Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
CLASSIFICATION OF NEOPLASMS
Anatomic/staging:
Tumor, Node, Metastasis (TNM) System 0 1 2
Benign 0 1 2
Histological:
Degree of differentiation 0 1 2
Type of tissue 0 1 2
Malignant 0 1 2
CANCER THERAPY - Care of patient
Radiation therapy/Type of radiation used:
Electromagnetic 0 1 2
Particulate 0 1 2
Alpha 0 1 2
Beta 0 1 2
Neutron 0 1 2
Pion(Pimeson) 0 1 2
Radiation therapy type:
Brachytherapy 0 1 2
External beam therapy 0 1 2
Interstitial RT 0 1 2
Systematic RT 0 1 2
Surgical intervention:
Bone marrow transplant:
Allogenic 0 1 2
Autologous 0 1 2
Syngenic 0 1 2
Curative surgery 0 1 2
Diagnostic surgery 0 1 2
Mechanical device insertion 0 1 2
Palliative surgery 0 1 2
Prophylactic surgery 0 1 2
Reconstructive or rehabitiaitive surgery 0 1 2
CHEMOTHERAPY - Administration
IM 0 1 2
IV-Implanted 0 1 2
IV-Peripheral 0 1 2
Intra-arterial infusion 0 1 2
Intracavitary infusion 0 1 2
Intrathecal injection 0 1 2
Instillation through ventricular reservoir 0 1 2
CHEMOTHERAPY - Administration (CONT)
Oral 0 1 2
SQ 0 1 2
Topical application 0 1 2
CHEMOTHERAPY - Equipment
Hickman catheter 0 1 2
Infusaid 0 1 2
Infuse-A-Port 0 1 2
Infusion pumps 0 1 2
Intraperitoneal port 0 1 2
Ommaya reservoir 0 1 2
PCA/CADD 0 1 2
PICC 0 1 2
Port-A-Cath 0 1 2
Tenckhoff catheter 0 1 2
Prevention/recognition/mgmt of extravasation 0 1 2
ANTINEOPLASTIC AGENTS
Alkylating agents:
Busulfan (Myleran) 0 1 2
Cholrambucil (Leukeran) 0 1 2
Cisplatin (Platinol) 0 1 2
Cyclophosphamide (Cytoxan, Neosar) 0 1 2
Mechlorethamine (Mustargen) 0 1 2
Knowledge of adverse reactions:
Alopecia 0 1 2
Glonadal suppression 0 1 2
Hematura 0 1 2
Hemorrhagic cystitis 0 1 2
Hyperuricemia 0 1 2
Ototoxicity 0 1 2
Antineoplastic antibiotics:
Bleomycin (Blenozane) 0 1 2
Dactinomycin (Actinomycin-D, Cosmegan) 0 1 2
Danorubicin (Cerubidine) 0 1 2
Doxorubicin (Adriamycin) 0 1 2
Knowledge of adverse reactions:
Alopecia 0 1 2
CHF 0 1 2
Cardiomyopathy 0 1 2
Gonadal suppression 0 1 2
Hyperuricemia 0 1 2
Phlebitis at infusion site 0 1 2
Stomatitis 0 1 2
Antimetabolites:
Cytarabine (ARCA-C,
Cytosine Arabinoside, Cytosar-U 0 1 2
Fluorouracil (5-FU, Adrucil,
Efudex, Fluoroplex) 0 1 2
Mercaptopurine (6-MP, Purinethol) 0 1 2
Knowledge of adverse reactions:
Alopecia 0 1 2
Diarrhea 0 1 2
Hepatotoxicity 0 1 2
Hyperuricemin 0 1 2
Photosensitivity 0 1 2
Stomatis 0 1 2
Hormonal antineopplastic agents:
Diethylstilbestrol (DES) 0 1 2
Megestrol (Megace, Pallace) 0 1 2
Prednisone (Deltasone) 0 1 2
Tamoxifen (Nolvadex) 0 1 2
Testosterone (Andro, Depo-Testosterone,
Testex) 0 1 2
Knowledge of Adverse reactions:
Edema 0 1 2
Gynecomastia 0 1 2
Hypercalcemia 0 1 2
Impotence 0 1 2
Knowledge of signs/symptoms of complications:
Dehydration 0 1 2
Extravasation 0 1 2
Nausea 0 1 2
Phlebitis 0 1 2
Vomiting 0 1 2
Lab Values:
Cell differential 0 1 2
Complete blood count 0 1 2
Platetet count 0 1 2
Leucovorin rescue protocol 0 1 2
Patient teaching 0 1 2
Vinca alkaloids:
Vinblastine (Velban) 0 1 2
Vincristine (Oncovin) 0 1 2
Vindesine (Eldisine-Canada only) 0 1 2
Knowledge of adverse reactions:
Alopecia 0 1 2
Anorexia 0 1 2
Constipation 0 1 2
Hyperuricemia 0 1 2
Peripheral neuopathy 0 1 2
Phlebitis at IV site 0 1 2
Stomatitis 0 1 2
Care of the Patient with Cancer of the:
GI tract 0 1 2
Head, neck, chest 0 1 2
Hematologic system 0 1 2
Reproductive tract 0 1 2
Skin:
Malignant melanomas 0 1 2
Nonmelanomas 0 1 2
Urinary tract 0 1 2
NUTRITION
Assess nutritional status:
24-hour dietary recall 0 1 2
Lab 0 1 2
Measurement of skin fold thickness 0 1 2
Support therapy programs:
Enteral tube feedings 0 1 2
Oral 0 1 2
Peripheral parenteral nutrition 0 1 2
NURSING MANAGEMENT
Nursing interventions for:
Alopecia 0 1 2
Anemia 0 1 2
Constipation 0 1 2
Diarrhea 0 1 2
Fatigue 0 1 2
Nausea & vomiting 0 1 2
Neutropenia 0 1 2
Pain 0 1 2
Stomatitis & mucositis 0 1 2
Thrombocytopenia 0 1 2
Working w/patient & family psychosocial needs:
Acute phase 0 1 2
Chronic Phase:
Continued treatment 0 1 2
During treatment 0 1 2
Terminal phase 0 1 2
Bereavement phase 0 1 2
After treatment (survivorship) 0 1 2
ONCOLOGIC EMERGENCIES - Care of Patient
Cardiac tamponade 0 1 2
Disseminated intravascular coagulation 0 1 2
Hypercalcmia 0 1 2
Organ obstruction 0 1 2
Sepsis 0 1 2
Spinal cord compression 0 1 2
Superior vena cava syndrome 0 1 2
Tumor lysis syndrome 0 1 2
SPECIALTY AREA
Acute care:
Adults 0 1 2
Pediatrics 0 1 2
Bone marrow unit 0 1 2
Cancer Center
Clinic 0 1 2
Home health care 0 1 2
Hospice 0 1 2
Physician’s office 0 1 2
Radiation 0 1 2
Research/clinical trials 0 1 2
Surgery 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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