This checklist was electronically signed on (Today’s date)
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
Proficiency Scale:
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
Intramuscular Injections
Z-Track Injections
Ophtalmic Drops
Nasal Drops
Topical Ointments
Emergency Meds-Crash cart
Heparin Lock
Subcultaneous Injections
Intradermal
Inhalers
Vaginal Suppositiories
Ophthalmic Ointments
Oral Medications
Rectal Suppositories
Starting an IV
Change IV tubing
Discontinuing an IV
Piggyback Administration
Plasma
Packed RCB
Regulate Flow
Medication Addition
Whole Blood Administration
Serum Albumin
Platelets
CVP Line
Chemo-therapy
IV Push Drugs
Hyperalimentation
Maintain IV Site
Knowledge of Universal Precautions
Knowledge of Waste Disposal
Proper Disposal of Sharps
Cleaning of Equipment
Care of Patient in Reverse isolation
Management of Patient in Respiratory isolation
Perform Neurological Assessment
Performa Cardiovasicular Assessment
Perform Genitourinary Assessment
Perform Respiratory Assessment
Perform Maskuloskelatal Assesment
Management of the Patient with Drug Interaction/ Allergic Reaction
Management of Patient with Cardio Pulmornary Arrest
Lifting and Pulling
Transfer to Chair
Tranfer Patient to and from Gurney
Turning and Postioning
Transfer Patient to Wheelchair
Transfer Patient to and from Toilet
Observation of Patients in Restraints
Documentation
Application of Soft Limb Restraints
Application of Posey Restraints
Knowledgeable of Safety Guidelines for Patients in Restraints
Application of Leather Restraints
Hemovac / Davol Suction Pump
Care of Patient with PCA (Patient Control Anesthesia) Pump
Infusion Devices (Volumetric Pump)
Venturi Mask
Management of Trach Collar
Knowledge of USe of Bed Scale
Management of Oxygen Mask
ABG Kits
Use of Hoyer Lamp
Use of Heart Lamp
Use of Blood Glucose Monitors
Use of Wall Suction
Alternate Pressure Mattress
Humidifiers
Use of Corstavac Suction
Knowledge of Use of Heating Pad
Assist with / Set up of Water Seal Suction
Knowledge of USE of Incentive Spriometer
Pieurevac/ Emerson Suction
Knowledge of Use of Egg crate Mattress
Enteral Pump
Management of Nasal Cannula
Ue of Ambu - Bag
Application of TED Hose
Obtain Urine for Specific gravity
Obtain Sputum Specimen
Instruct Patient / Assist with Clean
Obtain Stool Hemocuit
Catch/ Midstream Urine Specimen
Obtain Foley Catheter Specimen
Perform Straight Catherterization
Collect 24 Hour Urine Spicemen
Obtain Urine Culture
Perform Personal Hygiene / Oral Care
Administer Fleets Enema
Perform Wet to Dry Dressings
Perform Bladder Irrigation
Management of Leviene Tube
Management of Jejunostomy
Management of Chest Tube
Perform Oral Suctioning
Perform Wound Irrigation
Perform Sterile Dressing Changes
Perform NG Tube Feeding
Set up / Instruct Patient in Sitz Bath
Administer Tap/ Saline Enema
Administer Soap Suds Enema
Administer Douches
Perform Catheterization (female & male)
Adminstrater Oil Retention Enema
Perform Ostomy Care
Perform Nasal Suctioning
Management of Nephrostomy Catheter
Performing Team Lead Duties
Giving Tape Report
Giving Oral Report
Making Assigments
Reporting on Assigned Patients
Making Rounds
Infant (Birth to 1 year)
Toddler (1-3 years)
Pre-school (3-6 years)
School Age (6-12 years)
Adolescent (12-18 years)
Young Adult (18-30 years)
Elderly (>60 years)
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