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
Z-track 0 1 2
IV Push 0 1 2
IV Drip 0 1 2
Hyperalimentation-central 0 1 2
Hyperalimentation-peripheral 0 1 2
Lipids 0 1 2
Chemotherapy 0 1 2
Metered dose inhaler 0 1 2
Calculation of Pediatric dosages 0 1 2
IV THERAPY
Start peripheral IV - angio cath 0 1 2
Start peripheral IV - butterfly 0 1 2
Mixing IV’s 0 1 2
Replace fluids 0 1 2
Central Lines 0 1 2
PICC lines 0 1 2
Broviac lines 0 1 2
Portacath 0 1 2
Groshong 0 1 2
Hickman 0 1 2
Quinton 0 1 2
CVP monitoring 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
12 lead EKG interpretation 0 1 2
Ausculation (rate/rhythm) 0 1 2
Blood pressure-non invasive 0 1 2
Defibrillation/cardioversion 0 1 2
CARDIOVASCULAR (CONT)
Doppler 0 1 2
EKG interpretation 0 1 2
Heart sounds/murmurs 0 1 2
Non-invasive hemodynamic monitoring 0 1 2
Perfusion 0 1 2
Care of Patient
Bacterial endocarditis 0 1 2
Cardiac arrest 0 1 2
Cardiomyopathy 0 1 2
Congenital heart disease/defects 0 1 2
Congestive heart failure 0 1 2
Myocarditis 0 1 2
Pericarditis 0 1 2
Post cardiac surgery 0 1 2
Post interventional cardiac cath 0 1 2
Rheumatic fever 0 1 2
Shock 0 1 2
Medications
Digoxin 0 1 2
RESPIRATORY
Assessment 0 1 2
Breathing patterns and rate 0 1 2
Chest exam & ausculation 0 1 2
Chest pain 0 1 2
Cough/secretions/hemoptysis 0 1 2
Dyspnea/SOB 0 1 2
Inspiratory/expiratory evaluation 0 1 2
Retractions-Intercostal 0 1 2
Retractions-Subcostal 0 1 2
Retractions-Supraclavicular 0 1 2
Skin-color 0 1 2
Assist with intubation 0 1 2
Extubation 0 1 2
Care of Patient
Asthma 0 1 2
Bronchiolitis (RSV) 0 1 2
Bronchopulmonary Dysplasia 0 1 2
Croup/LTB 0 1 2
Cystic Fibrosis 0 1 2
RESPIRATORY - Care of Patient (CONT)
Epiglottis 0 1 2
Pertussis 0 1 2
Pneumonia 0 1 2
Pneumothorax 0 1 2
Pulmonary Edema 0 1 2
Suction-endotracheal 0 1 2
Tonsilitis 0 1 2
Tuberculosis 0 1 2
Chest physiotherapy 0 1 2
Chest tubes-insertion/setup 0 1 2
Chest tubes-maintenance care 0 1 2
Suction-bulb syringe 0 1 2
Suction-nasopharyngeal 0 1 2
Suction-oropharyngeal 0 1 2
Suction-tracheostomy 0 1 2
Tracheostomy care 0 1 2
Collection of sputum specimen 0 1 2
Apnea monitor 0 1 2
Oxygen Therapy
Ambu bag and mask 0 1 2
ETCO2 monitoring 0 1 2
Face mask 0 1 2
Inhalers 0 1 2
Nasal cannula 0 1 2
Nebulizer 0 1 2
Oxyhood 0 1 2
Portable Oxygen tank 0 1 2
Pulse oximetry 0 1 2
Trach collar 0 1 2
Blood Gases
Interpretation of gases 0 1 2
Medications
Alupent (Meraproteranol) 0 1 2
Aminophylline (Theopyhlline) 0 1 2
Isuprel (Isopreternol) 0 1 2
Ventolin (Albuterol) 0 1 2
NEUROLOGICAL
Assessment-Neurological status 0 1 2
Bear hugger 0 1 2
Developmental level 0 1 2
Hyper/hypo therma blanket 0 1 2
ICP monitoring 0 1 2
Intracranial pressure monitoring 0 1 2
Level of consciousness 0 1 2
Warming lights 0 1 2
Care of Patient
Assisting with LP 0 1 2
Battered child syndrome 0 1 2
Closed head trauma 0 1 2
CNS infection 0 1 2
Cranial tumors 0 1 2
Encephalitis 0 1 2
Febrile seizures 0 1 2
Meningitis 0 1 2
Multiple sclerosis 0 1 2
Multiple trauma 0 1 2
Near drowning 0 1 2
Neuromuscular disease 0 1 2
Seizures 0 1 2
Spinal Cord injury 0 1 2
Status epilepticus 0 1 2
Medications
Dilantin 0 1 2
Phenobarbital 0 1 2
Tegretol (Carbemazepine) 0 1 2
Valium (Diazepam) 0 1 2
GASTROINTESTINAL
Assessment - Abdominal 0 1 2
Assessment-nutritional 0 1 2
Assessment-bowel sounds 0 1 2
Penrose drain 0 1 2
Test for occult blood 0 1 2
GASTROINTESTINAL - Feedings
Bottle 0 1 2
Breast 0 1 2
Gastrostomy/button 0 1 2
I-tubes 0 1 2
Jejunal 0 1 2
Abdominal decompression devices 0 1 2
Gavage 0 1 2
Placement of gastrostomy/button tubes 0 1 2
Placement of jejunal tubes 0 1 2
Placement of nasogastric/orogastric tubes 0 1 2
Care of Patient
Anal fissure 0 1 2
Anorexia/bulimia 0 1 2
Bowel obstruction 0 1 2
Cleft lip/palate 0 1 2
Colostomy 0 1 2
Diaphragmatic hernia 0 1 2
Failure to thrive (FTT) 0 1 2
Gastroenteritis 0 1 2
GE reflux 0 1 2
GI bleeding 0 1 2
Ileostomy 0 1 2
Intestinal parasites 0 1 2
Necrotizing enterocolitis (NEC) 0 1 2
Post abdominal surgery 0 1 2
Pyloric stenosis 0 1 2
Severe dehydration 0 1 2
Ulcerative colitis 0 1 2
ORTHOPEDICS
Specialized orthodpedic bed 0 1 2
Traction 0 1 2
Patient care
Application of splints 0 1 2
Cast 0 1 2
Circulation checks for neurovascular
assessment 0 1 2
Clubfoot 0 1 2
Craniofacial reconstruction 0 1 2
Osteogenic sarcoma 0 1 2
ORTHOPEDICS - Patient care (CONT)
Osteomyelitis 0 1 2
Pinned fractures 0 1 2
Medications
Clonazepam (Klonopin) 0 1 2
Corticosteriods 0 1 2
RENAL/GENITOURINARY
Assessment of fluid balance 0 1 2
Interpretation of Lab Results
BUN 0 1 2
Creatine 0 1 2
Electrolysis 0 1 2
Urinalysis 0 1 2
Collection of urine specimens 0 1 2
Assist with supra-pubic tap 0 1 2
Insertion & care of foley catheter-female 0 1 2
Insertion & care of foley catheter-male 0 1 2
Patient Care
CAVH 0 1 2
Circumcision 0 1 2
ENT surgery 0 1 2
Glomerulonephritis 0 1 2
Hemodialysis 0 1 2
Hemolytic uremic syndrome (HUS) 0 1 2
Hypospadias 0 1 2
Ileal conduit uretal 0 1 2
Infantile polycystic disease 0 1 2
Kidney transplant 0 1 2
Nephrotic syndrome 0 1 2
Peritoneal dialysis 0 1 2
Renal failure 0 1 2
Urinary tract infection 0 1 2
Wilm’s tumor 0 1 2
METABOLIC/ENDOCRINE
Assessment of electrolyte balance 0 1 2
Blood glucose testing/evaluation 0 1 2
Thyroid studies-interpretation of results 0 1 2
METABOLIC/ENDOCRINE - Care of patient
Adrenal disorders 0 1 2
Cushings syndrome 0 1 2
Diabetes 0 1 2
Insulin pump 0 1 2
Pituitary disorders 0 1 2
Thyroid dysfunction 0 1 2
Medications
Growth hormone 0 1 2
Insulin 0 1 2
Thyroid 0 1 2
ONCOLOGY/HEMATOLOGY
Assessment 0 1 2
Nutritional status 0 1 2
Reverse isolation 0 1 2
Interpretation of blood chemistry & counts 0 1 2
Patient Care
Pre/post splenectomy 0 1 2
Anemia 0 1 2
Bone marrow transplant 0 1 2
Depressed immune system 0 1 2
DIC 0 1 2
Hemophilia 0 1 2
Hodgkin’s disease 0 1 2
Infectious mononucleosis 0 1 2
Inpatient chemotherapy 0 1 2
Leukemia 0 1 2
Malignant tumors 0 1 2
Radiation implants 0 1 2
Sickle cell anemia 0 1 2
Administration of Chemotherapy 0 1 2
Chemotherapy certification 0 1 2
ONCOLOGY/HEMATOLOGY - Medications
Prednisone 0 1 2
ONCOLOGY/HEMATOLOGY -
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
Air fluidized, low airloss beds 0 1 2
Statis ulcers 0 1 2
Sterile dressing changes 0 1 2
Surgical wound healing 0 1 2
Wound care/irrigations 0 1 2
Patient Care
Pressure sores 0 1 2
Staged decubitus ulcers 0 1 2
Surgical wounds with drain(s) 0 1 2
Traumatic wounds 0 1 2
Burns
1st degree 0 1 2
2nd degree 0 1 2
3rd degree 0 1 2
INFECTIOUS DISEASE MANAGEMENT
Interpretation of lab results-blood count 0 1 2
Fever management 0 1 2
Patient Care
AIDS 0 1 2
Common childhood-communicable
diseases 0 1 2
Cytomegalovirus (CMV) 0 1 2
Hepatitis 0 1 2
Kawasaki disease 0 1 2
Lyme disease 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/tolerance 0 1 2
Epidural anesthesia 0 1 2
IV conscious sedation 0 1 2
Narcotic analgesia 0 1 2
CARE OF THE DYING CHILD
Level of comfort/providing support 0 1 2
Knowledge of resources 0 1 2
MISCELLANEOUS
Application of restraints 0 1 2
Care of child with cognitive
developmental delay 0 1 2
Care of child with motor
developmental delay 0 1 2
Depression 0 1 2
Eye surgery 0 1 2
Ingestion of foreign body 0 1 2
Ingestions/overdose 0 1 2
Knowledge of normal growth &
development 0 1 2
Plastic surgery 0 1 2
Recognize/report signs of child abuse 0 1 2
Pyxis System 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)
A
B
C
D
E
F
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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