Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
IV THERAPY
Start peripheral IV 0 1 2
Mixing IV’s 0 1 2
Assist with central line insertion 0 1 2
Maintain of central lines 0 1 2
PICC line 0 1 2
Broviac lines 0 1 2
Portacaths 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
Syring pumps 0 1 2
PCA pumps 0 1 2
Drawing blood from central line 0 1 2
Drawing venous blood 0 1 2
CARDIOVASCULAR
Normal hemodynamic values 0 1 2
Assist with insertion of arterial line 0 1 2
D/C arterial line 0 1 2
Arterial line blood draws 0 1 2
Assessment 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
Patient Care
Cardiac arrest 0 1 2
Cardiac transplant 0 1 2
Hypovolemic shock 0 1 2
Pacemaker-Permanent 0 1 2
Pacemaker-Temporary 0 1 2
Post cardiac surgery 0 1 2
Post interventional cardiac cath 0 1 2
Post-op abdominal aortic aneurysm patient 0 1 2
Post-op vacular patient 0 1 2
CARDIOVASCULAR - Doppler’s
Assess extremities for color, temp
sensation 0 1 2
Location of peripheral pulses 0 1 2
Medications
Dobutamine (Dobutrex) 0 1 2
Dopamine (Intropin) 0 1 2
Epinephrine (Adrenalin) 0 1 2
Nipride (Nitroprusside) 0 1 2
Nitroglycerine (Tridil) 0 1 2
Sodium bicarbonate 0 1 2
RESPIRATORY
Chest exam & auscultation 0 1 2
Inspiratory/expiratory evaluation 0 1 2
Assist with intubation 0 1 2
Assist with extubatioin 0 1 2
Patient Care
Chest tubes-maintenance care 0 1 2
Chest tubes-insertion/setup 0 1 2
ENT surgery 0 1 2
Fresh tracheostomy 0 1 2
Hemothorax 0 1 2
Pneumothorax 0 1 2
Suction-nasopharyngeal 0 1 2
Suction-oropharyngeal 0 1 2
Suction-tracheostomy 0 1 2
Ventilator 0 1 2
Airway Maintenance
Chin lift 0 1 2
Jaw thrust 0 1 2
Insertion or oral airway 0 1 2
Insertion of nasal airway 0 1 2
Removal of nasal or oral airway 0 1 2
Apnea monitor 0 1 2
Pulse oximetry 0 1 2
Oxygen Therapy
Nasal cannula 0 1 2
Face mask 0 1 2
RESPIRATORY - Masks
Venti 0 1 2
Non-rebreather mask 0 1 2
Aerosol 0 1 2
Ambu bag and mask 0 1 2
Blood Gases
Obtaining from arterial line 0 1 2
Arterial puncture 0 1 2
Interpretation of gases 0 1 2
NEUROLOGICAL
Assessment-Neurological status 0 1 2
Assess level of consciousness 0 1 2
Bear hugger 0 1 2
Hyper/hypo therma blanket 0 1 2
Intracranial pressure monitoring 0 1 2
Seizure precautions 0 1 2
Post-op craniotomy 0 1 2
Seizures 0 1 2
Administration of anti-convulsants 0 1 2
Administration of steroids 0 1 2
GASTROINTESTINAL
Assessment-abdominal 0 1 2
Placement of nasogastric/orogastric tubes 0 1 2
Patient Care
Enterostomy care 0 1 2
Fresh ostomy 0 1 2
Gastrostomy/jejunostomy 0 1 2
Liver transplant 0 1 2
Post-op abdominal surgery 0 1 2
Surgical abdomen 0 1 2
ORTHOPEDICS
Cast care 0 1 2
Circulation assessment 0 1 2
Continuous Passive motion 0 1 2
Traction 0 1 2
ORTHOPEDICS - Patient Care
Circulation checks for neurovascular
assessment 0 1 2
Multiple fractures 0 1 2
Pinned fractures 0 1 2
Post vertebral surgery 0 1 2
Post-op joint replacement 0 1 2
RENAL/GENITOURINARY
Assessment of fluid balance 0 1 2
Electrolyte implacement/replacement 0 1 2
Interpretation of lab results 0 1 2
GU irrigation 0 1 2
Insertion & care of foley catheter 0 1 2
Supra-pubic catheter care 0 1 2
Patient Care
Nephrostomy/suprapubic tubes 0 1 2
Renal transplant 0 1 2
TURP 0 1 2
Post renal transplant 0 1 2
METABOLIC/ENDOCRINE
Blood glucose testing 0 1 2
Patient Care
Diabetes 0 1 2
Insulin pump 0 1 2
ONCOLOGY/HEMATOLOGY
Assessment 0 1 2
Interpretation of blood chemistry & counts 0 1 2
Patient Care
Fresh oncology surgery 0 1 2
Hemophilia pre/post splenectomy 0 1 2
Administration of Blood Products
RBC 0 1 2
Platelets 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
Patient Care
Surgical wounds with drain’s 0 1 2
PAIN MANAGEMENT
Assessment of pain level/tolerance 0 1 2
IV Sedation
Morphine 0 1 2
Meperidine 0 1 2
Fentanyl 0 1 2
Epidural Anesthesia
Assist with insertion of epidural catheter 0 1 2
Assess epidural anesthesia level 0 1 2
Assess spinal anesthesia level 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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