This checklist will be used to assess your suitability for placement.
Experience Guide
1 - Not Applicable -
minimal or no exposure to clinical aspect or care.
2 - Beginner -
sufficient knowledge to understand the contextual nature of the function, able to perform routine functions independently, requires assistance when setting priorities in complex situations, needs to gain speed and flexibility to be competent.
3 - Competent -
perceives situations and functions as a whole, has knowledge of the typical events to expect in a given situation and the appropriate responses, flexible in decision making.
4 - Proficient -
considerable background and experience, can grasp situations intuitively, mastery in performance, incorporates elements of innovation and creativity in clinical experience.
Systems Assessment
Postpartum Interventions
Post/Partum Interventions
Experience 1 2 3 4
Bladder Distention
Breast Engorgement
Dvt (deep Vein Thrombosis)
Epidural Block Recovery
Episiotomy
Fluid Balance
Fundal Height
Gi Function Post Anesthesia
Lochia Amount
Parental/infant Interaction/attachment
Perineum: Hematoma
Perineum: Hemorrhoids
Procedures
Experience 1 2 3 4
Breastfeeding/Positioning and Latching On
Formula Preparation And Feeding
Foster Parent/infant Attachment
Infant Care Restraint Systems
Infant Caretaking Skills
Perineal Care
Post Cesarean Care
Post General Anesthesia
Post Local Anesthesia
Post Spinal Block
Sitz Bath
Use Of Breast Pumps
Nursery
Experience 1 2 3 4
Assess Circumcision Site Post Op
Eye Prophylaxis
Incubator/Isolette Usage
Infant Bathing Teaching
Infant Identification
Neonatal CPR
Obtain Urine Specimens Via Bag
Phototherapy
Suctioning/Bulb, DeLee
Teach Circumcision Care To Parents
Teach Cord Care to Parents
Test Stool For Blood, Reducing Substances
Vitamin K
Skilled Nursing Care
Skilled Nursing Care
Experience 1 2 3 4
Administration of Blood/Blood Products
Airway Management
Assess Circulation
Assessment Management of Pain
Assist/Monitor Post Anesthesia(Regional/Spinal/Epidural)
Automated Medication Dispensing Systems
Bar Coding
Blood Glucose Monitoring
Buretrol/Soluset/IV Piggyback Safeguards
Calculate IV Fluid Rates
Calculate Medication by Weight
Calculate Total Intake and Output by Weight
Cardiac Arrest/ACLS Adults
Cardiac Arrest/CPR Pediatrics
Cardiac Arrest/NPR Neonatal
Cardiac Monitoring
Care of Isolation Patient
Care of Restrained Patient
Coaching Family Needs: Physical/Emotional/Comfort
Computer Documentation
Computerized Charting
End of Life Care
Heparin Lock and Saline Flush
Interpretationof ABGs
Intramuscular Injections ( Adult & Neonate )
Intramuscular Route ( Adult & Neonate )
Intravenous Infusions/Buretrol/Soluset
IV Piggyback
IV Push Neonatal
IV Push Neonatal Safeguards
Knowledge and Communication of Normal Lab Values
Lift/Transfer Devices
Manangment of Fluid/Electrolytes Balance
NG Tube Insertion/Maintenance
Oral/Nasotracheal Suctioning
Oxygen Delivery
Patient/Family Teaching
PCAs
Peripheral IVs/Blood Draw
Pulse Oximetry
Scalp Veins
Seizure Precaution
Suctioning
TPN/Lipids
Universal Precautions
Urinary Catheter Insertion/Maintenance
Use of Doppler
Use of Infusion Pumps/IV Monitoring
Age Specific Practice Criteria
Please check the boxes below for each age group for which you have expertise in providing age-appropriate nursing care.
A.
New Born/Neonate
(Birth - 30 days)
B.
Infant
(30 days - 1 Year)
C.
Toddler
(1 - 3 Years)
D.
Preschooler
(3 - 5 Years)
E.
School age children
(5 - 12 Years)
F.
Adolescents
(12 - 18 Years)
G.
Young Adults
(18 - 39 Years)
H.
Middle Adults
(39 - 64 Years)
I.
Older Adults
( +64 Years)
Experience With Age Groups
Able to adapt care to incorporate normal growth and development
A
B
C
D
E
F
G
H
I
Able to adapt method and terminology of patient information to their age, comprehension and maturity level.
A
B
C
D
E
F
G
H
I
Can ensure a safe environment reflecting specific needs of varying age groups.
A
B
C
D
E
F
G
H
I
By submitting this checklist you agree to the following:
I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize the Company to release this Skills Checklist to the Client facilities in relation to consideration of employment as a per diem nurse with those facilities.
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