NEONATAL NICU SKILLS CHECKLIST

Name:

When completing this ckecklist, please indicate your level of proficiency in each area according to the scale below. Place a check mark in box which best describes your expertiese with each skill. The scale is as follows: 1. Not performed   2. Intermitten experience   3. Very experienced.

CARDIOVASCULAR Assessment   Blood pressure non-invasive   1 2 3 Blood pressure invasive   1 2 3 Pulses   1 2 3 Perfusion   1 2 3 Heart sounds/murmurs   1 2 3 Procedures:   EKG interpretation   1 2 3 Defibrillation/cardioversion   1 2 3 Invasive hemodynamic monitoring   1 2 3 Cardiac monitoring   1 2 3 Care of infant:   Cardiac arrest   1 2 3 Cardiac transplant   1 2 3 Cardiomyopathy   1 2 3 Congenital heart disease/defects   1 2 3 Hemodynamic instability   1 2 3 Hypovolemic shock   1 2 3 Pre & post cardiac surgery   1 2 3 Pre & post cardiac cath   1 2 3 Medications:   Digoxin   1 2 3 Dobutamine   1 2 3 Dopamine   1 2 3 Epinephrine   1 2 3 Lidocaine   1 2 3 Nipride   1 2 3 Sodium bicarbonate   1 2 3 Verapamil   1 2 3 GASTROINTESTINAL Abdominal assessment   1 2 3 Bowel sounds   1 2 3 Suck/swallow   1 2 3 Assist with breast feeding   1 2 3 Bottle feeding   1 2 3 Breast milk handling/storage   1 2 3 Gavage   1 2 3 Use and care of:   Gastrostomy tube   1 2 3 Jejunal gastro tube   1 2 3 Nasogastric/orogastric tube   1 2 3 Test for occult blood   1 2 3 Care of patient with:   Bowel obstruction   1 2 3 Cleft lip/palate   1 2 3 Colostomy/ileostomy   1 2 3 Esophageal atriesia   1 2 3 Omphalocele   1 2 3 GI bleeding   1 2 3 Inguinal hernia   1 2 3 Necrotizing enterocolitis (NEC)   1 2 3 Pyloric stenosis   1 2 3 Post abdominal surgery   1 2 3 Reflux precautions   1 2 3 Tracheoesophageal fistula (TEF)   1 2 3 NEUROLOGY Assessment of neuro signs   1 2 3 Assessment of Fontanels   1 2 3 Anticonvulsant medication   1 2 3 Care of infant with:   Brain death/organ procurement   1 2 3 Cephalic shunt   1 2 3 External VP shunt   1 2 3 Increased intracranial pressure monitoring   1 2 3 Meningitis   1 2 3 Seizures   1 2 3 Hemorrage   1 2 3 Glasgow Coma scale   1 2 3 Assist with lumbar puncture   1 2 3 PROCEDURES Interpretation of lab results   CBC/differential   1 2 3 Blood culture   1 2 3 Maternal lab results   1 2 3 Bilirubin   1 2 3 Urine test   1 2 3 Collect culture specimens   1 2 3 Collection of urine specimens   1 2 3 Phototherapy for jaundice   1 2 3 Isolation techniques   1 2 3 Standard precautions (universal)   1 2 3 Administration of blood/blood products   1 2 3 Delivery systems   IV pump   1 2 3 Syringe pump   1 2 3 TPN line   1 2 3 Blood draw from central line   1 2 3 Venous blood draw   1 2 3 Heel stick   1 2 3 Intralipid   1 2 3 Starting and managing IV’s   Central line   1 2 3 Percutaneous arterial line   1 2 3 Percutaneous venous line   1 2 3 Peripheral line/dressing   1 2 3 Umbilical arterial line   1 2 3 Umbilical venous line   1 2 3 Apgar scoring   1 2 3 Eye exam (r/o retinopathy)   1 2 3 Screen for hearing loss   1 2 3 Bereavement/postmortem care   1 2 3 Immunization   1 2 3 Cord care   1 2 3 Neonatal skin care   1 2 3 Positioning devices   1 2 3 Weaning to open crib/bassinet   1 2 3 Weights/bed scale   1 2 3 Calculation of dosage   1 2 3 Emergency drug action & reaction   1 2 3 Eye prophylaxis - Vitamin K   1 2 3 Neonatal drug action & reactions   1 2 3 Thermo Regulators:   Warming lights   1 2 3 Isolette   1 2 3 Radiant warmer   1 2 3 Bililight   1 2 3 Recognition of heat loss   1 2 3 Peritoneal dialysis   1 2 3 RESPIRATORY Breath sounds   1 2 3 Assessment of breathing   1 2 3 Airway Procedures:   Assist with intubation   1 2 3 Bulb syringe   1 2 3 CPAP   1 2 3 Endotracheal tube   1 2 3 Open ET catheter suction   1 2 3 Apnea monitor   1 2 3 Chest tube (assist with)   1 2 3 ECMO (extracorporeal membrane oxygenation)   1 2 3 Nitric oxide   1 2 3 Thoracentesis   1 2 3 Use of artificial surfactant   1 2 3 High frequency oscillatory ventilator   1 2 3 Care of infant with:   Bronchopulmonary dysplasia (BPD)   1 2 3 Cardiogenic/hypovolemic shock   1 2 3 Diaphragmatic hernia   1 2 3 Tracheostomy   1 2 3 Meconium aspiration   1 2 3 Hyaline membrane disease   1 2 3 Persistent pulmonary hypertension (PPHN)   1 2 3 Pneumothorax   1 2 3 RDS   1 2 3 Medications:   Aminophylline   1 2 3 Prostaglandin   1 2 3 SPECIFIC PATHOLOGIC CONDITIONS Care of infant with:   Infant of a diabetic mother   1 2 3 Hepatitis surface antigen+ mother   1 2 3 HIV positive mother   1 2 3 Bacterial sepsis   1 2 3 Viral sepsis   1 2 3 Exchange transfusion   1 2 3 Congenital anomalies   1 2 3 Premature infants   1 2 3 Micro-preemies   1 2 3 Acute renal failure   1 2 3 DIC(disseminated intra vascular coagulation)   1 2 3 Disorders of internal/external organs   1 2 3 Drug addiction/withdrawal   1 2 3 Hypo/hyperkalemia   1 2 3 Hypo/hypernatremia   1 2 3 Malformations of the GU tract, kidney   1 2 3

PROFESSIONAL EXPERIENCE AND CERTIFICATIONS

1. Are you BCLS certified? Yes   No
2. Are you NRP certified? Yes   No
3. Are you PALS certified? Yes   No
4. Other: 
5. Number of years of experience?  
6. Is your nursing experience (check one) Level I   Level II   Level III
7. Do you have transport experience? Yes   No  
8. Air or ground?
9. Number of years?
10. Do you have charge experience? Yes   No  
11. Number of years?

The information I have given is true and accurate to the best of my knowledge. Please sign and date below.

SIGNATURE: (Last 4 digits of your SSN)    Reenter your last 4 digits of your SSN:   DATE:

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