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 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 0 1 2
Mixing IV’s 0 1 2
IV TPA 0 1 2
Replace fluids 0 1 2
Central lines 0 1 2
PICC lines 0 1 2
Broviac lines 0 1 2
Portacaths 0 1 2
Groshong 0 1 2
Hickman 0 1 2
Quinton 0 1 2
CVP 0 1 2
IVAC pumps 0 1 2
IMED pumps 0 1 2
Syringe 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-Neonate 0 1 2
Normal hemodynamic values-Infant 0 1 2
Normal hemodynamic values-Child 0 1 2
Normal hemodynamic values-Adolescent 0 1 2
Assessment 0 1 2
Heart sounds/murmurs 0 1 2
Central venous pressure 0 1 2
CARDIOVASCULAR (C0NT)
Debfibrillation/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
Bacterial endocarditis 0 1 2
Assist with pericardial tap 0 1 2
Cardiac arrest 0 1 2
Cardiac transplant 0 1 2
Cardiogenic shock 0 1 2
Cardiomyopathy 0 1 2
Congential heart disease/defects 0 1 2
Hypovolemic shock 0 1 2
Myocarditis 0 1 2
Post cardiac surgery 0 1 2
Post interventional cardiac cath 0 1 2
Pacemaker-Temporary 0 1 2
Pacemaker-Permanent 0 1 2
Pacemaker-Trans-thoracic 0 1 2
IABP 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
Amicdarone 0 1 2
Digoxin 0 1 2
Bumex 0 1 2
RESPIRATORY
Chest exam & ausculation 0 1 2
Crackles 0 1 2
Coarseness 0 1 2
Diminished 0 1 2
Tachypnea 0 1 2
Inspiratory/expiratory evaluation 0 1 2
Stridor 0 1 2
Wheezing 0 1 2
Dyspnea/SOB 0 1 2
RESPIRATORY - Oxygen Therapy
Nasal cannula 0 1 2
Face mask 0 1 2
Nebulizer 0 1 2
Oxyhood 0 1 2
Non-rebreather mask 0 1 2
Ambu bag and mask 0 1 2
ECMO (extracorporeal membrane
oxygenation) 0 1 2
ETCO2 monitoring 0 1 2
Blood Gases
Obtaining from arterial line 0 1 2
Arterial puncture 0 1 2
Heelstick 0 1 2
Interpretation of gases 0 1 2
Pulse oximetry 0 1 2
Medications
Aminophylline (Theophylline) 0 1 2
Prostaglandin 0 1 2
NEUROLOGICAL
Assessment-Neurological Status 0 1 2
Developmental level 0 1 2
Glasgow Coma Scale 0 1 2
Intracranial pressure monitoring 0 1 2
Hyper/hypo therma blanket 0 1 2
Bear hugger 0 1 2
Warming lights 0 1 2
Patient Care
Brain death/organ procurement 0 1 2
Coma 0 1 2
Encephalitis 0 1 2
Externalized VP shunt/reservoirs 0 1 2
Head trauma 0 1 2
Meningitis 0 1 2
Neuromuscular disease 0 1 2
Post neuromuscular disease 0 1 2
Spinal Cord injury 0 1 2
Status epilepticus 0 1 2
CNS infection 0 1 2
Hydrocephalus 0 1 2
Seizures 0 1 2
Cranial tumors 0 1 2
Assisting with LP 0 1 2
RESPIRATORY (CONT)
Retractions-Intercostal 0 1 2
Retractions-Subcostal 0 1 2
Retractions-Supraclavicular 0 1 2
Assist with intubation 0 1 2
Extubation 0 1 2
Patient Care
Asthma 0 1 2
Assist with broncoscopy 0 1 2
Assist with rapid induction 0 1 2
Bronchopulmonary Dysplasia 0 1 2
ENT surgery 0 1 2
Bronchitis 0 1 2
Croup 0 1 2
Cystic Fibrosis 0 1 2
Epiglottitis 0 1 2
Flail chest 0 1 2
Fresh tracheostomy 0 1 2
Hemothorax 0 1 2
Near drowning 0 1 2
Near SIDS 0 1 2
Pneumonia 0 1 2
Pulmonary Edema 0 1 2
Pneumothorax 0 1 2
RDS 0 1 2
RSV 0 1 2
Thoracentesis 0 1 2
Chest tubes-insertion/setup 0 1 2
Chest tubes-maintenance care 0 1 2
Chest tubes-removal 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
CPAP/BiPAP machines 0 1 2
High frequency jet ventilator 0 1 2
IMV 0 1 2
Weaning 0 1 2
Home ventilators 0 1 2
Apena monitro 0 1 2
NEUROLOGICAL - Medications
Administration of anti-convulsants 0 1 2
GASTROINTESTINAL
Assessment-abdominal 0 1 2
Assessment-nutritional 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
Test of occult blood 0 1 2
Patient Care
Fresh ostomy 0 1 2
Gastroenteritis 0 1 2
Severe dehydration 0 1 2
GE reflux 0 1 2
Anorexia/bulimia 0 1 2
GI bleeding 0 1 2
Hepatic failure 0 1 2
Necrotizing enterocolitis (NEC) 0 1 2
Pancreatitis 0 1 2
Post abdominal surgery 0 1 2
Stress ulcer 0 1 2
Surgical abdomen 0 1 2
ORTHOPEDICS
Specialized orthopedic bed 0 1 2
Traction 0 1 2
Care of Patient
Pinned fractures 0 1 2
Post vertebral surgery 0 1 2
Circulation checks for neurovascular
assessment 0 1 2
Craniofacial reconstruction 0 1 2
Multiple fractures 0 1 2
RENAL/GENITOURINARY
Assessment of fluid balances 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 supra-pubic catheter 0 1 2
Renal/Genitourinary - Patient Care
Acute renal failure 0 1 2
CAVH 0 1 2
Diabetes Insipidus (DI) 0 1 2
Hemodialysis 0 1 2
Hemolytic Uremic Syndrome (HUS) 0 1 2
Nephritis 0 1 2
Nephrotic syndrome 0 1 2
Peritoneal dialysis 0 1 2
Post renal transplant 0 1 2
Syndrome Inappropriate ADH (SIADH) 0 1 2
METABOLIC/ENDOCRINE
Diabetic ketoacidosis 0 1 2
Diabetes 0 1 2
Hyperbillirubinemia 0 1 2
Acid base imbalance 0 1 2
Thyroid dysfunction 0 1 2
Insulin pump 0 1 2
ONCOLOGY/HEMATOLOGY
Assessment 0 1 2
Nutritional status 0 1 2
Pain control 0 1 2
Reverse isolation 0 1 2
Interpretation of blood chemistry & counts 0 1 2
Patient Care
Acute tumor lysis syndrome 0 1 2
Bone marrow transplant 0 1 2
DIC 0 1 2
Fresh oncology surgery 0 1 2
Inpatient chemotherapy 0 1 2
Inpatient hospice 0 1 2
Leukemia 0 1 2
Malignant tumors 0 1 2
Radiation implants 0 1 2
Sickle cell anemia 0 1 2
AIDS 0 1 2
Anemia 0 1 2
Hemophilia 0 1 2
Pre/post splenectomy 0 1 2
Radiation therapy 0 1 2
Administration of Chemotherapy 0 1 2
ONCOLOGY/HEMATOLOGY -
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
Statis ulcers 0 1 2
Surgical wound healing 0 1 2
Air fluidized, low airloss beds 0 1 2
Sterile dressing changes 0 1 2
Wound care/irrigations 0 1 2
Patient Care
Burns 0 1 2
Pressure sores 0 1 2
Staged decubitus ulcers 0 1 2
Surgical wounds with drain(s) 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
IV conscious sedation 0 1 2
Epidural anesthesia 0 1 2
CARE OF THE DYING CHILD
Level of comfort/providing support 0 1 2
Knowledge of resources 0 1 2
MISCELLANEOUS
Knowledge of normal growth &
development 0 1 2
Recognize/report signs of child abuse 0 1 2
Anaphylactic shock 0 1 2
Application of restraints 0 1 2
Blunt trauma 0 1 2
Cardiogenic shock 0 1 2
Care of child with cognitve development
delay 0 1 2
Care of child with motor development
delay 0 1 2
Cleft lip and/or palate 0 1 2
Gun shot/open chest 0 1 2
Hypovolemic shock 0 1 2
Kawasaki disease 0 1 2
Multiple trauma 0 1 2
Near drowning 0 1 2
Penetrating trauma 0 1 2
Suicidal ideation/attempt 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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