NORTHWEST NURSE STAFFING - Home



NAME: FORMTEXT ?????ID #: FORMTEXT ?????DATE: FORMTEXT ?????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.DESCRIPTION1234VENOUS STASIS ULCER TREATMENT1. Compression Therapy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Ulcer Assessment Characteristics FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Skin Signs of Venous Stasis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX PERIPHERAL ARTERIAL ULCER (PAD)1. Ankle Brachial Index FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Ulcer Assessment Characteristics FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Skin Signs of Diminished Circulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OTHER WOUNDS1. Fistulae – Pouching, Skin Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Drains – Management of FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. G/J Tubes – Anchoring, Skin Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX WOUND CARE TREATMENT1. Debridement a. Autolytic FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Enzymatic FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Mechanical FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Sharp FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Surgical FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Dressings/Treatments a. Hydrogels FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Hydrocolloids FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Silver Products FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Foams FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Alginates FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX f. VAC (Vacuum Assisted Closure) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX g. Growth Factors FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX h. Skin Substitutes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX i. Hyperbaric Oxygen Therapy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX j. Culturing of Wounds FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX k. Electrical Stimulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX l. Enzymatic Debriding Agents FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX DIRECTIONS: Please indicate your level of experience by placing a check (√) in the box. Experience level: 1NO EXPERIENCE2MINIMAL EXPERIENCE-requires supervision/assistance3MODERATELY EXPERIENCED-requires initial review, then performs independently4VERY EXPERIENCED- proficientDESCRIPTION1234 m. Debriding Ointments FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX n. Mist Therapy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX o. Electrical Stimulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX COLOSTOMY 1. Loop w/Rod Stoma FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. End Stoma FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Mucous Fistula FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Double Barrel Stoma FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Irrigation Procedure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Stoma Within Incision FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Related Conditions/Surgeries a. Abdominoperineal Resection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Rectal Cancer/Colon Cancer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Diverticulitis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Colitis/Crohn’s Disease FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Pelvic Exenteration Anterior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX f. Pelvic Exenteration Posterior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ILEOSTOMY 1. Loop w/Rod Stoma FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CONTINENT ILEOSTOMY 1. Kock Pouch FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Pelvic Pouch FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX UROSTOMY 1. Catheterization for Culture and Sensitivity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Related Conditions/Surgeries a. Pelvic Exenteration FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Bladder Cancer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Neurogenic Bladder FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Interstitial Cystitis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CONTINENT UROSTOMY 1. Kock Pouch FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Indiana Pouch FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Neobladder FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Name: FORMTEXT ?????ID #: FORMTEXT ????? DESCRIPTION1234STOMAL, PERISTOMAL SKIN CONDITIONS 1. Flush or Recessed Stoma FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Stomal Necrosis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Stomal Prolapse FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Peristomal Hernia FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Denuded Skin/Ulcerations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Skin Infections/Fungal Infections FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Mucocutaneous Separation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Hyperplasia FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Pyoderma Gangrenosum FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Stoma Plane Dynamics FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OSTOMY EQUIPMENT 1. One-Piece/Two-Piece Appliance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Open End, Closed End, Clip or Velcro Closure for Pouches FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Convex/Flexible Pouching Systems FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Skin Barriers/Sealants FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Barrier Pastes/ Strips/ Rings/ Discs/ Washers FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Wound Pouches FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Molding Kit for Custom Appliances FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Irrigation Procedure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Single/Double Lumen Catheters for Culture FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Reusable Ostomy Equipment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Measure for Ostomy Belts/Peristomal Hernia Support Belt FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CONTINENCE EVAULATION/ASSESSMENT 1. Urodynamics FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Manometry FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Electromyography FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Leak Point Pressures FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Cystometrogram FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Uroflametry FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Biofeedback – Diagnostic/Treatment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. PNTML (Pudendal Nerve Terminal Motor Latency) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Ultrasound FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CONTINENCE SKIN CARE/CONTAINMENT 1. Skin Sealants FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX DESCRIPTION1234 2. Moisture Barriers FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Absorbent Garments FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Skin Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CONTINENCE THERAPUTIC DEVICES 1. Vaginal Cones FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Penile Clamps FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Male Urinals FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Male External Catheters FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Internal Urethral Inserts (Female) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Catheters – Indwelling FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Catheters – Intermittent Self Cath and Teaching for FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Magnetic Therapy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Urinary Incontinence/Bladder Programs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Fecal Incontinence/Bowel Programs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX PEDIATRIC RELATED CONDITIONS 1. Necrotizing Enterocolitis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Inflammatory Bowel Disease FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Irritable Bowel Syndrome FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Meckel Diverticulum FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Familial Adenomatous Polyposis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Distal Ureter or Bladder Defects FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Hirschsprung’s Disease FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Megacolon FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Malabsorption Syndromes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Obstructive Disorders FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX a. Spinal Cord Injury FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Neurogenic Bladder FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. Diaper Dermatitis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13. Stoma Care – Loop Stoma FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14. Dehydration Risks in Pediatric Patients FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15. High Output Stoma – Skin Barrier Issues FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX G/J TUBES 1. Anchoring Devices FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Skin Protection for Leakage of Gastric Contents FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Long Term Tubes/Skin Level Devices for Feeding FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Procedures for Flushing/Treatment for Clogging FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OTHER 1. IV Infiltration Wounds FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Incision Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Name: FORMTEXT ?????ID #: FORMTEXT ????? OTHER (CONT)DESCRIPTION1234 3. Burns FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Bariatric Patients FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Self-Catheterization/Teaching FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Indwelling Catheter Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Medications FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Bowel and Bladder Training Programs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX INTERPRETATION OF LAB RESULTS 1. Albumin/Total Protein FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Obtaining Wound Cultures FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Urine Cultures FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Tumor Staging FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Pathology Reports FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX MISCELLANEOUS 1. National Patient Safety Goals FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Computerized Charting a. Cerner FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Eclipsys FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Epic FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. McKesson FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Meditech FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX f. Other: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Name: FORMTEXT ?????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.ABCDEFGHI FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Able to adapt care according to normal growth and development.ABCDEFGHI FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Able to communicate and instruct patient according to their age, maturity and comprehension ability.ABCDEFGHI FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Able to provide a safe environment according to the specific needs of various age groups.ABCDEFGHI FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX MY EXPERIENCE IS PRIMARILY IN:NEUROLOGY FORMTEXT ????? yearsPULMONARY FORMTEXT ????? yearsSURGICAL FORMTEXT ????? yearsMEDICAL FORMTEXT ????? yearsCARDIAC CARE FORMTEXT ????? yearsTELEMETRY FORMTEXT ????? yearsI HAVE CURRENT CERTIFICATIONS FOR:TYPE EXPIRATION DATE (MM/DD/YY)ARRHYTHMIA FORMTEXT ?????CRITICAL CARE FORMTEXT ?????ACLS FORMTEXT ?????BLS FORMTEXT ?????TNCC FORMTEXT ?????NRP FORMTEXT ?????PALS FORMTEXT ?????NALS FORMTEXT ?????Other FORMTEXT ????? FORMTEXT ?????Other FORMTEXT ????? FORMTEXT ?????Other FORMTEXT ????? FORMTEXT ?????Other FORMTEXT ????? FORMTEXT ?????The information I have provided in this knowledge and skills checklist it true and accurate to the best of my knowledge. FORMTEXT ????? FORMTEXT ?????Signature (Written/Electronic)DateID #: FORMTEXT ?????This skills checklist has been reviewed and approved by Nicole Bloxham, RN. FORMTEXT ????? FORMTEXT ?????Signature (Written/Electronic)DateID #: FORMTEXT ?????Please return to: Northwest Nurse Staffing Company, PA ATTN: Records Dept. Fax: (888) 936-8383 Email: records@ ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download