Wound Care Skills Checklist

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Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

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

PRESSURE ULCER:

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 - Ulcer Characteristics	123
Prevention - Risk Assessment Tool (Braden, Norton)	123

PRESSURE ULCER STAGING:

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 *

Reactive Hyperemia	123
Stage One	123
Stage Two	123
Stage Three	123
Stage Four	123
Deep Tissue Injury	123

PRESSURE ULCER SUPPORT SURFACES:

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 *

Static Air	123
Alternating Air	123
Foam	123
Gel	123
Water	123
Combination	123
Low Airloss	123
Dynamic (Kinetic) Air	123
Air Fluidized	123
Continuous Lateral Rotation	123

NEUROPATHIC (DIABETIC FOOT) ULCER 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 *

Offloading	123
Serial Debridement	123
Prevention/Diabetic Teaching	123
Ulcer Assessment Characteristics	123

VENOUS STASIS ULCER 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 *

Compression Therapy	123
Ulcer Assessment Characteristics	123
Skin Signs of Venous Stasis	123

PERIPHERAL ARTERIAL ULCER (PAD):

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 *

Ankle Brachial Index	123
Ulcer Assessment Characteristics	123
Skin Signs of Diminished Circulation	123

OTHER WOUNDS:

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 *

Fistulae - Pouching, Skin Care	123
Drains - Management of	123
G/J Tubes - Anchoring, Skin Care	123

WOUND CARE 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 *

Debridement	123
Autolytic	123
Enzymatic	123
Mechanical	123
Sharp	123
Surgical	123
Dressings/Treatments	123
Hydrogels	123
Hydrocolloids	123
Silver Products	123
Foams	123
Alginates	123
VAC (Vacuum Assisted Closure)	123
Growth Factors	123
Skin Substitutes	123
Hyperbaric Oxygen Therapy	123
Culturing of Wounds	123
Electrical Stimulation	123
Enzymatic Debriding Agents	123
Debriding Ointments	123
Mist Therapy	123

COLOSTOMY:

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 *

Loop w/Rod Stoma	123
End Stoma	123
Mucous Fistula	123
Double Barrel Stoma	123
Irrigation Procedure	123
Stoma Within Incision	123
Related Conditions/Surgeries	123
Abdominoperineal Resection	123
Rectal Cancer/Colon Cancer	123
Diverticulitis	123
Colitis/Crohn’s Disease	123
Pelvic Exenteration Anterior	123
Pelvic Exenteration Posterior	123

ILEOSTOMY:

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 *

Loop w/Rod Stoma	123
End Stoma	123
Ileal Lavage	123
Related Conditions	123
Crohn’s Disease	123
Ulcerative Colitis	123
Familial Polyposis	123
Short Bowel Syndrome	123

CONTINENT ILEOSTOMY:

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 *

Kock Pouch	123
Pelvic Pouch	123

CONTINENT UROSTOMY:

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 *

Kock Pouch	123
Indiana Pouch	123
Neobladder	123

STOMAL, PERISTOMAL SKIN CONDITIONS:

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 *

Flush or Recessed Stoma	123
Stomal Necrosis	123
Stomal Prolapse	123
Peristomal Hernia	123
Denuded Skin/Ulcerations	123
Skin Infections/Fungal Infections	123
Mucocutaneous Separation	123
Hyperplasia	123
Pyoderma Gangrenosum	123
Stoma Plane Dynamics	123

OSTOMY EQUIPMENT:

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 *

One-Piece/Two-Piece Appliance	123
Open End, Closed End, Clip or Velcro Closure for Pouches	123
Convex/Flexible Pouching Systems	123
Skin Barriers/Sealants	123
Barrier Pastes/Strips/Rings/Discs/Washers	123
Wound Pouches	123
Molding Kit for Custom Appliances	123
Irrigation Procedure	123
Single/Double Lumen Catheters for Culture	123
Reusable Ostomy Equipment	123
Measure for Ostomy Belts/Peristomal Hernia Support Belt	123

CONTINENCE EVALUATION/ASSESSMENT:

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 *

Urodynamics	123
Manometry	123
Electromyography	123
Leak Point Pressures	123
Cystometrogram	123
Uroflometry	123
Biofeedback - Diagnostic/Treatment	123
PNTML (Pudendal Nerve Terminal Motor Latency)	123
Ultrasound	123

CONTINENCE SKIN CARE/CONTAINMENT:

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 *

Skin Sealants	123
Moisture Barriers	123
Absorbent Garments	123
Skin Care	123

CONTINENCE THERAPEUTIC DEVICES:

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 *

Vaginal Cones	123
Penile Clamps	123
Male Urinals	123
Male External Catheters	123
Internal Urethral Inserts (Female)	123
Catheters - Indwelling	123
Catheters - Intermittent Self Cath and Teaching for	123
Magnetic Therapy	123
Urinary Incontinence/Bladder Programs	123
Fecal Incontinence/Bowel Programs	123

PEDIATRIC RELATED CONDITIONS:

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 *

Necrotizing Enterocolitis	123
Inflammatory Bowel Disease	123
Irritable Bowel Syndrome	123
Meckel Diverticulum	123
Familial Adenomatous Polyposis	123
Distal Ureter or Bladder Defects	123
Hirschsprung’s Disease	123
Megacolon	123
Malabsorption Syndromes	123
Obstructive Disorders	123
Spinal Cord Injury	123
Neurogenic Bladder	123
Diaper Dermatitis	123
Stoma Care - Loop Stoma	123
Dehydration Risks in Pediatric Patients	123
High Output Stoma - Skin Barrier Issues	123

G/J TUBES:

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 *

Anchoring Devices	123
Skin Protection for Leakage of Gastric Contents	123
Long Term Tubes/Skin Level Devices for Feeding	123
Procedures for Flushing/Treatment for Clogging	123

OTHER:

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 *

IV Infiltration Wounds	123
Incision Care	123
Burns	123
Bariatric Patients	123
Self-Catheterization/Teaching	123
Indwelling Catheter Care	123
Medications	123
Bowel and Bladder Training Programs	123

INTERPRETATION OF LAB RESULTS:

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 *

Albumin/Total Protein	123
Obtaining Wound Cultures	123
Urine Cultures	123
Tumor Staging	123
Pathology Reports	123

OSTOMY EQUIPMENT:

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 *

One-Pi

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. *