Instructions:

Please rate your experience / frequency (within the last year) using the following scale (check the appropriate boxes below):

  • 0 = No Experience / Observed Only
  • 1 = Limited Experience / Rarely Done (<6 times/year)
  • 2 = May Need Some Review / Occasionally Done (1 - 2 times/month)
  • 3 = Experienced / Frequently Done (daily or weekly)
  • AGE OF PATIENTS CARED FOR
    Newborn/Neonate (birth to 30 days)
    Infant (31 days to 12 months)
    Toddler/Preschool (13 months to 5 years)
    School Age Child/adolescent (6 years to 18 years)
    Young Adults/ Middle Adult (19 years to 64 years)
    Older Adults/Elderly (65+ years)
    GENERAL SKILLS
    Care of Patient in Restraints
    Automated Med Dispensing Systems
    Other Automated Med Dispensing Systems:
    Electronic Documentation
    Other Electronic Documentation:
    IV Pumps
    Other IV Pumps:
    Peripheral IV Insertion, Care and Maintenance
    Access/Management of Implanted Ports
    Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
    Administration of Blood/Blood Products
    Knowledge of "Do Not Use Abbreviations"
    Do you have charge/supervisor experience?
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    HEMODIALYSIS SETTING / PROCEDURES EXPERIENCE
    Acute / Inpatient Dialysis
    Apheresis
    Chronic / Outpatient Dialysis
    Dialysis Home Care
    Pediatric Dialysis
    Predialysis Nursing Assessment
    Plasmapheresis
    CARE OF PATIENT WITH
    Nephrostomy Tube
    A V Fistula / A V Graft
    Tunneled / Non-Tunneled Catheter
    Insertion of urinary catheter (straight cath or foley)
    Ileal Conduit
    Supra-Pubic Catheter
    Renal Failure
    TURP
    Peritoneal Dialysis
    Hemodialysis
    SET UP / INITIATE DIALYSIS TREATMENT
    Anticoagulation
    Bicarbonate Dialysate
    Conductivity Testing
    Priming Dialyzer
    Checks for Machine / Alarm Settings
    Prep Vascular Access
    Fistula Gortex / Bovine Graft
    Dialysis
    Collect Blood Specimens
    Cannulating Buttonholes
    Continuous Renal Replacement Therapy (CRRT)
    Peritoneal Dialysis
    ASSESS PATIENT AND EQUIPMENT DURING DIALYSIS
    Volume Status
    Vascular Access Function
    Arterial and Venous Pressures
    Blood Flow Rate
    Subjective Response to Treatment
    Management of Anticoagulation
    Conductivity
    Ultrafiltration Calculation
    Operation of Myron L. Meter
    Administration of Mannitol
    Sequential Ultrafiltration / PUF
    Documentation of Dialysis Treatment
    MANAGEMENT OF PATIENT WITH
    Anticoagulation Emergency
    Anemia
    Air Embolus
    Cardiopulmonary Arrest
    Chest Pain
    Clotted Access / Poor Blood Flow Rate from Catheter
    Disequilibrium syndrome
    Filter Blood Leak
    Fluid Overload
    Hemolysis
    Hypertension
    Hypotension
    Hyperkalemia
    Muscle Cramps
    Neuropathy
    Pericarditis
    Pyrogenic Reaction
    Seizures
    MACHINE ALARM TROUBLESHOOTING PROCEDURES
    Blood Leak Alarm
    Arterial Pressure Alarm
    Venous Pressure Alarm
    Conductivity Alarm
    Ultrafiltration Alarm
    High Temperature Alarm
    Air / Foam Detector Alarm
    Power Failure Alarm
    Blood Pump Alarm
    LIST ANY CERTIFICATIONS HELD:
    Other:
    EQUIPMENT USED
    Baxter
    Fresnius
    Cobe
    Gambro
    Phoenix
    T Machine
    Other: