Pediatric Intensive Care Unit Skills Checklist
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1 _ XXX-XX- Print Name Last 4 of SS # Date Completed Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional. 1 - No (has never done or observed) 2 - Requires Training (In-Service) - not performed within last 36 months 3 - Limited (requires assistance or training) - performed within the last 24 months 4 - d (routinely performs without assistance) - performed within the last 12 months 5 - Able to Supervise, Precept and Teach - performed within the last 6 months MEDICATIONS ADMINISTER PO MEDICATIONS ADMINISTER RECTAL MEDICATIONS ADMINISTER NG MEDICATIONS ADMINISTER IM & SQ MEDS IV PUSH MEDS ADMINISTER EYE / EAR MEDS METERED DOSE INHALER KNOWLEDGE ROUTINE PEDS MEDS CALCULATION OF PEDIATRIC DOSES KNOWLEDGE OF EMERGENCY MEDS PAIN ASSESSMENT / MANAGEMENT ADMIN. HYPERALIMENTATION / PTN KNOWLEDGE OF IMMUNIZATION SCHED HICKMAN / BROVIAC CATHETERS EPIDURAL ANESTHESIA / ANALGESIA CONSCIOUS SEDATION Version: 07/03/2012 Page 1 out of 10
2 NARCOTIC ANALGESIA PCA PUMP ACUTE TUMOR LYSIS SYNDROME HEMATOLOGY/ONCOLOGY ASSESS NUTRITIONAL STATUS INTERPRETATION OF LAB RESULTS REVERSE ISOLATION ANEMIA LEUKEMIA HIV / AIDS HEMOPHILIA DEPRESSED IMMUNE SYSTEM BONE MARROW TRANSPLANT SICKLE CELL DISEASE PRE / POST ONCOLOGIC SURGERY SPLEEN TRAUMA / SPLENECTOMY CHEMOTHERAPY DIC INFUSION THERAPY - PERIPHERAL IV INSERTION - BUTTERFLY HEPARIN / SALINE LOCK ANGIOCATH NEEDLE-LESS SYSTEMS MIX IV INFUSION W/ ADDITIVES INFUSION PUMPS SYRINGE PUMPS IV DRESSING & TUBING CHANGES IV SITE & PATENCY ASSESSMENT DISCONTINUE PERIPHERAL IVS Version: 07/03/2012 Page 2 out of 10
3 INFUSION THERAPY - PERIPHERAL IV INSERTION CVLS DRESSING CHANGE FLUID RESUSCITATION GROSHONG QUINTON IMPLANTABLE VENOUS PORT (PORTACATH) PICC LINE VASCULAR DRAW VENOUS BLOOD (PERIPHERAL) INTERPRETATION OF LAB RESULTS DRAW BLOOD FROM CENTRAL LINE ADMIN BLOOD / BLOOD PRODUCTS - PACKED RBCS CRYOPRECIPITATE PLASMA / ALBUMIN WHOLE BLOOD ASSESS FOR EDEMA / FLUID OVERLOAD PERIPHERAL PULSES ULTRASONIC DOPPLER INFECTIOUS DISEASES ASSESS / INTERPRET LAB STUDIES FEVER MANAGEMENT COMMON CHILDHOOD DISEASES CYTOMEGALO VIRUS (CMV) KAWASAKI DISEASE LYME DISEASE CARDIAC ASSESS CARDIAC & PERFUSION STATUS ASSESS HEART SOUNDS Version: 07/03/2012 Page 3 out of 10
4 CARDIAC ASSESS BP (NONINVASIVE) USE OF CARDIAC MONITORS INTERPRETATION OF ARRHYTHMIAS ASSIST WITH CODE / CPR DEFIBRILLATION / CARDIOVERSION KNOWLEDGE OF EMERGENCY MEDS KNOWLEDGE OF CARDIAC MEDS ASSIST WITH INSERTION & MAINTAIN - ARTERIAL LINES CENTRAL VENOUS CATHETER PA CATHETER PRE / POST CARDIAC CATH PRE / POST CARDIAC SURGERY HYPOVOLEMIC SHOCK CARDIOGENIC SHOCK CONGESTIVE HEART FAILURE CONGENITAL HEART DEFECTS / DISEASE PATENT DUCTUS ARTERIOSUS (PDA) ATRIOVENTRICULAR SEPTAL DEFECTS COARCTATION OF THE AORTA TRANSPOSITION OF THE GREAT ARTERIES PULMONARY ATRESIA HEART TRANSPLANT NEUROLOGY NEUROLOGICAL ASSESSMENT GLASCOW COMA SCALE (PEDS) ASSIST WITH LUMBAR PUNCTURE INTRACRANIAL PRESSURE MONITORING SEIZURE PRECAUTIONS Version: 07/03/2012 Page 4 out of 10
5 NEUROLOGY KNOWLEDGE / USE OF ANTICONVULSANTS OPEN / CLOSED HEAD INJURY INTERNAL / EXTERNAL SHUNTS ACUTE SPINAL CORD INJURY MENINGITIS / ENCEPHALITIS OVERDOSE / INGESTION NEAR DROWNING SPINA BIFIDA REYE'S SYNDROME BATTERED CHILD SYNDROME NEUROMUSCULAR DISEASE BRAIN DEATH / ORGAN PROCUREMENT STATUS EPILEPTICUS ORTHOPEDIC SPECIALIZED ORTHOPEDIC BED CAST CARE / SPICA CAST MULTIPLE FRACTURES AMPUTATION SKELETAL TRACTION SKIN TRACTION POST HARRINGTON ROD INSERTION OSTEOMYELITIS RESPIRATORY ASSESS RESPIRATORY STATUS ASSESS BREATH SOUNDS ORAL AIRWAY & SUCTIONING USE OF BULB SYRINGE OBTAIN ABGS - ARTPUNCTURE / HEELSTICK Version: 07/03/2012 Page 5 out of 10
6 RESPIRATORY OBTAIN ABGS - ARTERIAL LINE INTERPRET ABGS ASSIST W/ INTUBATION (ETT) ETT MAINTENANCE AND SUCTIONING END TIDAL CO2 MONITOR ETT EXTUBATION VENTILATE WITH AMBU-BAG APNEA MONITOR NEBULIZER OXYGEN DELIVERY - ISOLETTE HOOD / TENT NASAL CANNULA & FACE MASK PRESSURE VENTILATOR VOLUME VENTILATOR CPAP / PEEP / IMV VENTILATOR WEANING ECMO CHEST PHYSIOTHERAPY CHEST TUBES-ASSIST INSERTION/REMOVAL ASTHMA / STATUS ASTHMATICUS EPIGLOTTITIS & TONSILLITIS BRONCHIOLITIS (RSV) SEVERE RESPIRATORY DISTRESS PNEUMONIA TRACHEOSTOMY BRONCHOPULMONARY DYSPLASIA(BPD) CYSTIC FIBROSIS TRACHEO-ESOPHAGEAL FISTULA Version: 07/03/2012 Page 6 out of 10
7 HEMO / PNEUMO THORAX FOREIGN BODY ASPIRATION LUNG TRANSPLANT WOUND MANAGEMENT ASSESS SKIN FOR BREAKDOWNS SURGICAL WOUND CARE TRAUMATIC WOUND CARE WOUND DRAINS (JP / HEMOVAC) USE OF AIR BEDS PRESSURE SORES / DECUBITUS ULCERS BURNS (1ST & 2ND DEGREE) BURNS (3RD DEGREE) ENDOCRINE ASSESS / INTERPRET LAB STUDIES DIABETIC TEACHING ADRENAL DISORDERS CUSHING'S SYNDROME JUVENILE DIABETES INSULIN PUMP PITUITARY DISORDERS THYROID DISORDERS GASTROINTESTINAL ASSESS BOWEL SOUNDS INSERTION / MONITORING NG TUBE INSERTION / MONITORING OG TUBE ASSIST W/ BOTTLE & BREAST FEEDING TUBE FEEDINGS VIA FLEXIBLE TUBES GASTROSTOMY TUBE FEEDING Version: 07/03/2012 Page 7 out of 10
8 GASTROENTERITIS / SEVERE DEHYDRATION GASTROSCHISIS PRE / POST ABDOMINAL SURGERY GE REFLUX GI BLEED COLOSTOMY / ILEOSTOMY NECROTIZING ENTEROCOLITIS (NEC) PANCREATITIS HEPATITIS HEPATIC FAILURE ABDOMINAL WOUNDS & DRAINS FAILURE TO THRIVE CLEFT LIP / PALATE CRANIOFACIAL RECONSTRUCTION LIVER TRANSPLANT GENERAL NURSING ADMIT & ORIENT PATIENTS NORMAL GROWTH AND DEVELOPMENT RECOGNIZE SIGNS OF ABUSE / NEGLECT WEIGH PATIENT DISCHARGE PATIENTS SUPERVISE UNLICENSED PERSONNEL PULSE OXIMETRY BLOOD GLUCOSE MONITORING POSITIONING / TRANSFERRING RESTRAINTS ISOLATION TECHNIQUES UNIVERSAL PRECAUTIONS / PEP Version: 07/03/2012 Page 8 out of 10
9 RENAL/GENITOURINARY STRAIGHT / FOLEY CATH FEMALE STRAIGHT / FOLEY CATH MALE COLLECT URINE SPECIMEN(DIAPER / BAG) ASSIST WITH SUPRA-PUBIC TAP INTERPRET ELECTROLYTES, BUN, CREAT INTERPRET URINALYSIS TEST & INTERPRET URINE / LABSTIX TEST & INTERPRET URINE SP. GR NEPHROSTOMY TUBE GENITOURINARY TRAUMA ACUTE RENAL FAILURE NEPHRITIS SHUNTS & FISTULAS RENAL TRANSPLANT HEMODIALYSIS PERITONEAL DIALYSIS NEPHROTIC SYNDROME POST URINARY DIVERSION HEMOLYTIC UREMIC SYNDROME DIABETES INSIPIDUS (DI) SYNDROME INAPPROPRIATE ADH (SIADH) PRE-OPERATIVE CARE / PREPARATION GENERAL POST-ANESTHESIA CARE MULTIPLE TRAUMA PATIENT PENETRATING TRAUMA PATIENT INGESTIONS DEPRESSION ANOREXIA / BULIMIA SUICIDAL THREATS / ACTIONS Version: 07/03/2012 Page 9 out of 10
10 ENT SURGERY / PROCEDURES OPHTHALMIC SURGERY PLASTIC SURGERY POSTMORTEM CARE AGE APPROPRIATE CARE INFANT (30 DAYS - 1 YEAR) TODDLER (1-3 YEARS) PRESCHOOLER (3-5 YEARS) SCHOOL AGE (5-12 YEARS) ADOLESCENTS (12-18 YEARS) YOUNG ADULTS (18-39 YEARS) MIDDLE ADULTS (39-64 YEARS) OLDER ADULTS (64+ YEARS) The information represented above is true and correct to the best of my knowledge. I also authorize Specialty Professional Services, Corp to share the above skills checklist with its facility clients. Signature Date Completed Fax: Version: 07/03/2012 Page 10 out of 10
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