Neonatal Intensive Care Unit Skills Checklist
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- Alaina Elizabeth Campbell
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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 NEUROLOGY ICP MONITORING NEUROLOGICAL ASSESSMENT SPINAL DISORDERS EXTERNAL VP SHUNTS SEIZURES DRUG/ALCOHOL WITHDRAWAL MENINGITIS NEUROLOGICAL DEVELOPMENT CARDIOVASCULAR HYOPOLEMIC SHOCK PULSE/PERFUSION ASSESSMENT CONGENITAL HEART DISEASE HEMODYNAMIC MONITORING HEMODYNAMIC INSTABILITY CARDIOVERSION CARDIAC ARREST POST CARDIAC SURGERY Version: 07/03/2012 Page 1 out of 6
2 CARDIOVASCULAR HEART SOUND AUSCULTATION DINAMAP/BP MONITORING CV ASSESMENT NRP PROTOCOLS & MEDICATIONS USE OF S.T.A.B.L.E PROGRAM & PROTOCOLS EKG INTERPRETATION & TREATMENT CARE OF PATIENT WITH CHF RESPIRATORY TRACHEOSTOMY DIAPHRAGMATIC HERNIA PERIPHERAL ARTERIAL LINES INTUBATION ASSISTANCE ABG / CAPILLARY ABG / UAC ABG INTERPRETATION ETT STABILIZATION BAG AND MASK/SELF INFLATING PULSE OXIMETER ORAL/NASAL SUCTIONING TRANSCUTANEOUS MONITORING MECONIUM ASPIRATIONS/MAS ETT CATHETER SUCTIONING CHEST AUSCULTATION / EXAM BAG AND MASK/ANESTHESIA ARTIFICIAL SURFACTANT USE OXYHOOD CPAP/PEEP NITRIC OXIDE THERAPY PNEUMOTHORAX OSCILLATOR Version: 07/03/2012 Page 2 out of 6
3 RESPIRATORY IMV NASAL CANNULA RDS HIGH FREQUENCY JET VENT (HFJV) PARTIAL LIQUID VENTILATION CARE OF PATIENT WITH APNEA IV THERAPY & PHLEBOTOMY HICKMAN UVC PICC BROVIAC IV PUMPS PERCUTANEOUS ARTERIAL LINE HYPERALIMENTATION BLOOD /BLOOD BYPRODUCTS CENTRAL LINE BLOOD SAMPLES VENIPUNCTURE IV START UP PIV HYPERALIMENTATION GASTROINTESTINAL NECROTIZING ENTEROCOLITIS NASOGASTRIC TUBES BOWEL SOUNDS POST ABDOMINAL SURGERY FEEDING INTOLERANCE OCCULT BLOOD TESTING ABDOMINAL GIRTH TRACHEOESOPHOGEAL FISTULA REFLUX PRECAUTIONS Version: 07/03/2012 Page 3 out of 6
4 GASTROINTESTINAL ILEOSTOMY CARE INGUINAL HERNIA SWALLOW/SUCK PATTERN NGT/NJT/OGT PLACEMENT CLEFT PALATE/LIP BREASTFEEDING ASSISTANCE OMPHALOCELE COLOSTOMY CARE GASTROSTOMY TUBES GASTROSCHISIS GAVAGE FEEDINGS BOTTLE FEEDINGS INFECTIOUS DISEASES ISOLATIONS PROCEDURES CULTURE SPECIMENS LUMBAR PUNCTURE ASSISTANCE HBSAG +/ MOTHER CBC/DIFFERENTIALS RESPIAM / SYNERGIS PROPHYLAXIS UNIVERSAL PRECAUTIONS MATERNAL SERUM LAB VALUES HIV +/MOTHER CULTURE SPECIMENS NEONATAL SEPSIS IMMUNIZATIONS ANTI-INFECTIVES GENITOURINARY & RENAL EXTERNAL ORGAN DISORDER CIRCUMCISION ASSISTANCE PERITONEAL DIALYSIS Version: 07/03/2012 Page 4 out of 6
5 GENITOURINARY & RENAL GU TRACT MALFORMATIONS ACUTE RENAL FAILURE POST CIRCUMCISION CARE URINARY CATHETER INSERTION & MANAGEMENT PHARMACOLOGY PROSTAGLANDIN INSULIN DRIPS NAHCO STEROIDS AMINOPHYLLINE NAHCO ENDOCRINE IDM CARE ELECTROLYTE/FLUID IMBALANCE NORMAL SERUM LABS GLUCOMETER/ACCUCHECK MISCELLANEOUS PAIN MANAGEMENT/POST-OP WOUND HEALING PAIN LEVEL ASSESSMENT SEDATION WITH A NEONATE SKIN COLOR CHANGE/INTEGRITY LOW BIRTH WEIGHT NURSING CARE ISOLETTE W/ HUMIDITY APGAR SCORING HIGH RISK DELIVERIES PHOTOTHERAPY CARE DUBOWITZ GESTATIONAL AGE BALLARD GESTATIONAL AGE RADIANT WARMER Version: 07/03/2012 Page 5 out of 6
6 MISCELLANEOUS OPTHAMOLOGY SCREENING HEARING SCREENING POST MORTEM BEREAVEMENT EYE EXAM CARE OF INFANT UNDER PHOTOTHERAPY EXPERIENCE IN LEVEL I NURSERY EXPERIENCE IN LEVEL II NURSERY AGE APPROPRIATE CARE NEONATAL (LESS THEN 23 WEEKS) NEONATAL (24-28 WEEKS) NEONATAL (29-32 WEEKS) NEONATAL (33 WEEKS OR GREATER) 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 6 out of 6
Experience. Initials Medical Staffing Network Rev. 06/15 F01201 NNICU 2 of 5
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