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1111 North 3rd StreetPhoenix, Arizona 85004
Phone 602-264-1444 Fax 602-264-1443
Copyright © 2014 Dependable Staffing Services, LLC. All rights reserved. Page 1 of 6
NICU SKILLS CHECKLIST
Instructions: Please complete this checklist to enable us to match your skills and interests with available assignments.
Place an "X" in the appropriate column that best describes your experience level with each skill.
LEVELS OF PROFICIENCY:1. Experienced - performs well and independently (at least 1 year experience)2. Limited experience - some assistance or practice needed (6 months to 1 year experience)3. Little experience - need more experience, assistance required (less than 6 months experience)4. No experience
SKILLS 1 2 3 4
A. CARDIOVASCULAR 1. Assessment Auscultation (Rate, Rhythm, Volume) ____ ____ ____ ____ Blood Pressure/ Invasive (Arterial line) ____ ____ ____ ____ Blood Pressure/ Non-Invasive ____ ____ ____ ____ Heart Sounds/ Murmurs ____ ____ ____ ____ Perfusion ____ ____ ____ ____ Pulses ____ ____ ____ ____ 2. Equipment & Procedures EKG Interpretation ____ ____ ____ ____ Defibrillation/ Cardioversion ____ ____ ____ ____ Invasive Hemodynamic Monitoring ____ ____ ____ ____ Central Venous Pressure ____ ____ ____ ____ 3. Care of the Neonate with Cardiac Arrest ____ ____ ____ ____ Cardiac Transplant ____ ____ ____ ____ Cardiomyopathy ____ ____ ____ ____ Congenital Heart Disease/ Defects ____ ____ ____ ____ Hemodynamic Instability ____ ____ ____ ____ Hypovolemic Shock ____ ____ ____ ____ Post Cardiac Surgery ____ ____ ____ ____ Post Interventional Cardiac Cath ____ ____ ____ ____ 4. Medications Dobutamine ____ ____ ____ ____ Dopamine ____ ____ ____ ____ Epinephrine ____ ____ ____ ____ Nipride ____ ____ ____ ____ Sodium Bicarbonate ____ ____ ____ ____
B. PULMONARY 1. Assessment Breath Sounds ____ ____ ____ ____ Rate and Work of Breathing ____ ____ ____ ____ 2. Interpretation of Lab Results Blood Gases ____ ____ ____ ____ Interpretation of x-ray reports ____ ____ ____ ____
1111 North 3rd Street Phoenix, Arizona 85004
Phone 602-264-1444 Fax 602-264-1443
Copyright © 2014 Dependable Staffing Services, LLC. All rights reserved. Page 2 of 6
3. Equipment & Procedures Airway Management Assist with Intubation ____ ____ ____ ____ Bulb Syringe ____ ____ ____ ____ CPAP (Nasal Prongs) ____ ____ ____ ____ Endotracheal Tube Stabilization ____ ____ ____ ____ Endotracheal Tube Suctioning ____ ____ ____ ____ Apnea Monitor ____ ____ ____ ____ Cardiac Resuscitation ____ ____ ____ ____ Apnea Monitor Insertion ____ ____ ____ ____ Removal ____ ____ ____ ____ Set-up ____ ____ ____ ____ ECMO (Extracorporeal Membrane Oxygenation) ____ ____ ____ ____ O2Therapy Delivery Systems Bag (Anesthesia) & Mask ____ ____ ____ ____ Bag (Self-inflating) & Mask ____ ____ ____ ____ Nasal Cannula ____ ____ ____ ____ Nebulizer ____ ____ ____ ____ Oxyhood ____ ____ ____ ____ Tent ____ ____ ____ ____ Trach Collar ____ ____ ____ ____ Obtaining Blood Gases Arterial ____ ____ ____ ____ Heelstick ____ ____ ____ ____ Peripheral ____ ____ ____ ____ Umbilical Line ____ ____ ____ ____ Thoracentesis ____ ____ ____ ____ Use of Artificial Surfactant ____ ____ ____ ____ Ventilator Care CPAP/PEEP ____ ____ ____ ____ High Frequency Jet Ventilator ____ ____ ____ ____ Home Ventilator ____ ____ ____ ____ IMV ____ ____ ____ ____ Oscillating ____ ____ ____ ____ Pressure Ventilator ____ ____ ____ ____ Volume Ventilator ____ ____ ____ ____ Weaning ____ ____ ____ ____ 4. Care of the Neonate with Bronchopulmonary Dysplasia (BPD) ____ ____ ____ ____ Cardiogenic/Hypovolemic Shock ____ ____ ____ ____ Diaphragmatic hernia ____ ____ ____ ____ Fresh Tracheostomy ____ ____ ____ ____ Meconium Aspiration ____ ____ ____ ____ Persistent Pulmonary Hypertention (PPHN) ____ ____ ____ ____ Pneumothorax ____ ____ ____ ____ Respiratory Distress Syndrome (RDS) ____ ____ ____ ____ Respiratory Failure ____ ____ ____ ____ 5. Medications Aminophylline ____ ____ ____ ____ Prostaglandin ____ ____ ____ ____
1111 North 3rd Street Phoenix, Arizona 85004
Phone 602-264-1444 Fax 602-264-1443
Copyright © 2014 Dependable Staffing Services, LLC. All rights reserved. Page 3 of 6
C. NEUROLOGICAL 1. Assessment Intracranial Pressure Monitoring ____ ____ ____ ____ Neurological Status ____ ____ ____ ____ 2. Care of Neonate with Brain Death/ Organ Procurement ____ ____ ____ ____ Externalized VP Shunt/ Reservoirs ____ ____ ____ ____ Increased Intracranial Pressure ____ ____ ____ ____ Meningitis ____ ____ ____ ____ Seizures ____ ____ ____ ____ 3. Medications Anticonvulsant Medication ____ ____ ____ ____
D. GASTROINTESTINAL 1. Assessment Abdominal Girth ____ ____ ____ ____ Bowel Sounds ____ ____ ____ ____ Palate ____ ____ ____ ____ Suck/Swallow ____ ____ ____ ____ 2. Equipment & Procedures Abdominal Girth ____ ____ ____ ____ Feeding Assist with Breast Feeding ____ ____ ____ ____ Bottle ____ ____ ____ ____ Breast Milk Handling/ Storage ____ ____ ____ ____ Gavage ____ ____ ____ ____ Hospital Grade Electric Breast Pump ____ ____ ____ ____ Placement of Intestinal Tubes Jejunal Gastro ____ ____ ____ ____ Nasogastric/Orogastric ____ ____ ____ ____ Test for Occult Blood ____ ____ ____ ____ 3. Care of the Neonate with Cleft Palate ____ ____ ____ ____ Colostomy/Ileostomy ____ ____ ____ ____ Gastroschisis/Omphalocele ____ ____ ____ ____ GI Bleeding ____ ____ ____ ____ Inguinal Hernia ____ ____ ____ ____ Necrotizing Enterocolitis (NEC) ____ ____ ____ ____ Post Abdominal Surgery ____ ____ ____ ____ Reflux Precautions ____ ____ ____ ____ Tracheoesophageal Fistula (TEF) ____ ____ ____ ____
E. ENDOCRINE/METABOLIC 1. Assessment Finnegan ____ ____ ____ ____ Fluid & Electrolyte Balance ____ ____ ____ ____ 2. Interpretation of Lab Results Bilirubin ____ ____ ____ ____ Test Urine and Interpret Glucose ____ ____ ____ ____ Labstix ____ ____ ____ ____
1111 North 3rd Street Phoenix, Arizona 85004
Phone 602-264-1444 Fax 602-264-1443
Copyright © 2014 Dependable Staffing Services, LLC. All rights reserved. Page 4 of 6
Occult Blood ____ ____ ____ ____ pH ____ ____ ____ ____ Specific Gravity ____ ____ ____ ____ 3. Equipment & Procedures Collection of Urine Specimens ____ ____ ____ ____ Assist with Supra Pubic Tap ____ ____ ____ ____ Catheter ____ ____ ____ ____ Diaper/Bag ____ ____ ____ ____ Phototherapy for Jaundice ____ ____ ____ ____ Post Circumcision Care ____ ____ ____ ____ 4. Care of the Neonate with Acute Renal Failure ____ ____ ____ ____ DIC (Disseminated Intravascular Coagulation ____ ____ ____ ____ Disorders of Internal/External Organs ____ ____ ____ ____ Drug Addiction/Withdrawal ____ ____ ____ ____ Hypo/Hyperkalemia ____ ____ ____ ____ Hypo/Hypernatremia ____ ____ ____ ____ IDM (Infant of a Diabetic Mother) ____ ____ ____ ____ Malformation of the GU Tract, Kidney ____ ____ ____ ____ Peritoneal Dialysis ____ ____ ____ ____
F. INFECTIOUS DISEASES 1. Interpretation of Lab Results CBC/Differential ____ ____ ____ ____ Culture Reports ____ ____ ____ ____ Maternal Lab Results ____ ____ ____ ____ 2. Equipment & Procedures Assist with Lumbar Puncture ____ ____ ____ ____ Maternal Lab Results ____ ____ ____ ____ Isolation Techniques ____ ____ ____ ____ Standard (Universal) Precautions ____ ____ ____ ____ 3. Care of the Neonate with Hepatitis Surface Antigen+ Mother ____ ____ ____ ____ HIV Positive Mother ____ ____ ____ ____ Neonatal Sepsis ____ ____ ____ ____ 4. Medications - Immunizations HBIG ____ ____ ____ ____ HBV ____ ____ ____ ____ HIV ____ ____ ____ ____ Polio ____ ____ ____ ____ DPT ____ ____ ____ ____ RespiGam/Synergis Prophylaxis ____ ____ ____ ____
G. PHLEBOTOMY/IV THERAPY 1. Equipment & Procedures Administration of Blood/ Blood Products Cryoprecipitate ____ ____ ____ ____ Packed Red Blood Cells ____ ____ ____ ____ Plasma/Albumin ____ ____ ____ ____ Whole Blood ____ ____ ____ ____ Delivery Systems
1111 North 3rd Street Phoenix, Arizona 85004
Phone 602-264-1444 Fax 602-264-1443
Copyright © 2014 Dependable Staffing Services, LLC. All rights reserved. Page 5 of 6
IV Pump ____ ____ ____ ____ Syringe Pump ____ ____ ____ ____ Drawing Blood from Central Line ____ ____ ____ ____ Drawing Venous Blood ____ ____ ____ ____ Hyperlimentation/TPN ____ ____ ____ ____ Intralipid ____ ____ ____ ____ Managing IV Therapy Discontinuing ____ ____ ____ ____ Dressing & Tubing Change ____ ____ ____ ____ Rate Calculation ____ ____ ____ ____ Site & Patency Assessment ____ ____ ____ ____ Starting IVs Angiocath ____ ____ ____ ____ Butterfly ____ ____ ____ ____ Heparin Lock ____ ____ ____ ____ 2. Care of Neonate with Central Line/Catheter/Dressing Products Broviac ____ ____ ____ ____ Groshong ____ ____ ____ ____ Hickman ____ ____ ____ ____ Portacath ____ ____ ____ ____ Quinton ____ ____ ____ ____ Percutanious Arterial Line ____ ____ ____ ____ Percutanious Venous Line ____ ____ ____ ____ Peripheral Line/Dressing ____ ____ ____ ____ PICC (Peripherally Inserted Central Catheter) ____ ____ ____ ____ Umbilical Artery Line ____ ____ ____ ____ Umbilical Venous Line ____ ____ ____ ____
H. PAIN MANAGEMENT 1. Assessment of Pain Level ____ ____ ____ ____ 2. Care of the Neonate with Sedation, i.e. Morphine ____ ____ ____ ____
I. MISCELLANEOUS 1. Assessment Apgar Scoring ____ ____ ____ ____ Eye Exam (r/o Retinopathy) ____ ____ ____ ____ Gestational Age Ballard ____ ____ ____ ____ Dubowitz ____ ____ ____ ____ Other (Specify) ____ ____ ____ ____ Maternal History ____ ____ ____ ____ Screen for Hearing Loss ____ ____ ____ ____ 2. Equipment & Procedures Bereavement/Postmortem Care ____ ____ ____ ____ Consents Immunization ____ ____ ____ ____ Procedural ____ ____ ____ ____ Treatment ____ ____ ____ ____ Cord Care ____ ____ ____ ____ Neonatal Skin Care ____ ____ ____ ____
1111 North 3rd StreetPhoenix, Arizona 85004
Phone 602-264-1444 Fax 602-264-1443
Copyright © 2014 Dependable Staffing Services, LLC. All rights reserved. Page 6 of 6
Positioning Devices ____ ____ ____ ____ Preparation for Transport/Transfer ____ ____ ____ ____ Thermoregulation Isolette with Humidity ____ ____ ____ ____ Radiant Warmer ____ ____ ____ ____ Temperature (Axillary, rectal, skin) ____ ____ ____ ____ Weaning to Open Crib/Bassinet ____ ____ ____ ____ Weights Bed Scale ____ ____ ____ ____ Scale ____ ____ ____ ____ 3. Medications Calculation of Dosage ____ ____ ____ ____ Emergency Drug Action and Reaction ____ ____ ____ ____ Eye Prophylaxis - Vitamin K ____ ____ ____ ____ Neonatal Drug Action and Reaction ____ ____ ____ ____
Age Specific Experience Circle each of the following age groups you have experience providing age specific care to:
Neonatal Infant-Children(0-11) Adolescent (12-18) Adult Geriatric
_______________________________________________ ________________ Employee Signature Date
