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
    Neonate <23 weeks
    Neonate 23-28 weeks
    Neonate 29-32 weeks
    Neonate >32 weeks
    Full Term Newborn
    GENERAL SKILLS
    Automated Med Dispensing Systems
    Other Automated Med Dispensing Systems:
    Electronic Documentation
    Other Electronic Documentation:
    Peripheral IV Insertion, Care and Maintenance
    Access/Management of Central Lines
    Cardiac Monitoring/Interpretation
    Titration of drips
    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
    Crash Carts
    Defibrillators
    Apgar scoring
    Cord care
    Neonatal skin care
    Positioning Devices
    Attending deliveries
    IV Pumps
    Other IV Pumps:
    NEUROLOGICAL
    Assessment of neurological status
    Intracranial pressure monitoring
    NEUROLOGICAL-Care of Neonate with:
    Brain death/organ procurement
    Internal/Externalized VP shunt/reservoirs
    Intraventricular hemorrhage
    Increased intracranial pressure
    Meningitis
    Seizures
    Myelomeningocele
    Spina Bifida
    Peri-Ventricular Leukomalacia
    Care for a Myleo (wound/cathing)
    Hypoxic/Ischemic Encephalopathy (HIE) CFM/Cool Cap
    Lumbar Puncture to r/o Meningitis
    KNOWLEDGE AND USE OF
    Anticonvulsants
    CARDIOVASCULAR
    Assessment/Auscultation (rate, rhythm, volume)
    Blood pressure/invasive (arterial line)
    Blood Pressure/non-invasive
    Heart Sounds/Murmurs
    Perfusion
    Pulses
    Defibrillation/Cardioversion
    Invasive hemodynamic monitoring
    Central venous pressure
    Echocardiogram
    CARDIOVASCULAR-Care of Neonate with:
    Cardiac Arrest
    Cardiac Transplant
    Cardiomyopathy
    Congenital Heart Disease/Defects
    Hemodynamic instability
    Cardiogenic/Hypovolemic Shock
    Post cardiac Surgery
    Post Cardiac Cath
    Hyper/hypotension
    KNOWLEDGE AND USE OF
    Digoxin
    Dobutamine
    Dopamine
    Epinephrine
    Nipride
    Precedex
    Vasopressin
    Milrinone
    RESPIRATORY
    Assessment of Breath Sounds
    Rate and work of breathing
    Interpretation of ABGs
    Airway Management
    Assist with Intubation
    Bulb Syringe
    Laryngeal Mask Airway (LMA)
    Endotracheal Tube Suctioning
    ETT Sutured In - Post mandibular Distraction, Airway Anomalies
    In-Line Suction
    Open ET catheter suction
    Extubation
    Nasal/Oral airway/suctioning
    Tracheostomy/suctioning
    Emergency Tracheostomy at Bedside
    Apnea Monitor
    Respiratory Arrest/Insufficiency
    Chest Tube Care and Maintenance
    Assist with Chest Tube Insertion
    Pneumo Kit for Tension Pneumo - Emergent
    Assist with Chest Tube Removal
    ECMO (Extracorporeal Membrane Oxygenation)
    O2 Therapy Delivery Systems
    Bag and Mask
    Blow -by Oxygen
    Nasal cannula
    Nebulizer
    Oxyhood/Tent
    Trach collar
    Obtaining Blood Samples
    Arterial
    Heelstick
    Peripheral
    Umbilical Line
    Use of Ventilators
    CPAP/PEEP
    High frequency jet ventilator
    Home ventilator
    IMV
    Nasal IMV
    Oscillating
    Pressure ventilator
    Volume ventilator
    CO2 Monitoring
    Weaning
    RESPIRATORY-Care of Neonate with:
    Apnea/Bradycardia/Desaturations
    Meconium aspiration
    Cystic Adenomatoid malformation (CAM)
    Pulmonary Interstitial Emphysema (PIE)
    Persistent pulmonary hypertension (PPHN)
    Bronchopulmonary dysplasia (BPD)
    Transient Tachypnea of the Newborn (TTN)
    Diaphragmatic hernia
    Fresh tracheostomy
    Pneumothorax
    Respiratory distress syndrome (RDS)
    Respiratory failure
    KNOWLEDGE AND USE OF
    Caffeine
    Prostaglandin
    Bronchodilators
    Steroids
    Lasix
    Aldactazide
    Diamox
    Istat
    Thoracentesis
    Artificial surfactant
    GASTROINTESTINAL
    Abdominal girth
    Bowel sounds
    Palate
    Wound Vac
    Extreme Gastrochisis
    Ostomies
    Suck/Swallow
    Care of gastrostomy tube
    Feedings
    Assist with breast feeding
    Bottle
    Breast milk handling/storage
    Gavage
    Hospital grade electric breast pump
    Placement of intestinal tubes
    Jejunal/gastro
    Nasogastric/or gastric
    Transpyloric
    Weighted NG/OG
    Gastric Aspiration to Check Placement
    Test for occult blood
    GASTROINTESTINAL-Care of Neonate with:
    Cleft lip/palate
    GI bleed
    Ostomy
    Post abdominal surgery
    Diaphragmatic Hernia
    Pnemotosis
    MSPF - Malrotation
    Adhesions/Strictures
    Inguinal hernia
    Necrotizing enterocolitis
    Gastroschesis/omphalocele
    Duodenal Atresia
    Bowel Obstruction
    Biliary Atresia
    Hirschsprungs Disease
    Reflux
    Tracheoesophageal fistula (TEF)
    RENAL/GU/METABOLIC/ENDOCRINE
    Fluid & electrolyte balance
    Calculating Output
    Knowledge/Interpretation of Lab Results/Chemistry
    Bilirubin
    Test Urine and Interpret
    Glucose Gel
    Labstix
    Occult Blood
    pH
    Cholestatic Jaundice
    Liver, Jaundice
    Specific gravity
    Collection of urine specimens
    Assist with suprapubic tab
    Catheter
    Diaper/bag
    RENAL/GU/METABOLIC/ENDOCRINE-Care of Neonate with:
    Phototherapy for jaundice
    Post circumcision care
    Acute renal failure
    Polycystic Kidneys
    DIC (disseminated intravascular coagulation)
    Disorders of internal/external organs
    Ascites
    Acute Tubular Necrosis
    Drug addiction/withdrawal
    Hyper/hypokalemia
    Hyper/hyponatremia
    Infant of Diabetic Mother- Monitor for Hyper/hypoglycemia
    Malformations of the GU tract, kidney
    Peritoneal dialysis
    INFECTIOUS DISEASES
    Assist with lumbar puncture
    Collect culture specimens
    Isolation techniques
    Standard precautions
    Knowledge of Lab Results
    CBC/differential
    Culture reports
    Maternal lab results
    INFECTIOUS DISEASE-Care of Neonate with:
    Hepatitis surface antigen+ mother
    HIV positive mother
    Neonatal sepsis
    Cytomegalovirus (CMV)
    Group B Strep
    KNOWLEDGE AND USE OF
    Antibiotics
    HBIG
    HBV vaccine
    HIB
    RespiGam/synagis prophylaxis
    MEDICATION SKILLS/KNOWLEDGE & USE
    Calculation of dosage
    Prep and Administration of Emergency Meds
    Emergency drug action & reaction
    Eye Prophylaxis - Vitamin K
    Neonatal drug action & reactions
    PAIN MANAGEMENT
    Assessment of pain level using age appropriate scales
    Care of Neonate with sedation
    Use of Sedation Reversal Agents
    Fentanyl
    Versed
    Morphine
    Ativan
    Pavulon
    IV THERAPY/PHLEBOTOMY
    Administration of blood/blood products
    Cryoprecipitate
    Packed red blood cells
    Plasma/albumin
    Whole blood
    Drawing blood from central line
    Drawing venous blood
    Hyperalimentation/TPN/PPN
    Intralipid
    Delivery Systems
    IV pump
    Syringe pump
    Managing IV Therapy
    Insertion
    IV Infiltrate reversal Drugs
    Discontinuation
    Dressing & tubing change
    Rate Calculation
    Site & patency assessment
    IV THERAPY/PHLEBOTOMY-Care of the Neonate with:
    Central Line/Catheter/Dressing
    Broviac
    Groshong
    Hickman
    Port-A-Cath
    Quinton
    Percutaneous arterial line
    PICC (peripherally inserted central catheter)
    Umbilical artery line
    Umbilical venous line
    GESTATIONAL AGE
    Ballard
    Dubowitz
    Gestational Age Assessment
    Maternal history
    Screen for hearing loss
    Congenital Heart Screen
    Car Seat Study
    Equipment & Procedures
    Bereavement/postmortem care
    CONSENTS
    Immunization
    Procedural
    Treatment
    FAMILY TEACHING/EDUCATION
    Care Planning
    Preparation for transport/transfer
    Thermoregulation
    Isolette with humidity
    Radiant warmer
    Temperature (axillary,rectal,skin)
    Weaning to open crib/bassinet
    Weights
    Bed scale
    Scale