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.)
    Cardiac Monitoring/Interpretation
    PCA/Epidural pumps
    Titration of drips
    Administration of Blood/Blood Products
    Knowledge of "Do Not Use Abbreviations"
    Cancer screening and detection
    Do you have charge/supervisor experience?
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    SETTINGS
    Inpatient
    Outpatient
    Hospice/palliative care
    Adults
    Pediatrics
    Research/Clinical Trials
    Bone Marrow Unit
    PAIN MANAGEMENT
    Pain Assessment
    Continuous Narcotic Infusion
    Continuous Epidural Infusion
    IV Push Narcotics
    Use of Narcotic Pain Patches
    Use of PCA Pump
    Adjuvant Medications
    Alternative Therapies
    Nonpharmacologic Strategies
    PHLEBOTOMY/IV THERAPY
    IV Insertion, Maintenance and Discontinuation
    Central Lines
    Hickman
    Groshong
    Multilumen
    Port-A-Cath
    Blood Draw from Central Lines/Ports
    Peripheral Venous Blood Draw
    PICC Line Care and Maintenance
    PICC Line Insertion
    Infuse-a-port/power port
    Administration of blood and blood products
    Check for blood return from IV/PICC/Lines
    Plum Pumps
    MEDICATION KNOWLEDGE AND ADMINISTRATION OF
    Antiemetics
    Avastin
    Benadryl
    Bleomycin ( Blenoxane)
    Biotherapeutic Agents ( Rituxan)
    Bulsulfan ( Myleran)
    Corticosteroids
    Carboplatin
    Chlorambucil ( Leukeran)
    Cyclophosphamide ( Cytoxan)
    Cistplatin
    Cytarabine ( Ara-C)
    Dactinomycin ( Actinomycin)
    Daunorubicin ( Daunoxome)
    Doxorubicin ( Adriamycin)
    Decadron
    Dilantin
    Etoposide ( VP-16-213)
    Epogen/neupogen
    Fluorouracil ( 5 - FU)
    Herceptin
    Hormonal Antineoplastics
    Hydroxyurea ( Hydrea)
    IVIG
    Oxaliplatin
    Leucovorin Rescue Protocol)
    Melphalan ( Alkeran)
    Mercaptopurine ( 6-MP)
    Methotrexate ( amethopterin)
    Mitomycin ( Mutamycin)
    Taxotere
    Taxol
    Usulfan ( Myleran)
    Vinblastine ( Velban)
    Vincritstine ( Oncovin)
    EDUCATION AND CARE OF PATIENT WITH FOLLOWING EFFECTS OF CHEMOTHERAPY
    Abnormal Lab Values (Neutropenia, Pancytopenia, etc)
    Fatigue
    Nausea/Vomiting
    Anorexia
    Constipation/Diarrhea
    Mucositis/Stomatitis
    Renal or Hepatic Toxicity
    Cardiac Toxicity
    Alopecia
    Dermatitis
    Cystitis
    Neurotoxicity
    Pneumonitis
    Fever/Infection
    Depression/Anxiety
    Neuropathy
    Altered skin integrity
    Neutropenia Precautions
    Chemo Precautions
    Septic Shock
    CARDIOVASCULAR
    Cardiac toxicity
    Cardiac tamponade
    Cardiac dysrhythmias
    Phlebitis
    Extravasation
    Lymphedema
    RESPIRATORY
    Atelectasis
    Edema
    Pneumonia
    Pneumonitis
    Pulmonary Embolism
    Fibrosis
    GU/GI
    Anorexia/dehydration
    Nausea/Vomiting
    Constipation/Diarrhea
    Bowel Obstruction
    Renal or Hepatic Toxicity
    Renal Failure
    GI Bleed
    Cystitis
    Pancreatitis
    HEMATOLOGIC
    Anemia
    Disseminated Intravascular Coagulation ( DIC)
    Hemorrhage
    Leukopenia
    Thrombocytopenia
    Transfusion Reaction
    Fluid/electrolyte imbalance
    NEURO
    Neurotoxicity
    Ototoxicity
    Peripheral Neuropathy
    PSYCHOSOCIAL CARE
    Kubler-Ross stages of grieving
    Identify support groups for patients/family
    Self-care and coping skills
    Goal setting
    Advance directives
    Quality of life issues
    Palliative and Hospice care
    MISCELLANEOUS
    Manage Cytotoxic Spills
    Handle body fluids post chemo
    RADIATION THERAPY
    Knowledge of Early, Interim and Late Effects of Radiation
    Provide skin care post-radiation
    Brachytherapy - Interstitial/Intracavitary
    Nonsealed radioactive therapy
    Intraoperative radiotherapy (IORT)
    External radiotherapy
    Total body irradiation (TBI)
    Radiation safety precautions
    BONE MARROW TRANSPLANT
    Adult BMT experience
    Pediatric BMT experience
    Stem cell transplant
    Graft rejection
    Venoocclusive disease
    Graft-versus-Host disease (GVHD)
    SKIN
    Wound debridement
    Wet to dry dressing changes
    Care of drains and tubes
    Stress Fractures
    Dermatitis
    Alopecia