Experience. Initials Medical Staffing Network Rev. 06/15 F01201 NNICU 2 of 5
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1 Neonatal Intensive Care Unit Self Assessment 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 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Print Name Last 4 Digits of SS# Date General Skills in level II nursing in level III nursing Awareness of HCAHPS Setting Childrens hospital University healthcare facility High risk delivery center Community hospital Family teaching Consents Specialty beds: giraffe incubator Specialty beds: radiant warmer bed Restrictive devices (restraints) Preparation for transport/transfer Air transport (jet or helicopter) Other transport experience: stable return transport Other transport experience: procedural transport End of life care/palliative care Wound assessment & care Automated Medication Dispensing System, Pyxis, Omnicell, or other Bar coding for medication administration Blood Glucose Monitoring (BGM) Insulin/dextrose administration National Patient Safety Goals Accurate patient identification Effective communication Interpretation & communication of lab values Medication administration Infant dosage calculations Delivery methods: IM/IV/SQ Medication reconciliation Medical Staffing Network Rev. 06/15 F01201 NNICU 1 of 5
2 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) General Skills - cont. Labeling (medications & specimens) Anticoagulation therapy Steroids (inhaled/iv/po) Monitoring conscious sedation Pain assessment & management Infection control Universal precautions Isolation Minimize risk falls Skin assessment Prevention of pressure ulcers IV Therapy Starting & maintaining IVs Blood draw: heel stick/venous Central venous insertion & management Blood draw: central line Maintain umbilical catheter (arterial/venous) TPN administration Administration of blood & blood products Infusion pumps Cardiovascular CV assessment Invasive hemodynamic monitoring Cardiac Monitoring & Emergency Care NRP protocols & medication Use of S.T.A.B.L.E. program & protocols Broslow system EKG interpretation & treatment Use of rapid response teams Defibrillation/cardioversion Congenital heart disease CHF Hemodynamic instability Hypovolemic shock Post cardiac surgery Medical Staffing Network Rev. 06/15 F01201 NNICU 2 of 5
3 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Cardiovascular - cont. Medication Administration Antidysrythmics Antihypertensives Cardiac glycoside (digoxin) Platelet inhibitors (aggrastat/integrillin/reopro) Vasoactive agents Pulmonary Respiratory Assessment Obtain & interpret blood gases Airway management (nasal/oral/et) Tracheostomy care & management Oxygen therapy (NC/oxyhood) Pulse oximeter Ventilation & management High Frequency Jet Vent (HFJV) Partial liquid ventilation Nitric oxide therapy Surfactant therapy ECMO Assist with & manage chest tube Care of Child with: Apnea Bronchopulmonary Dysplasia (BPD) Diaphragmatic hernia MAS (Meconium Aspiration Syndrome) Pulmonary edema Persistent Pulmonary Hypertension (PPHN) Respiratory Distress Syndrome (RDS) Pneumothorax Medication Administration Bronchodilators Neurological Neurological assessment Drug withdrawal & abstinence scoring Seizures Meningitis Medical Staffing Network Rev. 06/15 F01201 NNICU 3 of 5
4 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Neurological - cont. External VP shunt/reservoirs ICP monitoring Spinal disorders Neurological development & positioning Medications Anticonvulsants Gastrointestinal GI assessment (include palate & girth) Nutritional assessment Feedings Assist with breast/bottle feeding Breastmilk handling & storage Gavage Placement of OGT/NGT Gastrostomy tubes Colostomy/ileostomy care Tracheoesophogeal fistula (TEF) Cleft lip/palate Necrotizing Entercolitios (NEC) Gastroenteritis/omphaloocele Inguinal hernia Post abdominal surgery Renal/GU Urinary catheter insertion & management Peritoneal dialysis Assist with circumcision Post circumcision care Acute renal failure Malformations of GU tract Hydronephrosis Infectious Diseases Assist with lumbar puncture Neonatal sepsis HIV positive mother HBsAg positive mother Medical Staffing Network Rev. 06/15 F01201 NNICU 4 of 5
5 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Infectious Diseases - cont. Medication Immunizations Anti-infectives Respigam/synergis prophylaxis Admission/Assessment Attending high risk deliveries APGAR scoring Gestational age Eye exam Hearing screen Thermoregulation Care of infant under phototherapy in level II nursery in level III nursery Age Specific Competencies Neonatal (< 23 weeks) Neonatal (24-28 weeks) Neonatal (29-32 weeks) Neonatal (>33 weeks) Please list any Additional Skills: Additional training: Additional equipment: Fax to: The information on this and all preceding pages is true and correct. Signature Date 2015 Medical Staffing Network Rev. 06/15 F01201 NNICU 5 of 5
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