PICU Skills Checklist

Requested by:

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

GENERAL SKILLS 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 *

Setting - Children’s hospital	123
Setting - University healthcare facility	123
Setting - Community hospital	123
Family teaching	123
Assessment of normal growth & development	123
Recognize/report signs of child abuse/neglect	123
Consents	123
Specialty beds	123
Restrictive devices (restraints)	123
End of life care/pallative care	123
Wound assessment & care	123
Automated Medication Dispensing System, Pyxis, Omnicell, or other	123
Bar coding for medication administration	123
Diabetic care & education	123
Blood Glucose Monitoring (BGM)	123
Insulin administration	123
National Patient Safety Goals	123
Accurate patient identification	123
Awareness of HCAHPS	123
Effective communication	123
Interpretation & communication of lab values	123
Medication administration	123
Pediatric dosage calculations	123
Delivery methods: eye/ear/IM/IV/SQ	123
Medication reconciliation	123
Labeling (medications & specimens)	123
Anticoagulation therapy	123
Pain assessment & management	123
Steroids (inhaled/IV/PO)	123
Monitoring conscious sedation	123
Infection control	123
Universal precautions	123
Isolation	123
Minimize risk falls	123
Prevention of pressure ulcers	123

IV THERAPY 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 *

Starting & maintaining peripheral IVs	123
Blood draw: venous	123
Central line care (includes PICC/Broviac/Groshong/Hickman)	123
Blood draw: central line	123
Care & management of ports	123
Care & management of nonvascular devices (epidural, intrathecal)	123
TPN & lipids	123
Administration of blood & blood products	123
Infusion pumps	123

CARDIOVASCULAR 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 *

Pediatric CV assessment

123

ASSIST WITH INSERTION & MANAGEMENT OF:

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 *

Arterial line	123
CVC (central venous catheter)	123
Swanz-Ganz	123
Hemodynamic monitoring	123
Extra Corporeal Membrane Oxygenation (ECMO)	123
Use of doppler	123

CARDIAC MONITORING & EMERGENCY CARE:

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 *

Administration of PALS protocols & medications	123
Broslow system	123
Interpretation & treatment of dysrythmias	123
Rapid response team member	123
Use of rapid response teams	123

CARE OF CHILD 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 *

Bacterial endocarditis	123
DIC	123
Post cardiac cath	123
Cardiac transplant	123
Cardiogenic shock	123
Cardiomyopathy	123
Congenital heart disease/defects	123
Hypovolemic shock	123
Myocarditis/pericarditis	123
Permanent pacemaker	123
Temporary pacemaker	123

MEDICATIONS:

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 *

Antidysrythmics	123
Antihypertensives	123
Cardiac glycoside (digoxin)	123
Platelet inhibitors (Aggrastat/Integrilin/ReoPro)	123
Anti-rejection immunosuppressants	123
Vasoactive agents	123

PULMONARY 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 *

Respiratory assessment (rate & work of breathing)

123

EQUIPMENT/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 *

Metered dose inhaler	123
Nebulized medications	123
Assist with & manage intubation	123
Tracheostomy care	123
Assist with & maintain chest tube	123
Obtain & interpret Arterial blood gas	123
O2 therapy (NC/oxyhood/tent)	123
Thoracentisis	123
Ventilator management	123
Use of paralytics	123

CARE OF CHILD 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 *

Acute Respiratory Distress Syndrome (ARDS)	123
Respiratory Syncytial Virus (RSV)	123
Chronic respiratory disease	123
Croup	123
Epiglottits	123
Reactive Airway Disease (RAD)	123
Status asthmaticus	123
Pulmonary hypertension	123
Pneumonia	123
Near drowning	123

NEUROLOGICAL 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 *

Bronchodilators	123
Racemic epinephrine	123
Neurological Experience	123
Neuro assessment	123
Glascow coma scale	123

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 *

Assisting with LP	123
Intracranial pressure (ICP) insertion & monitoring	123

CARE OF CHILD 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 *

Muscular degenerative diseases	123
Meningitis	123
Coma	123
Brain death/organ procurement	123
Encephalitis/encephalopathy	123
External ventricular drains	123
VP shunts/reservoirs	123
TBI (Traumatic Brain Injury)	123
Status epilepticus	123
Spinal cord injury	123
Post nuero surgery	123

MEDICATIONS:

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 *

Anticonvulsants	123
Mannitol	123
Psychostimulants (Ritalin/Adderall)	123

ORTHOPEDICS 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 *

Orthopedic assessment

123

CARE OF CHILD 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 *

Traction	123
Cervical traction	123
Pinned fractures	123
Post vertebral surgery	123

GASTROINTESTINAL 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 *

GI assessment	123
Nutritional assessment	123

EQUIPMENT/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 *

Abdominal decompression (NG, sump tubes, intermittent & continuous suction)	123
Colostomy/ileostomy	123
Placement of feeding tubes (NG)	123
G-tube/J-tube	123
Gastrointestinal - cont. Experience	123

FEEDINGS:

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 *

Assist with breastfeeding	123
Breastmilk handling & storage	123
Bottle	123
Gavage	123
Use of feeding pumps	123

CARE OF CHILD 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 *

Abdominal trauma; bleeding	123
Ascites	123
Surgical abdomen	123
Severe dehydration/gastroenteritis	123
Hepatic failure	123
Hepatitis	123
Hyperbilirubinemia	123
Necrotizing Entercolitios (NEC)	123
Ruptured spleen	123
GI bleeding	123
GI organ transplants	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 fluid balance

123

EQUIPMENT/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 *

Assist with suprapubic taps	123
Insertion & care of foley catheter	123

CARE OF CHILD 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 *

Acute renal failure	123
Hemodialysis	123
Peritoneal dialysis	123
Hemolytic Uremic Syndrome (HUS)	123
Post renal transplant	123
Nephritis	123
Ileal conduit	123

SKIN CARE 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 *

Skin assessment	123
Surgical wound healing	123

CARE OF CHILD 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 *

Burns	123
Traumatic wounds	123
Vacuum Assisted Device (VAC)	123

ONCOLOGY 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 *

Administration of chemotherapy	123
Monitoring of chemotherapy (does not initiate)	123
Assist with bone marrow aspiration	123

CARE OF CHILD 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 *

Acute anemia	123
Acute tumor lysis syndrome	123
Bone marrow transplant	123
Leukemia	123
Malignant tumors	123
Neutropenia	123
Radiation implant	123
Sickle cell anemia	123
Hemophilia	123
Graft verses host disease	123
Inpatient hospice	123

AUTOIMMUNE DISEASES 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 *

Addison’s disease	123
Cushing’s disease	123
Celiac disease/gluten intolerance	123
Grave’s disease	123
Hypothyroidism	123
Lupus	123

INFECTIOUS DISEASES 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 *

Usual child diseases (mumps/measles/chicken pox)	123
CMV/HIV/AIDS	123
Tuberculosis	123
Septic shock	123
Fever management	123

MEDICATION/ADMINISTRATION:

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 *

Antiinfectives

123

MISCELLANEOUS EXPERIENCE - CARE OF CHILD 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 *

Trauma	123
Craniofacial reconstruction	123
ENT surgery	123
Ingestions/overdose	123
Suicidal ideation/attempts	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. *