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
Eye prophylaxis 0 1 2
IM 0 1 2
Z-track 0 1 2
IV Push 0 1 2
IV Drip 0 1 2
Calculation of dosages 0 1 2
Emergency drug actions & reactions 0 1 2
Hyperalimentation 0 1 2
Neonatal drug actions & reactions 0 1 2
IV THERAPY
Start peripheral IV - angio cath 0 1 2
Start peripheral IV - butterfly 0 1 2
Rate calculation 0 1 2
Mixing IV’s 0 1 2
Umbilical arterial line 0 1 2
Umbilical venous line 0 1 2
Percutaneous arterial line 0 1 2
Percutaneous venous line 0 1 2
Central Lines 0 1 2
PICC line insertion 0 1 2
Broviac lines 0 1 2
Portacath 0 1 2
Groshong 0 1 2
Hickman 0 1 2
Quinton 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
CARDIOVASCULAR
Assessment 0 1 2
Assessment (rate, rhythm) 0 1 2
Blood pressure/invasive (arterial line) 0 1 2
CARDIOVASCULAR (CONT)
Blood pressure/noninvasive 0 1 2
Perfusion 0 1 2
Heart sounds/murmurs 0 1 2
Central venous pressure 0 1 2
Defibrillation/cardioversion 0 1 2
EKG interpretation 0 1 2
Invasive hemodynamic monitoring 0 1 2
12 lead EKG interpretation 0 1 2
Swan-Ganz 0 1 2
Care of Patient
Cardiac arrest 0 1 2
Cardiac transplant 0 1 2
Cardiomyopathy 0 1 2
Congenital heart disease/defects 0 1 2
Hemodynamic instability 0 1 2
Hypovolemic shock 0 1 2
Post cardiac surgery 0 1 2
Post interventional cardiac cath 0 1 2
Medications
Dobutamine (Dobutrex) 0 1 2
Dopamine (Intropin) 0 1 2
Epinephrine (Adrenalin) 0 1 2
Nipride (Nitroprusside) 0 1 2
Sodium bicarbonate 0 1 2
RESPIRATORY
Chest exam & auscultation 0 1 2
Inspiratory/expiratory evaluation 0 1 2
Care of Patient
Assist with intubation 0 1 2
Extubation 0 1 2
Bronchopulmonary Dysplasia 0 1 2
Cardiogenic/hypovolemic shock 0 1 2
Diaphragmatic hernia 0 1 2
Fresh tracheostomy 0 1 2
Meconium aspiration 0 1 2
Persistent pulmonary hypertension (PPHN) 0 1 2
Pneumothorax 0 1 2
RDS 0 1 2
Respiratory failure 0 1 2
RESPIRATORY - Care of Patient (CONT)
Thoracentesis 0 1 2
Use of artificial surfactant 0 1 2
Chest tubes-insertion/setup 0 1 2
Chest tubes-removal 0 1 2
Collection of sputum specimen 0 1 2
Suction-bulb syringe 0 1 2
Suction-endotracheal 0 1 2
Suction-nasopharyngeal 0 1 2
Suction-oropharyngeal 0 1 2
Suction-tracheostomy 0 1 2
Tracheostomy care 0 1 2
Ventilator Care
CPAP/PEEP 0 1 2
High frequency jet ventilator 0 1 2
Home ventilators 0 1 2
IMV 0 1 2
Oscillating 0 1 2
Pressure ventilator 0 1 2
Volume ventilator 0 1 2
Weaning 0 1 2
Oxygen Therapy
Apnea monitor 0 1 2
Nasal cannula 0 1 2
Face mask 0 1 2
Nebulizer 0 1 2
Oxyhood 0 1 2
Tent 0 1 2
Trach collar 0 1 2
Non-rebreather mask 0 1 2
Ambu bag and mask 0 1 2
ECMO (extracorporeal membrane
oxygenation) 0 1 2
Blood Gases
Obtaining from arterial line 0 1 2
Arterial 0 1 2
Heelstick 0 1 2
Peripherial 0 1 2
Umbilical line 0 1 2
Interpretation of gases 0 1 2
Pulse oximetry 0 1 2
RESPIRATORY - Medications
Aminophylline (Theopyhlline) 0 1 2
Prostaglandin 0 1 2
NEUROLOGICAL
Assessment-Neurological status 0 1 2
Assist with Lumbar puncture 0 1 2
Intracranial pressure monitoring 0 1 2
Care of Patient
Brain death/organ procurement 0 1 2
Increased intracranial pressure 0 1 2
Externalized VP shunt/reservoirs 0 1 2
Meningitis 0 1 2
Seizures 0 1 2
Medications
Administration of anti-convulsants 0 1 2
GASTROINTESTINAL
Assessment - Abdominal 0 1 2
Assessment-Abdominal girth 0 1 2
Assessment-bowel sounds 0 1 2
Assessment-palate 0 1 2
Assessment-suck/swallow 0 1 2
Placement of gastrostomy/button tubes 0 1 2
Feedings
Assist with breast feeding 0 1 2
Bottle 0 1 2
Breast milk handling/storage 0 1 2
Electric breast pump 0 1 2
Gavage 0 1 2
Placement of nasogastric/orogastric tubes 0 1 2
Placement of jejunal gastro tubes 0 1 2
Test for occult blood 0 1 2
Care of Patient
Cleft palate 0 1 2
Gastroenteritis 0 1 2
Colostomy/ileostomy 0 1 2
Gastroschisis/omphalocele 0 1 2
GI bleeding 0 1 2
Inguinal hernia 0 1 2
Necrotizing enterocolitis (NEC) 0 1 2
Post abdominal surgery 0 1 2
GASTROINTESTINAL - Care of Patient (CONT)
Reflux precautions 0 1 2
Tracheoesophageal (TEF) 0 1 2
Medications
Antiemetics 0 1 2
Antispasmodic 0 1 2
RENAL/GENITOURINARY
Assessment of fluid balance 0 1 2
Interpretation of lab results 0 1 2
Specific gravity 0 1 2
Collection of urine specimens 0 1 2
Insertion & care of foley catheter 0 1 2
Insertion & care of supra-pubic catheter 0 1 2
Assist with supra pubic tap 0 1 2
Care of patient
Acute renal failure 0 1 2
Malformations of the GU track/kidney 0 1 2
Peritoneal dialysis 0 1 2
METABOLIC/ENDOCRINE
Assessment of electrolyte balance 0 1 2
Interpretation of lab results-bilirubin 0 1 2
Interpretation of lab results-glucose 0 1 2
Interpretation of lab results-occult blood 0 1 2
Interpretation of lab results-pH 0 1 2
Interpretation of lab results-specific gravity 0 1 2
Care of Patient
Hyperbilirubinemia 0 1 2
Acid base imbalance 0 1 2
Phototherapy for jaundice 0 1 2
Disorders of internal/external organs 0 1 2
Drug addiction/withdrawal 0 1 2
Hypo/hyperkalemia 0 1 2
Hypo/hypernatremia 0 1 2
Infant of diabetic mother 0 1 2
ONCOLOGY/HEMATOLOGY
Assessment 0 1 2
Interpretation of blood chemistry & counts 0 1 2
Interpretation of culture reports 0 1 2
Interpretation of maternal lab results 0 1 2
ONCOLOGY/HEMATOLOGY - Care of patient
Hepatitis surface antigen+mother 0 1 2
HIV positive mother 0 1 2
DIC 0 1 2
Immunizations
HBIG 0 1 2
HBV 0 1 2
Polio 0 1 2
DPT 0 1 2
RespiGam/synergis prophylaxis 0 1 2
Administration of Blood Products
RBC 0 1 2
Platelets 0 1 2
Cryoprecipitate 0 1 2
FFP 0 1 2
Albumin/Plasma 0 1 2
Whole blood 0 1 2
WOUND & SKIN MANAGEMENT
Assessment of skin 0 1 2
Neonatal skin care 0 1 2
Cord care 0 1 2
Positioning devices 0 1 2
Thermoregulation
Isolette with humidity 0 1 2
Radiant warmer 0 1 2
Temperature (axillary, skin) 0 1 2
Weaning to open crib/bassinet 0 1 2
ISOLATION
Standard 0 1 2
Contact 0 1 2
Enteric 0 1 2
Respiratory 0 1 2
MRSA 0 1 2
VRE 0 1 2
PAIN MANAGEMENT
Assessment of pain level 0 1 2
Care of the neonate with sedation 0 1 2
MISCELLANEOUS
Normal growth and development
adaptations 0 1 2
Bereavement/postmortem care 0 1 2
Preparation for transport/transfer 0 1 2
GESTATIONAL AGE
Ballard 0 1 2
Dubowitz 0 1 2
Other 0 1 2
Screen for hearing loss 0 1 2
Maternal history 0 1 2
CONSENTS
Immunization 0 1 2
Procedural 0 1 2
Treatment 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/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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