Patient controlled analgesia (PCA) 0 1 2
MISCELLANEOUS
Bone marrow transplant 0 1 2
Chemotherapy 0 1 2
Diabetic teaching 0 1 2
Obtaining consents 0 1 2
Oncology 0 1 2
Patient in restraints 0 1 2
Plastic surgery-post-op 0 1 2
Radiation implants 0 1 2
Radiation therapy 0 1 2
Suture/staple removal 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=Adolescent (13-18 yrs) B=Young Adult (19-39 yrs) C=Middle Adult (40-64 yrs) D=Older Adult (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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