IV THERAPY KNOWLEDGE & SKILLS CHECKLIST

NAME:
ID #:
DATE:

This Skills Checklist is for use by nurses with more than one year experience in their discipline and specialty. Please be accurate with your assessment.

DESCRIPTION / 1 / 2 / 3 / 4
PATIENT RIGHTS
1. Communicates and obtains
information while respecting the rights, privacy, and confidentiality of information in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPPA)
2. Involves the patient and family and
respects their role in determining the nature of care to be provided, including Advance Directives.
3. Complies withnursing staff
responsibility included in the hospital policy related to Organ Donation.
4. Meets patient’s and families’ needs
regarding communication, including interpreter services.
5. Provides accurate information to
patient and families in a timely manner.
INFECTION CONTROL
1. Proper Use of Specific Barrier Methods:
a. Gloves
b.Gown
c. Mask / Goggles
2. Protective / Reverse Isolation
3. Body Substance Isolation
4. TB Precautions
5. MRSA Precautions
6. Hand Washing
7. Infectious / Hazardous Waste Disposal
8. Supply / Equipment Disposal
9. Use of Disposable Thermometer
10. Use of CPR Mask / Bag
11. AIDS

DIRECTIONS: Please indicate your level of experience by placing a check (√) in the box. Experience level:

1 / NO EXPERIENCE
2 / MINIMAL EXPERIENCE-requires supervision/assistance
3 / MODERATELY EXPERIENCED-requires initial review, then performs independently
4 / VERY EXPERIENCED- proficient
DESCRIPTION / 1 / 2 / 3 / 4
12. Hepatitis B
VITAL SIGNS AND WEIGHTS
1. Recognizing Cardiac Arrest
2. Activating Code Team
3. Initiating CPR
4. Bringing Emergency Equipment to
Room
5. Providing Appropriate Code Support
6. Use of Electronic VS Equipment
a. Automatic BP Machine (Dynamap)
b. Electronic Thermometer
c. Applying Oximeter
SAFETY AND ACTIVITY
1. Determining Patient ID
2. Identifying Safety Hazards
3. Determining Need for Additional Help
4. Assessing Safety and ADL Needs and Restraints
5. Maintaining Orderly Work Area
6. Disposing of Sharps
7. Handling Hazardous Materials
8. Proper Body Mechanics
9. Reporting Broken Equipment
10. Responding to Safety Hazards
11. Use of Wheel Locks
12. Use of Call Light
13. Application of Restraints
SPECIMENS
1. Venipuncture
2. Arterial Draw
3. Line Draw
4. Culture Specimens
5. Labeling Specimens and Preparing for
Transport
Name:
ID #:
DESCRIPTION / 1 / 2 / 3 / 4
SKIN HYGIENE
1. Risk Factors for Skin Breakdown
2. Observing Sites for Redness or
Breakdown
3. Treatment of Infiltrates
4. Reducing Pressure and Friction
PROCEDURES
1. Insertion of:
a. Peripheral IV – Adult
b. Peripheral IV – Child
c. Peripheral IV – Neonate
d. PICC Line
e. Interosseous Needles
CARE OF AND DRESSING CHANGE TO:
1. Interosseous Line
2. Subcutaneous Needles
3. Groshong
4. Portacath
5. Hickman
6. Access Ports
7. Vascath
8. Multilumen Catheters
9. Scalp Vein
10. Heparin Lock
11. Subclavian Line
12. Interjugular Line
FLUIDS / MEDICATIONS
1. Chemotherapy
2. Dopamine
3. Heparin
4. Lidocaine
5. Regitine
6. Streptokinase
7. TpA
8. TPN / Lipids
9. Wydase
10. Blood Products
DESCRIPTION / 1 / 2 / 3 / 4
EQUIPMENT AND TROUBLESHOOTING
1. CADD Pumps
2. IVAC Pumps
3. Blood Warmer
4. Needleless Systems
5. Pressure Lines
6. Bard Pumps
7. PCA Pumps
8. Repair PICC Line
9. Declotting Peripheral Site
10. Declotting Central Lines
11. Sterile Dressing Change, One Person
12. Sterile Dressing Change, Two Person
COMPUTERIZED CHARTING
1. Cerner
2. Eclipsys
3. Epic
4. McKesson
5. Meditech
6. Other:
Name:

Please check the boxes below for each age group for which you have expertise in providing age-appropriate nursing care.

A. Newborn/Neonatal (birth – 30 days)
B. Infant (30 days – 1 year)
C. Toddler (1 – 3 years)
D. Preschool (3 – 5 years)
E. School Age Children (5 – 12 years)
F. Adolescent (12 – 18 years)
G. Young Adults (18 – 39 years)
H. Middle Adults (40 – 64 years)
I. Older Adults (64 + years)

EXPERIENCE WITH AGE GROUPS:

1. Able to assess age appropriate behavior, motor skills and physiological norms.

A / B / C / D / E / F / G / H / I

2. Able to adapt care according to normal growth and development.

A / B / C / D / E / F / G / H / I

3. Able to communicate and instruct patient according to their age, maturity and comprehension ability.

A / B / C / D / E / F / G / H / I

4. Able to provide a safe environment according to the specific needs of various age groups.

A / B / C / D / E / F / G / H / I

MY EXPERIENCE IS PRIMARILY IN:

NEUROLOGY / years
PULMONARY / years
SURGICAL / years
MEDICAL / years
CARDIAC CARE / years
TELEMETRY / years

I HAVE CURRENT CERTIFICATIONS FOR:

TYPE COURSE DATE (MM/DD/YY)

ARRHYTHMIA
CRITICAL CARE
ACLS
BLS
TNCC
NRP
PALS
NALS
Other
Other
Other
Other

The information I have provided in this knowledge and skills checklist it true and accurate to the best of my knowledge.

Signature (Written/Electronic) / Date
ID #:

This skills checklist has been reviewed and approved by Nicole Bloxham, RN.

Signature (Written/Electronic) / Date
ID #:

Please return to: NORTHWEST NURSE STAFFING COMPANY, PA

ATTN: Records Dept.

Fax: (866) 352-4338

Email:

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