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
IV Push 0 1 2
IV Drip 0 1 2
Calculation of dosages 0 1 2
Emergency drug actions & reactions 0 1 2
IV THERAPY
Start peripheral IV - angio cath 0 1 2
Start peripheral IV - butterfly 0 1 2
Assists with cutdown 0 1 2
Rate calculation 0 1 2
Mixing IV’s 0 1 2
Central Lines 0 1 2
PICC line insertion 0 1 2
PICC line discontinue 0 1 2
PICC line care 0 1 2
Broviac 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
TPN 0 1 2
PPN (peripheral parental nutrition) 0 1 2
Lipids 0 1 2
ADMINISTRATION OF BLOOD & PRODUCTS
Autotransfusion 0 1 2
Cryoprecipitate 0 1 2
Packed red blood cells 0 1 2
Plasma/Albumin 0 1 2
Whole blood 0 1 2
CARDIOVASCULAR
12 lead EKG interpretation 0 1 2
Assessment 0 1 2
Auscultation (rate, rhythm, volume) 0 1 2
Interpretation of coagulation studies 0 1 2
Heart sounds/murmurs 0 1 2
Pulses/circulation checks 0 1 2
Arrhythmia interpretation 0 1 2
Lead placement 5 electrode 0 1 2
Lead placement: I, III, V-leads 0 1 2
Lead Placement: Lead II & MCL 1 0 1 2
CVP readings 0 1 2
Cardioversion - assist 0 1 2
Cardioversion - perform 0 1 2
Defibrillation - assist 0 1 2
Defibrillation - perform 0 1 2
Doppler 0 1 2
Care of Patient
Acute MI - post 24-48 hours 0 1 2
Aneurysm 0 1 2
Angina 0 1 2
Cardiac arrest 0 1 2
Cardiomyopathy 0 1 2
Carotid endarterectomy 0 1 2
Congestive Heart Failure 0 1 2
Femerol-popliteal bypass 0 1 2
Post angioplasty 0 1 2
Post CABG (24 hours) 0 1 2
Pre cardiac cath 0 1 2
Post cardiac cath 0 1 2
Pre stent placement 0 1 2
Post stent placement 0 1 2
Equipment & Procedures
Assist with insertion & set-up Arterial Line 0 1 2
Assist with insertion & set-up Central Line 0 1 2
Assist with insertion & set-up Pacemaker 0 1 2
Assist with insertion & set-up Swan-Ganz 0 1 2
Assist with pericardiocentesis 0 1 2
CARDIOVASCULAR - HEMODYNAMIC MONITORING
A-line radial 0 1 2
Swan Ganz monitoring 0 1 2
Femoral artey sheath removal 0 1 2
Medications
Adenosine (adenocard) 0 1 2
Admiodarone (Cordarone) 0 1 2
Atropine 0 1 2
Bretylium (Bretylol) 0 1 2
Digoxin (Lanoxin) 0 1 2
Diltiazem (Cardizem) 0 1 2
Dobutamine (Dobutrex) 0 1 2
Dopamine (Intropin) 0 1 2
Epinephrine (Adrenalin) 0 1 2
Heparin sc, IV drip 0 1 2
Lidocaine (Xylocaine) 0 1 2
Nipride (Nitroprusside) 0 1 2
Nitroglycerin (Tridil) 0 1 2
Oral & IVP antihypertensives 0 1 2
Oral & topical nitrates 0 1 2
Thrombolytic therapy 0 1 2
Verapamil (Calan, Isoptin, Verelan) 0 1 2
RESPIRATORY
Chest exam & ausculation 0 1 2
Inspiratory/expiratory evaluation 0 1 2
Care of Patient
Assist with intubation 0 1 2
Airway - establish 0 1 2
Assist with extubation 0 1 2
Chest physiotherapy 0 1 2
Chest tubes - insertion/setup 0 1 2
Chest tubes - measuring output 0 1 2
Chest tubes - removal 0 1 2
Aspiration 0 1 2
Asthma 0 1 2
Collection of sputum specimen 0 1 2
ARDS 0 1 2
Asthma 0 1 2
Bronchoscopy 0 1 2
COPD 0 1 2
Fresh tracheostomy 0 1 2
Lobectomy 0 1 2
Pneumonectomy 0 1 2
Pneumonia 0 1 2
RESPIRATORY - Care of Patient (CONT)
Pneumothorax 0 1 2
Pulmonary edema 0 1 2
Pulmonary embolism 0 1 2
Status asthmaticus 0 1 2
Thoracentesis - Assist 0 1 2
Thoracotomy 0 1 2
Tracheostomy care 0 1 2
Tuberculosis 0 1 2
Suctioning
Suction - endotracheal 0 1 2
Suction - nasopharyngeal 0 1 2
Suction - oropharyngeal 0 1 2
Suction - tracheostomy 0 1 2
Ventilator care
Monitoring and maintenance 0 1 2
Weaning modes 0 1 2
Oxygen Therapy
Ambu bag and mask 0 1 2
ET Tube 0 1 2
Face mask 0 1 2
Inhalers 0 1 2
Incentive spirometry 0 1 2
Nasal Cannula 0 1 2
Nebulizer 0 1 2
Non-rebreather mask 0 1 2
Oximetry 0 1 2
Portable oxygen tank 0 1 2
T-piece 0 1 2
Trach collar 0 1 2
Blood Gases
Obtaining from A-line 0 1 2
Obtaining from femoral artery 0 1 2
Obtaining from radial artery 0 1 2
Interpretation of gases 0 1 2
Blood Chemistry
Interpretation of results 0 1 2
Medications
Alupent (Metaproterenol sulfate) 0 1 2
Aminophylline (Theopyphylline) 0 1 2
Bronkosol (Isoetharine hydrochloride) 0 1 2
Epinephrine (Adrenaline) 0 1 2
Steriods 0 1 2
Ventolin (Albuterol) 0 1 2
NEUROLOGICAL ASSESSMENT
Neurological status 0 1 2
Cerebellar function 0 1 2
Cranial nerves 0 1 2
Glasgow coma scale 0 1 2
Level of consciousness 0 1 2
Reflex/motor deficits 0 1 2
Visual or communications deficits 0 1 2
Equipment & Procedures
Assist with Lumbar puncture 0 1 2
Halo traction 0 1 2
Nerve stimulator 0 1 2
Rotation bed 0 1 2
Seizure precautions 0 1 2
Use of hyper/hypothermia blanket 0 1 2
Care of Patient
Aneurysm 0 1 2
Basal skull fracture 0 1 2
Closed head injury 0 1 2
Coma 0 1 2
Care of Patient
Cranial hemorrhage 0 1 2
CVA/TIA 0 1 2
DT’s 0 1 2
Encephalitis 0 1 2
Enternalized VP shunts 0 1 2
Meningitis 0 1 2
Multiple sclerosis 0 1 2
Neuromuscular disease 0 1 2
Neuro surgery pre & post op 0 1 2
Overdose 0 1 2
Post craniotomy 0 1 2
Seizures 0 1 2
Spinal cord injury 0 1 2
Medications
Carbamazepine (Tegretol) 0 1 2
Carbidopa-Levodopa (Sinemet) 0 1 2
Clonazepam (Klonopin) 0 1 2
Dilantin (Phenytoin) 0 1 2
Phenobarbital 0 1 2
Solu-Medrol (Methylprednisolone) 0 1 2
Valium (Diazepam) 0 1 2
GASTROINTESTINAL
Assessment - Abdominal/bowel sound 0 1 2
Fluid balance 0 1 2
Nutritional status 0 1 2
Equipment & Procedures
Insertion of nasogastric tube 0 1 2
Administration of tube feeding - gravity 0 1 2
Administration of tube feeding - pump 0 1 2
Flexible feeding tube (i.e. Dobhoff) 0 1 2
Salem sump to suction 0 1 2
Saline lavage 0 1 2
Management of:
Gastrostromy tube 0 1 2
Jejunostomy tube 0 1 2
T-tube 0 1 2
Care of Patient
Bowel obstruction 0 1 2
Colostomy 0 1 2
ERCP 0 1 2
Esophagel bleeding 0 1 2
GI surgery 0 1 2
GI bleeding 0 1 2
Hepatitis 0 1 2
Ileostomy 0 1 2
Inflammatory bowel disease 0 1 2
Liver failure 0 1 2
Liver transplant 0 1 2
Pancreatitis 0 1 2
Paralytic ileus 0 1 2
Whipple procedure 0 1 2
Medications
Antiemetics 0 1 2
Antispasmodic 0 1 2
RENAL/GENITOURINARY
Assessment of fluid & electrolyte balance 0 1 2
Assessment of A-V fistula/shunt 0 1 2
Interpretation of lab results 0 1 2
Interpretation of BUN & creatinine 0 1 2
Equipment & Procedures
Bladder irrigation - continous 0 1 2
Bladder irrigation - intermittent 0 1 2
Collection of urine specimens, routine, 24 hr 0 1 2
Insertion & care of foley catheter - female 0 1 2
Insertion & care of foley catheter - male 0 1 2
Manual CAPD administration 0 1 2
Nephrostomy tube care 0 1 2
TURP 0 1 2
METABOLIC/ENDOCRINE
Signs & Symptoms of diabetic coma 0 1 2
Signs & symptoms of insulin reaction 0 1 2
Blood glucose monitoring
Insulin administration - IV drip 0 1 2
Interpretation of lab results - glucose 0 1 2
Interpretation of lab results - thyroid levels 0 1 2
Performing finger stick 0 1 2
Visual blood glucose strips 0 1 2
Care of Patient
Addison’s disease 0 1 2
Cushing’s syndrome 0 1 2
Diabetes insipidus 0 1 2
Diabetes mellitus 0 1 2
Diabetic ketoacidosis 0 1 2
Drug overdose 0 1 2
Hyperthyoidism (Grave’s disease) 0 1 2
Hypothyroidism 0 1 2
Pancreatitis 0 1 2
Pheochromocytoma 0 1 2
Post adrenalectomy 0 1 2
Post hypophysectomy 0 1 2
Post thyroidectomy 0 1 2
METBOLIC/ENDOCRINE - MEDICATIONS
Hydrocortisone 0 1 2
IM Vasopressin (Pitressin) 0 1 2
Insulin 0 1 2
Prednisone 0 1 2
Radioactive iodine 0 1 2
WOUND & SKIN MANAGEMENT
Assessment - skin for impending breakdown 0 1 2
Assessment - stasis ulcers 0 1 2
Assessment - surgical wound healing 0 1 2
Equipment & Procedures
Air fluidized, low airloss beds 0 1 2
Sterile dressing changes 0 1 2
Wound care/irrigations 0 1 2
Care of Patient
Burns 0 1 2
Pressure sores 0 1 2
Staged decubitus ulcers 0 1 2
Surgical wounds with drain(s) 0 1 2
Traumatic wounds 0 1 2
PAIN MANAGEMENT
Anesthesia/analgesia 0 1 2
Assessment of pain level 0 1 2
IV conscious sedation 0 1 2
Narcotic analgesia 0 1 2
Patient controlled analgesia (PCA) 0 1 2
MISCELLANEOUS
Delirium Tremens (DT’s) 0 1 2
Patient in restraints 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=Adolescent (13-18 yrs) B=Young Adult (19-39 yrs) C=Middle Adult (40-64 yrs) D=Older Adult (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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