IV Therapy Skills Checklist

IV Therapy Skills Checklist

First Name*

Last Name*

Years of Experience*

E-mail*

example@example.com

ANSWER KEY

PROFICIENCY

1=Not Applicable 2=No Experience 3=Some Experience

4=Experienced 5=Very Experienced

FREQUENCY

1=Never Performed 2=Assisted Only 3=Rarely Performed

4=Occasionally Performed 5=Regularly Performed

General Skills*

	Proficiency	Frequency
Standard Precautions
Isolation Precautions
Pediatric Respiratory / Cardiac Arrest
Adult Respiratory / Cardiac Arrest
Crash Carts
Defibrillators
Participation on Code Teams
Leading Code Teams
Care Patient in Restraints
Pain Management
Automated Med Dispensing Systems
Patient / Family Education
Electronic Documentation
Use of Computerized Patient ID Systems
Patient Head to Toe Assessment
Knowledge of Current IV Therapy Guidelines (INS, ISMP, CDC, State, etc.)
Knowledge of Anatomy

Insertion of*

	Proficiency	Frequency
Peripheral IV- Adult
Peripheral IV- Child
Peripheral IV- Neonate
Vein Selection- Peripheral IV’s
Interosseous Needles
Midline’s / PICC Placement
Midline Catheter Insertion- Adult
Midline Catheter Insertion- Child
Indication for Midline / PICC Placement
Contraindications for Midline / PICC Placement
Vein Selection
Measuring Techniques
Catheter and Introducer Device Selection
Correct Tip Placement
Insertion Technique- Basic (Vein)
Insertion Technique- Seldinger
Insertion Technique- Ultrasound
Assist With Insertion in Interventional Radiology
Conscious Sedation Procedures
Insertion Site Preparation
Maintaining Sterile Field
Securing Insertion Site Post Placement
X-Ray Assessment for Tip Location
Repositioning After X-ray

Care and Maintenance*

	Proficiency	Frequency
Peripheral IV
Scalp IV
Heparin / Saline Lock
Subcutaneous Needles
Groshong PICC
Groshong CVL
Hickman / Broviac
Port-A-Cath
Vascath
Multilumen Catheters
Subclavian Line
IJ Line
Femoral Line
Power PICC
Power PORT
Dressing Changes
Cap Changes
Flushing Lines (Frequency / Solutions)

Knowledge and Use of*

	Proficiency	Frequency
IV Fluids
Blood Products
Chemotherapy
Heparin
Streptokinase
Retavase
TPA (Alteplase)
Lidocaine
TPN / Lipids
Ativan (Lorazepam)
Valium (Diazepam)
Versed (Midazolam)
Fentanyl

Equipment*

	Proficiency	Frequency
IV Pumps
Needleless Systems
Bard Pumps
Baxter Pumps
CADD Pumps
IVAC Pumps
Blood Warmer
PCA Pumps
Pressure Lines

Troubleshooting / Complications*

	Proficiency	Frequency
Repair PICC
Repair Midline
Air Embolism
Bleeding
Brachial Plexus Injury
Cardiac Arrhythmia
Cardiac Tamponade
Catheter Erosion
Catheter Embolism
Catheter Occlusion
Catheter-Related Sepsis
Endocarditis
Exit Site Infection
Exit Site Necrosis
Extravasation
Hematoma
Laceration of Vessels or Viscus
Myocardial Erosion
Perforation of Vessels or Viscus
Phlebitis
Catheter Tip Malposition or Retraction
Thromboembolism
Venous Thrombosis
Ventricular Thrombosis
Vessel Erosion
Declotting Peripheral Site
Complications from Sedation

Discontinuing IV Therapy*

	Proficiency	Frequency
Peripheral IV’s
PICC / Midline
Central Lines

Age Specific Criteria*

	Proficiency	Frequency
Newborn / Neonatal (up to 30 days)
Infant (30 days to 1 year)
Toddler (1 to 3 years)
Preschooler (3 to 5 years)
School Age (5 to 12 years)
Adolescents (12 to 18 years)
Young Adults (18 to 39 years)
Middle Adults (40 to 64 years)
Older Adults (65 & up)

Background Experience*

	Proficiency	Frequency
Small Hospital
Large Hospital
Outpatient
Acute Care / Hospital
Cancer Center
Clinic
Managed Care
SNF / Long Term Care
Home Health

The information provided is true and to the best of my knowledge. I hereby authorize Summit Medical Staffing to present my Skills Checklist to facilities for the purpose of employment. Please Type Your Name in This Box to Electronically Sign this Form.*

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