Post Partum Nursery Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyWork SettingsPICU 1 2 3 4 Pediatric CVICU 1 2 3 4 Pediatric Step Down 1 2 3 4 Pediatric PACU 1 2 3 4 CardiovascularCongenital Heart Disease/Repair 1 2 3 4 Post Cardiac Surgery (Directly from OR) 1 2 3 4 Post Cardiac Surgery (NOT Directly from OR) 1 2 3 4 Post Diagnostic/Interventional Cardiac Cath 1 2 3 4 Heart Failure/Cardiogenic Shock 1 2 3 4 Cardiac Transplant 1 2 3 4 Hemodynamic Monitoring 1 2 3 4 Arrhythmia Interpretation 1 2 3 4 Pacemaker - Temporary/Permanent 1 2 3 4 SVO2 Monitoring 1 2 3 4 Intra-Aortic Balloon Pump 1 2 3 4 Ventricular Assist Device 1 2 3 4 ECMO 1 2 3 4 PulmonaryRespiratory Distress Syndrome/Resp. Failure 1 2 3 4 Reactive Airway Disease 1 2 3 4 ENT Surgery 1 2 3 4 Epiglottis 1 2 3 4 Epiglottitis 1 2 3 4 Cystic Fibrosis 1 2 3 4 Tuberculosis 1 2 3 4 Intubation/Extubation 1 2 3 4 Endotracheal Tube Management 1 2 3 4 Tracheostomy Management 1 2 3 4 Modes of Ventilation: AC/PC/SIMV/CPAP 1 2 3 4 Modes of Ventilation: Jet/Oscillator 1 2 3 4 Nitric Oxide 1 2 3 4 Hemo/Pneumothorax 1 2 3 4 Neurologic/OrthopedicBrain Injury 1 2 3 4 Craniotomy 1 2 3 4 Spinal Cord Injury 1 2 3 4 Seizure Disorders 1 2 3 4 ICP Monitoring 1 2 3 4 VP Shunt 1 2 3 4 Meningitis 1 2 3 4 Neuromuscular Disease 1 2 3 4 Post Vertebral Surgery 1 2 3 4 Traction - General 1 2 3 4 Traction - Halo 1 2 3 4 GastrointestinalAcute Surgical Abdomen 1 2 3 4 GI Bleeding 1 2 3 4 Pancreatitis 1 2 3 4 Hepatic Failure 1 2 3 4 Ostomy Management 1 2 3 4 Management of Gastric Tubes 1 2 3 4 Breast Milk Handling/Storage 1 2 3 4 Renal/GenitourinaryNephrotic Syndrome 1 2 3 4 Renal Transplant 1 2 3 4 Renal Replacement Therapy 1 2 3 4 Peritoneal Dialysis 1 2 3 4 Endocrine / MetabolicDiabetes - Hypo/Hyperglycemic Crisis 1 2 3 4 Diabetic Ketoacidosis 1 2 3 4 IV Insulin Pumps 1 2 3 4 Indwelling Insulin Pumps 1 2 3 4 Trauma/OtherBlunt/Penetrating Trauma 1 2 3 4 Burns 1 2 3 4 Craniofacial Reconstruction 1 2 3 4 Near Drowning 1 2 3 4 Poison Ingestion/Overdose 1 2 3 4 Bites-Animal/Snake/Human 1 2 3 4 Suicide Precautions 1 2 3 4 Wound Management/VAC 1 2 3 4 Specialty Beds 1 2 3 4 OncologyBone Marrow Transplant 1 2 3 4 Immunosuppressive Disorder 1 2 3 4 Hemophilia Crisis 1 2 3 4 Sickle Cell Crisis 1 2 3 4 MedicationsPediatric Dosage Calculations 1 2 3 4 Anti-Arrhythmics 1 2 3 4 Anticoagulants (IV, Oral & Injection) 1 2 3 4 Anti-Hypertensives 1 2 3 4 Anti-Seizure Medications 1 2 3 4 Benzodiazepines 1 2 3 4 Continuous IV Paralytics 1 2 3 4 Continuous IV Sedation 1 2 3 4 Procedural Sedation - Administration 1 2 3 4 Diuretics 1 2 3 4 Emergency Medication 1 2 3 4 Inhaled Medications 1 2 3 4 Insulin 1 2 3 4 IV Vasopressors 1 2 3 4 Narcotics/Opioid Analgesics (IV, Oral & Injection) 1 2 3 4 Non-Opioid Analgesics (IV, Oral & Injection) 1 2 3 4 Reversal Agents 1 2 3 4 Steroids (IV, Oral, Inhaled) 1 2 3 4 Automated Medication Dispensing (i.e. Pyxis,Omnicell) 1 2 3 4 IV TherapyStarting IVs 1 2 3 4 Central Line Blood Draw 1 2 3 4 Central Line/Implanted Line Care 1 2 3 4 TPN/Lipids 1 2 3 4 Blood Product Administration 1 2 3 4 Administration of Chemotherapy 1 2 3 4 Cardiac Monitoring & Emergency ResponseDysrhythmia Interpretation 1 2 3 4 Dysrhythmia Management 1 2 3 4 Management of Cardiac Arrest 1 2 3 4 Shock Management 1 2 3 4 Malignant Hyperthermia 1 2 3 4 Multisystem Organ Failure 1 2 3 4 Professional Knowledge and SkillsNational Patient Safety Goals/Core Measures 1 2 3 4 Recognize/Report Signs of Abuse 1 2 3 4 EMTALA 1 2 3 4 Fall Risk Assessment/Prevention 1 2 3 4 Pressure Ulcer Risk Assessment/Prevention 1 2 3 4 Restraints/Use of Least Restrictive Device 1 2 3 4 Normal Growth and Development 1 2 3 4 Age Specific/Population-Based Care 1 2 3 4 Patient Family Teaching 1 2 3 4 Isolation Precautions 1 2 3 4 Infection Prevention 1 2 3 4 Reporting Communicable Diseases 1 2 3 4 Pain Assessment & Management 1 2 3 4 Charge Experience 1 2 3 4 Interpretation and Communication of Lab Values 1 2 3 4 EMREpic 1 2 3 4 Cerner 1 2 3 4 Eclipsys 1 2 3 4 McKesson 1 2 3 4 Meditech 1 2 3 4 Other Computerized System 1 2 3 4 Computerized Physician Order Entry 1 2 3 4 Bar Coding for Medication Administration 1 2 3 4 EMR Conversion Yes No Age Specific CompetenciesInfant (Birth - 1 year) 1 2 3 4 Preschooler (ages 2-5 years) 1 2 3 4 Childhood (ages 6-12 years) 1 2 3 4 Adolescents (ages 13-21 years) 1 2 3 4 Young Adults (ages 22-39 years) 1 2 3 4 Adults (ages 40-64 years) 1 2 3 4 Older Adults (ages 65-79 years) 1 2 3 4 Elderly (ages 80+ years) 1 2 3 4 CertificationsBLS Yes BLS Expiration Date Month Day Year PALS Yes PALS Expiration Date Month Day Year ACLS Yes ACLS Expiration Date Month Day Year ACLS Yes ACLS Expiration Date Month Day Year PEARS Yes PEARS Expiration Date Month Day Year ENPC Yes ENPC Expiration Date Month Day Year CEN Yes CEN Expiration Date Month Day Year TNCC Yes TNCC Expiration Date Month Day Year Other: SpecifyOther Expiration Date Month Day Year Other: SpecifyOther Expiration Date Month Day Year AuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this PICU Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
