Dialysis Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

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WORK SETTING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Inpatient Acute Care Facility	123
Trauma Center	123
Academic/Teaching Facility	123
Outpatient Care Facility	123
Long term care/Skilled Nursing	123
Clinic/Ambulatory	123
Home Health Setting	123

RENAL/GENITOURINARY EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Assessment Of Renal/Gu System	123
Insertion Of Foley	123

CARE OF PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Nephrostomy Tube	123
Av Fistula / Av Graft	123
Tunneled / Non - Tunneled Catheter	123
Ileal Conduit	123
Supra - Pubic Catheter	123
Chronic Renal Failure	123
Acute Renal Failure	123
Nephrectomy	123
Turp	123
Peritoneal Dialysis	123
Hemodialysis	123
Fluid Overload	123
Hypo / Hypertension	123
Disequilibrium Syndrome	123
Hypo / Hyperkalemia	123
Seizures	123
Clotted Access / Poor Blood Flow	123
Pyrogenic Reaction	123
Hemolysis	123
Air Embolus	123
Chest Pain	123
Anemia	123
Neuropathy	123
Pericarditis	123
Filter Blood Leak	123
Cardiac Arrest	123

HEMODIALYSIS / PROCEDURES:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Acute / Inpatient Dialysis	123
Chronic / Outpatient Dialysis	123
Dialysis Home Care	123
Pediatric Dialysis	123
Predialysis Nursing Assessment	123
Teaching The Dialysis Patient And Family	123

SET-UP / STARTING DIALYSIS TREATMENT:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Collect Blood Specimens	123
Anticoagulation	123
Dialysis	123
Fistula Gortex / Bovine Graft	123
Prep Vascular Access	123
Checking Alarm Settings / Machine	123
Priming Dialyzer	123
Conductivity Testing	123
Bicarbonate Dialysis	123

ASSESS PATIENT & EQUIPMENT DURING DIALYSIS:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Systems Assessment Of Patient	123
Volume Status	123
Vascular Access Function	123
Arterial And Venous Pressures	123
Blood Flow Rate	123
Subjective Response To Treatment	123
Management Of Anticoagulation	123
Conductivity	123
Ultrafiltration Calculation	123
Operation Of Myron L Meter	123
Administration Of Blood/Blood Products	123
Administration Of Mannitol	123
Sequential Ultrafiltration / Puf	123
Documentation Of Treatment	123

DISCONTINUED DIALYSIS:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Dialysis Catheter	123
Fistula / Vein Graft	123
Return Of Blood	123
Post Treatment Access Care	123
Equipment Clean Up	123
Sterilization Procedures	123

MISCELLANEOUS:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Care Of Immuno- suppressed Patient	123
Care Of Patient With Aids	123
Isolation Techniques	123
Assessment Of Wound Healing	123
Sterile Dressing Changes	123
Phlebotomy / Venous Blood Draw	123
Patient Education regarding Organ & Tissue Donation	123

AGE-SPECIFIC EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Newborn / neonate (birth-30 days)	123
Infant (31 days-1 year)	123
Toddler (ages 2-3 years)	123
Preschool (ages 4-5 years)	123
School age (ages 6-12 years)	123
Adolescent (ages 13-21 years)	123
Young adult (ages 22-39 years)	123
Adult (ages 40-64 years)	123
Older adult (ages 65-79 years)	123
Elderly (ages 80+ years)	123

Attestation

ATTESTATION: *

I certify that the information provide above accurately reflects my experience in each of the clinical areas identified within the past three years.

If you agree with the Attestation above, please electronically sign your name. *