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)
  • IV THERAPY EXPERIENCE WITH THE FOLLOWING AGES:
    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:
    Access/Management of Implanted Ports
    Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
    Titration of drips
    Administration of Blood/Blood Products
    Leading Code Teams
    Use of Computerized Patient ID Systems
    Knowledge of Current IV Therapy Guidelines (INS, ISMP, CDC, State, Etc.)
    Knowledge of Anatomy
    Moderate Conscious Sedation
    Sedation Reversal Agents
    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
    INSERTION OF:
    Peripheral IV-Adult
    Peripheral IV-Child
    Peripheral IV-Neonate
    Vein Selection - Peripheral IV's
    Interosseous Needles
    MIDLINE'S/PICC LINES:
    Midline Catheter Insertion - Adult
    Midline Catheter Insertion - Child
    Indications for Midline/PICC Placement
    Contraindications for Midline/PICC Placement
    Vein Selection
    Measuring Techniques
    Catheter and Introducer Device Selection
    Correct Tip Placement
    Insertion Technique - Basic (Vein)
    Insertion Technique - Seldinger
    Insertion Technique - Ultrasound
    Assist with Insertion in Interventional Radiology
    Insertion Site Preparation
    Maintaining Sterile Field
    Securing Insertion Site Post Placement
    X-ray Assessment for Tip Location
    Repositioning After X-ray
    CARE AND MAINTENANCE:
    Peripheral IV
    Scalp IV
    Heparin/Saline Lock
    Groshong PICC
    Groshong CVL
    Hickman/Broviac
    Port-a-Cath
    Vascath
    Multilumen Catheters
    Subclavian Line
    IJ Line
    Femoral Line
    Power PICC
    Power PORT
    Dressing Changes
    Cap Changes
    Flushing Lines (Frequency/Solutions)
    MEDICATION ADMINISTRATION
    Chemotherapy
    Heparin
    Streptokinase
    TPA (Alteplase)
    Lidocaine
    TPN/Lipids
    Ativan (Lorazepam)
    Valium (Diazepam)
    Versed (Midazolam)
    Fentanyl
    EQUIPMENT:
    IV Pumps (check all that apply)
    Other IV Pumps:
    Needleless Systems
    Blood Warmer
    PCA Pumps
    Pressure Lines
    TROUBLESHOOTING/ COMPLICATIONS:
    Repair PICC
    Repair Midline
    Air Embolism
    Bleeding
    Brachial Plexus Injury
    Cardiac Arrhythmia
    Cardiac Tamponade
    Catheter Erosion
    Catheter Embolism
    Catheter Occlusion
    Catheter-Related Sepsis
    Endocarditis
    Exit Site Infection
    Exit Site Necrosis
    Extravasation
    Hematoma
    Laceration of Vessels or Viscus
    Myocardial Erosion
    Perforation of Vessels or Viscus
    Phlebitis
    Catheter Tip Malposition or Retraction
    Thromboembolism
    Venous Thrombosis
    Ventricular Thrombosis
    Vessel Erosion
    Declotting Peripheral Site
    Complications from Sedation
    DISCONTINUING IV THERAPY
    Peripheral IV's
    PICC/Midline
    Central Lines