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
    Do you have charge/supervisor experience?
    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"
    MEDICATION ADMINISTRATION
    Moderate/Conscious Sedation
    Sedation Reversal Agents
    CARDIOVASCULAR GENERAL SKILLS
    Blood pressure/invasive (arterial line)
    Heart Sounds/Murmurs
    Central venous pressure
    Invasive hemodynamic monitoring PA/Swan Ganz
    Defibrillation/Cardioversion
    EKG Interpretation (Basic and Advanced)
    CARDIOVASCULAR-Care of the Child With:
    Anaphylactic Shock
    Bacterial Endocarditis
    Coarctation of the Aorta
    Cardiac Arrest
    Cardiac Transplant
    Cardiogenic shock
    Cardiomyopathy
    Fresh Open Heart Surgery
    Hypoplastic Heart
    Hypovolemic Shock
    Myocarditis
    Open Heart Surgery, more than 6 hours
    Post Interventional Cardiac Cath
    Septal Defect
    Septic Shock
    Tetrology of Fallot
    Transposition of the Great Vessels
    RESPIRATORY GENERAL SKILLS
    Ability to Assess Lung Sounds
    Obtaining Blood Gases
    Pulse Oximeter
    Airway Management
    Assist with Intubation
    Assist with Extubation
    Suctioning
    Bulb Syringe
    Nasal airway/suctioning
    Oral airway/suctioning
    Apnea/Apnea Monitoring
    Chest Tube (assist with)
    Insertion
    Removal
    ECMO (Extracorporeal Membrane Oxygenation)
    End Tidal CO2
    O2 Therapy
    Bag & mask
    Isolette
    Oxyhood
    Tent
    Trach collar
    Thoracentesis
    Ventilators
    CPAP/PEEP/BIPAP
    High frequency jet ventilator
    Oscillating ventilator
    Pressure ventilator
    Volume ventilator
    Weaning
    RESPIRATORY-Care of Child With:
    Asthma
    Asphyxiation
    Bronchiolitis(RSV)
    Bronchopulmonary Dysplasia
    Pneumonia
    Croup
    Chronic respiratory disease
    Cystic Fibrosis
    Lung Transplant
    Epiglottitis
    Fresh tracheostomy
    Foreign body aspiration
    Flail Chest
    Hemothorax
    Near Drowning
    Tonsillitis
    Pertussis
    Pneumothorax
    Respiratory distress syndrome (RDS)
    Respiratory Arrest
    Respiratory failure
    NEURO GENERAL SKILLS
    Glasgow Coma Scale
    Assist with lumbar puncture
    Seizure Precautions
    Intracranial pressure monitoring
    NEURO-Care of Child With:
    Epilepsy
    Febrile Seizure
    Head Trauma
    Post Neurosurgery
    Spinal Cord Injury
    Status epilepticus
    Coma
    Brain death/organ procurement
    Encephalitis
    Meningitis
    Externalized VP shunt/reservoirs
    Neuromuscular disease
    Anticonvulsants
    GASTROINTESTINAL GENERAL SKILLS
    Abdominal Assessment
    Interpretation of Lab Results - Serum Electrolytes
    Ability to Set Up and Program Feeding Pumps
    Feedings (Storage and Prep of)
    Bottle
    Breast
    Gavage
    TPN
    PPN
    Gastrostomy/Button/NGT
    J-Tubes
    NG to Suction
    Gastric Lavage
    Placement of Naso/Orogastric Tube
    GASTROINTESTINAL-Care of Child with:
    Anal Fissure
    Anorexia/Bulimia
    Cleft Lip/Palate
    Colostomy
    Ileostomy
    Fresh Ostomy
    Diaphragmatic Hernia
    Severe Failure to Thrive (FTT)
    Pancreatitis
    Pyloric Stenosis Repair
    GE Reflux
    GI Bleeding
    Crohn's Disease
    Ulcerative Colitis
    Severe Gastroenteritis/Dehydration
    Intestinal Parasites
    Necrotizing Enterocolitis (NEC)
    Surgical Abdomen
    Liver Transplant
    Small Bowel Transplant
    Poison Ingestion/Overdose
    RENAL/GENITOURINARY GENERAL SKILLS
    Assessment of fluid balance
    Interpretation of Lab Results (UA/BUN/Creatinine)
    Test urine and interpret
    Collection of urine specimens
    Assist with suprapubic tap
    Insertion & Care of Straight and Foley Catheter
    Suprapubic
    RENAL/GENITOURINARY-Care of Child With:
    Acute renal failure
    CAVH
    Peritoneal dialysis
    Hemodialysis
    Hemolytic uremic syndrome (HUS)
    Nephritis
    Nephrotic syndrome
    Renal transplant
    Syndrome of inappropriate ADH (SIADH)
    ENDOCRINE/METABOLIC GENERAL SKILLS
    Diabetes mellitus
    Diabetic ketoacidosis
    Diabetic coma
    Hyper/hypocalcemia
    Hyperbilirubinemia
    Kawasaki's Disease
    Thyroid dysfunction
    ORTHOPEDICS GENERAL SKILLS
    Specialized orthopedic bed
    ORTHOPEDICS-Care of Child With:
    Cervical traction
    Fracture/Cast Care
    Splints
    Open Fracture
    Closed Fracture
    Pinned fractures
    Post vertebral surgery
    WOUND MANAGEMENT
    Assessment of skin status
    Stasis ulcers
    Multiple abdominal wounds and drains
    Gunshot Wounds
    Stab Wounds
    Hazardous Material Exposure
    Surgical wound healing
    Lacerations
    Sterile dressing changes
    Wound care/irrigations
    Drains
    JP
    Penrose
    Hemovac
    WOUNDS-Care of Child With:
    Burns
    Rule of Nines
    First Degree
    Second Degree
    Third Degree
    Fluid Resuscitation Burn Formulas
    Radiation Exposure
    Pressure sores
    Electrical Burns
    Traumatic wounds
    ONCOLOGY/BLOOD DYSCRASIAS
    Reverse isolation
    Interpretation of Lab Result
    ONCOLOGY-Care of Child With:
    Malignant tumors
    Hodgkins Disease
    Fresh oncologic surgery
    Acute tumor lysis syndrome
    Leukemia
    Wilm's Tumor
    Bone Marrow transplant
    Disseminated intravascular coagulation
    Sickle Cell Anemia
    Chemotherapy
    Radiation implant
    INFECTIOUS DISEASES GENERAL SKILLS
    COVID-19 Isolation
    Cultures (Including sensitivities)
    CBC/differential (shift)
    INFECTIOUS DISEASES-Care of Child With:
    Isolation Precautions/Procedures
    Cytomegalovirus (CMV)
    HIV/AIDS
    MRSA
    VRE
    CRE
    Tuberculosis
    C- Difficile
    Hepatitis
    Common childhood communicable diseases
    PHLEBOTOMY/IV THERAPY
    Peripheral IV Insertion, Care and Maintenance
    Intraosseous Line
    Hickman
    Groshong
    Saline Lock
    Aortocath
    Broviac
    Quinton Catheter
    Central Line Care and Maintenance
    PICC Line Care and Maintenance
    Peripheral Line
    Arterial Line
    Drawing Blood from Central Line/PICC Line
    Drawing Venous Blood
    Administration of Blood/Blood Products
    Cryoprecipitate
    Packed Red Blood Cells
    Whole Blood
    PAIN MANAGEMENT GENERAL SKILLS
    Assessment - Pain Level Using Age Appropriate Scales
    MISCELLANEOUS
    Phototherapy
    Normal Growth & Development
    Normal Laboratory Values
    Recognize Signs of Abuse or Neglect
    Immunization Schedule
    MISCELLANEOUS-Care of Child With:
    Anorexia/Bulimia
    Craniofacial Reconstruction
    Depression
    HEENT Surgery
    Suicide attempt
    MEDICATION ADMINISTRATION FOR CHILDREN
    Calculation of Pediatric Doses
    Titration of IV drips
    Eye/Ear Installations
    Metered Dose Inhaler
    Intravenous medications (IV)
    Subcutaneous (SQ) injections
    Z Trach
    Knowledge of emergency drug action and reaction
    Pediatric drug actions & reactions
    Antipyretics
    Adenosine
    Aminophylline
    Atropine
    Anticoagulants
    Anticonvulsants
    Antibiotics
    Antihypertensives
    Charcoal
    Cardizem
    Decadron
    Dilantin
    Dopamine
    Diuretics
    Digoxin
    Epinephrine
    Growth Hormone
    Heparin
    Hyperalimentation
    Immunizations
    Inotropes ( Dobutamine, Primacor)
    Intrathecal Medications
    Inocor
    Insulin
    Insulin Drips
    Isuprel
    Kayexalate
    Lidocaine
    Mannitol
    Narcotic Analgesics
    Narcan
    Nitroglycerin
    Nipride
    Steroids
    Sodium Bicarbonate
    TPA
    Vasopressin
    Ventolin (albuterol)