NICU / PICU Skills Competency Checklist Form

Name:*

Date

Total years of NICU / PICU experience:

Rate your skills:
0 - NO Experience. Theory only.
1 - Limited competency / proficiency.
2 - Performed Infrequently, may need some supervision required.
3 - Competent / proficient. Performed frequently and independently during the past 2 years.

Skill

I. CARE OF PATIENTS

Premature infants

0

1

2

3

Post-mature infants

0

1

2

3

Birth injuries

0

1

2

3

Soft tissue injury

0

1

2

3

Head trauma

0

1

2

3

Intracranial hemorrhage

0

1

2

3

Perinatal Hypoxic-Ischemic brain injury

0

1

2

3

Fractures

0

1

2

3

Paralysis

0

1

2

3

Dermatologic problems

0

1

2

3

Candidiasis

0

1

2

3

Erythema Toxicum Neonatorum

0

1

2

3

Bullous Impetigo

0

1

2

3

Cancer

0

1

2

3

Anemia

0

1

2

3

Hyperbilirubinemia

0

1

2

3

Hypocalcemia

0

1

2

3

Hyperglycemia

0

1

2

3

Hypoglycemia

0

1

2

3

Phenylketonuria (PKU)

0

1

2

3

Hypoglycemia

0

1

2

3

Hepatic Phototherapy

0

1

2

3

Galactosemia

0

1

2

3

Congenital Hypothyroidism

0

1

2

3

Down's Syndrome

0

1

2

3

RDS

0

1

2

3

Bronchopulmonary Dysplasia (BPD)

0

1

2

3

Low Apgar scores

0

1

2

3

Low birth weight

0

1

2

3

Small for gestational age

0

1

2

3

Large for gestational age

0

1

2

3

Apnea of prematurity

0

1

2

3

Seizures

0

1

2

3

Sepsis

0

1

2

3

Meconium aspiration

0

1

2

3

Persistent Patent Ductus Arteriosis

0

1

2

3

Persistent Pulmonary Hypertension

0

1

2

3

Retinopathy of Prematurity

0

1

2

3

Narcotic addicted infant

0

1

2

3

Fetal Alcohol Syndrome

0

1

2

3

Spina Bifida

0

1

2

3

Hydrocephalus

0

1

2

3

Skeletal defects

0

1

2

3

Acquired Infections from Mother

0

1

2

3

AIDS

0

1

2

3

Chickenpox

0

1

2

3

Chlamydia

0

1

2

3

Gonococcal Disease

0

1

2

3

Hepatitis B

0

1

2

3

Herpes

0

1

2

3

Listeriosis

0

1

2

3

Lyme Disease

0

1

2

3

Rubella

0

1

2

3

Syphilis

0

1

2

3

Toxoplamosis

0

1

2

3

Ingestion / Overdose

0

1

2

3

Blunt Trauma

0

1

2

3

Gun shot

0

1

2

3

Open chest

0

1

2

3

Kawasaki disease

0

1

2

3

Near drowning

0

1

2

3

Malnutrition / anorexia / bulimia

0

1

2

3

Penetrating trauma

0

1

2

3

Pneumonia

0

1

2

3

Meningitis

0

1

2

3

Congenital Heart Defects

0

1

2

3

II. ASSESSMENTS:

Cardiovascular

0

1

2

3

Pulmonary

0

1

2

3

GI

0

1

2

3

GU

0

1

2

3

Musculoskeletal

0

1

2

3

Neurological

0

1

2

3

Neurological reflexes

0

1

2

3

Integumentary

0

1

2

3

Lab values

0

1

2

3

Vital signs

0

1

2

3

E / SE Medication

0

1

2

3

Drug / Drug Interactions

0

1

2

3

III. CARDIOVASCULAR:

Heart sounds

0

1

2

3

BP interpretation

0

1

2

3

EKG

0

1

2

3

Cardiac catheterization

0

1

2

3

Shunt

0

1

2

3

IV. ENDOCRINE:

Preparation of Insulin

0

1

2

3

Administration of Insulin

0

1

2

3

Urine Testing

0

1

2

3

Blood Testing

0

1

2

3

V. PULMONARY:

Apnea Monitor

0

1

2

3

Oralpharyngeal suctioning

0

1

2

3

Nasotracheal suctioning

0

1

2

3

Tracheostomy Tube Cannula Change

0

1

2

3

Trach Cleaning & Suctioning

0

1

2

3

Stoma care

0

1

2

3

Oxygen / Oxygen equipment

0

1

2

3

Postural drainage, percussion & equipment

0

1

2

3

Chest tubes

0

1

2

3

Pulmonary toilet (CPT)

0

1

2

3

Use of pulmonaide

0

1

2

3

Use of Inhalers

0

1

2

3

Use of aerosolized medications

0

1

2

3

Hemovac

0

1

2

3

Ventilators

0

1

2

3

IMV / SIMV

0

1

2

3

PEEP

0

1

2

3

CPAP

0

1

2

3

CPR

0

1

2

3

Establish airway

0

1

2

3

ET intubation / extubation

0

1

2

3

VI. GI / GU:

NG insertion / removal

0

1

2

3

Nasogastric suction

0

1

2

3

T-Tub

0

1

2

3

Gastrostomy

0

1

2

3

Jejunostomy

0

1

2

3

Checking tube placement

0

1

2

3

Feeding preparation & administration

0

1

2

3

Manual disimpaction

0

1

2

3

Digital rectal exam

0

1

2

3

Ostomy irrigation

0

1

2

3

Periostomal skin care

0

1

2

3

Care of ostomy equipment / supplies

0

1

2

3

Jackson Pratt

0

1

2

3

Acute / chronic renal failure

0

1

2

3

Transplants

0

1

2

3

Foley catheter insertion / removal

0

1

2

3

Foley catheter irrigation

0

1

2

3

Suprapubic tube insertion / removal

0

1

2

3

Suprabubic tube irrigation

0

1

2

3

Nephrostomy tube irrigation

0

1

2

3

Peritoneal dialysis

0

1

2

3

Condom catheter

0

1

2

3

Bladder training

0

1

2

3

VII. NEUROLOGICAL:

Assess neurological status

0

1

2

3

Intracranial pressure monitoring

0

1

2

3

Externalized VP shunt / reservoirs

0

1

2

3

Spinal cord injury

0

1

2

3

Status epilepticus

0

1

2

3

VIII. INJECTIONS / WITHDRAWAL:

IM Injection

0

1

2

3

SQ Injection

0

1

2

3

ID Injection

0

1

2

3

Venipuncture

0

1

2

3

X. INFECTION CONTROL

Universal precautions

0

1

2

3

TB precautions

0

1

2

3

Blood borne pathogens

0

1

2

3

Disposal of hazardous waste

0

1

2

3

Particulate respirations

0

1

2

3

XI. MEDICATION:

Dobutrex (Dobutamine)

0

1

2

3

Intropin (Dopamine)

0

1

2

3

Adrenalin (Epinephrine)

0

1

2

3

Nitroprusside (Nipride)

0

1

2

3

Tridil (Nitroglycerine)

0

1

2

3

Sodium bicarbonate

0

1

2

3

Anticonvulsants

0

1

2

3

Chemotherapy

0

1

2

3

Administration of blood/blood products

0

1

2

3

Immunizations

0

1

2

3

XII. SAFETY MEASURES:

Aspiration precautions

0

1

2

3

Removal of environmental barriers

0

1

2

3

Oxygen precautions

0

1

2

3

Evacuation plans

0

1

2

3

Bleeding precautions

0

1

2

3

Seizures precautions

0

1

2

3

XIII. PHLEBOTOMY / IV THERAPY:

Care of child / neonate w/central line

0

1

2

3

Broviac

0

1

2

3

Groshong

0

1

2

3

Hickman

0

1

2

3

Procath

0

1

2

3

Quinton

0

1

2

3

PICC

0

1

2

3

Umbilical artery line

0

1

2

3

Umbilical venous line

0

1

2

3

Percutaneous arterial line

0

1

2

3

Percutaneous venous line

0

1

2

3

XIV. MISCELLANEOUS:

Apgar scoring

0

1

2

3

Ballard / Dubowitz

0

1

2

3

Bereavement / postpartum care

0

1

2

3

Preparation for transport / transfer

0

1

2

3

Screen for hearing loss

0

1

2

3

Craniofacial reconstruction

0

1

2

3

EXPERIENCE

# of Yrs of Experience

Comments

Do you speak any other language(s) besides English?

Yes

No

If YES, please list other language(s):

Are you familiar with computer charting?

Yes

No

If YES, what system(s) have you used

Comments:

I hereby certify that all information I have provided to PACE Medical Staffing, Inc. on this skills checklist is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Nurse Signature *

Date