NICU Skills Checklist

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Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

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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 *

Experience in level II nursing	123
Experience in level III nursing	123
Awareness of HCAHPS	123
Setting: Childrens hospital	123
Setting: University healthcare facility	123
Setting: High risk delivery center	123
Setting: Community hospital	123
Family teaching	123
Consents	123
Specialty beds: giraffe incubator	123
Specialty beds: radiant warmer bed	123
Restrictive devices (restraints)	123
Preparation for transport/transfer	123
Air transport (jet or helicopter)	123
Other transport experience: stable return transport	123
Other transport experience: procedural transport	123
End of life care/palliative care	123
Wound assessment & care	123
Automated Medication Dispensing System, Pyxis, Omnicell, or other	123
Bar coding for medication administration	123
Blood Glucose Monitoring (BGM)	123
Insulin/dextrose administration	123
National Patient Safety Goals	123
Accurate patient identification	123
Effective communication	123
Interpretation & communication of lab values	123
Medication administration	123
Infant dosage calculations	123
Delivery methods: IM/IV/SQ	123
Medication reconciliation	123
Labeling (medications & specimens)	123
Anticoagulation therapy	123
Steroids (inhaled/IV/PO)	123
Monitoring conscious sedation	123
Pain assessment & management	123
Infection control	123
Universal precautions	123
Isolation	123
Minimize risk falls	123
Skin assessment	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 IVs	123
Blood draw: heel stick/venous	123
Central venous insertion & management	123
Blood draw: central line	123
Maintain umbilical catheter (arterial/venous)	123
TPN administration	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 *

CV assessment	123
Invasive hemodynamic monitoring	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 *

NRP protocols & medication	123
Use of S.T.A.B.L.E. program & protocols	123
Broslow system	123
EKG interpretation & treatment	123
Use of rapid response teams	123
Defibrillation/cardioversion	123

CARE OF INFANT 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 *

Congenital heart disease	123
CHF	123
Hemodynamic instability	123
Hypovolemic shock	123
Post cardiac surgery	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 *

Antidysrythmics	123
Antihypertensives	123
Cardiac glycoside (digoxin)	123
Platelet inhibitors (aggrastat/integrillin/reopro)	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	123
Obtain & interpret blood gases	123
Airway management (nasal/oral/ET)	123
Tracheostomy care & management	123
Oxygen therapy (NC/oxyhood)	123
Pulse oximeter	123
Ventilation & management	123
High Frequency Jet Vent (HFJV)	123
Partial liquid ventilation	123
Nitric oxide therapy	123
Surfactant therapy	123
ECMO	123
Assist with & manage chest tube	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 *

Apnea	123
Bronchopulmonary Dysplasia (BPD)	123
Diaphragmatic hernia	123
MAS (Meconium Aspiration Syndrome)	123
Pulmonary edema	123
Persistent Pulmonary Hypertension (PPHN)	123
Respiratory Distress Syndrome (RDS)	123
Pneumothorax	123

Bronchodilators

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 *

Neurological assessment	123
Drug withdrawal & abstinence scoring	123

CARE OF INFANT 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 *

Seizures	123
Meningitis	123
External VP shunt/reservoirs	123
ICP monitoring	123
Spinal disorders	123
Neurological development & positioning	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

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 (include palate & girth)	123
Nutritional assessment	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 breast/bottle feeding	123
Breastmilk handling & storage	123
Gavage	123
Placement of OGT/NGT	123
Gastrostomy tubes	123
Colostomy/ileostomy care	123

CARE OF INFANT 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 *

Tracheoesophogeal fistula (TEF)	123
Cleft lip/palate	123
Necrotizing Entercolitios (NEC)	123
Gastroenteritis/omphaloocele	123
Inguinal hernia	123
Post abdominal surgery	123

RENAL/GU 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 *

Urinary catheter insertion & management	123
Peritoneal dialysis	123
Assist with circumcision	123
Post circumcision care	123

CARE OF INFANT 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
Malformations of GU tract	123
Hydronephrosis	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 *

Assist with lumbar puncture

123

CARE OF INFANT 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 *

Neonatal sepsis	123
HIV positive mother	123
HBsAg positive mother	123

MEDICATION:

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 *

Immunizations	123
Anti-infectives	123
Respigam/synergis prophylaxis	123

ADMISSION/ASSESSMENT 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 *

Attending high risk deliveries	123
APGAR scoring	123
Gestational age	123
Eye exam	123
Hearing screen	123
Thermoregulation	123
Care of infant under phototherapy	123
Experience in level II nursery	123
Experience in level III nursery	123

AGE-SPECIFIC COMPETENCIES 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 *

Neonatal (< 23 weeks)	123
Neonatal (24-28 weeks)	123
Neonatal (29-32 weeks)	123
Neonatal (>33 weeks)	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. *