CVPICU Skills Checklist

CVPICU 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

Cardiovascular*

Rows	Proficiency	Frequency
Abnormal Heart Sounds / Murmurs
Hypovolemic Shock
EKG Monitoring
Capillary Refill
Pre and Post Cardiac Catheter
Vital Sign Monitoring
Congestive Heart Failure
Hemodynamic (PA-Swan-Ganz)
Auscultation (Rate, Rhythm)
Congenital Heart Defects and Disease
Cardiogenic Shock
Color
Pre and Post Cardiac Surgery

General*

Rows	Proficiency	Frequency
Discharge
Pre-Operative Care / Prep
Electronic Medical Records
Postmortem Care
Reporting of Child Protective Agency
Advance Directives
Organ / Tissue Donation
Care of the Dying Pediatric Patient
Patient and Family Teaching
Admission
Intercession for the Parent of the Sick Child
Preoperative Teaching

Pulmonary*

Rows	Proficiency	Frequency
Oxygenation Status
Chest Trauma
Intussusception
Tracheo-Esophageal Fistula
Pulse Oximetry
Airway Obstruction
Cystic Fibrosis
Near SIDS
Tuberculosis
Nasal Flaring
Bronchiolitis (RSV)
Foreign Body Aspiration
Status Asthmaticus
Entidal CO2
Adventitious Breath Sounds
Broncho-Pulmonary Dysplasia
Epiglottitis and Tonsillitis
Pneumonia
Apnea
Rate and Work of Breathing
Croup
Near Drowning
Tracheostomy
Interpretation of ABGs

Gastrointestinal*

Rows	Proficiency	Frequency
Anorexia / Bulimia
Hepatic Failure
LFTs (Liver Function Test)
Bowel Sounds
Gastroenteritis / Severe Dehydration
Ingestions
Nutritional Status
GI Bleed
Pre / Post Abdominal Surgery
GI Assessment
Failure to Thrive
Inflammatory Bowel Disease
Serum Amylase
Colostomy / Illeostomy
Hepatitis
Serum Ammonia

Neurology*

Rows	Proficiency	Frequency
Level of Consciousness
Excess Muscle Involvement
Acute Spinal Cord Injury
ICP Monitoring
Open and Closed Head Injury
Neurological Assessment
Attention Span
Color Changes
Halo Traction / Cervical Tongs
Overdose and Ingestion
Glasgow Coma Scale
Suicidal Ideation
Mirroring Movement
Febrile Seizure
Neuromuscular Disease
Status Epilepticus
Non-Accidental Trauma
Hyperkinesia's
Battered Child Syndrome
Internal and External Shunts
Seizure Precautions
Reflex / Motor Deficits
Language
Coma
Meningitis and Encephalitis
Spina Bifida

Musculoskeletal*

Rows	Proficiency	Frequency
Pulse / Circulation Checks
Cast Care
Multiple Trauma / Fractures
Spica Casts
ROM
Crutch Walking
Muscular Dystrophy
Buck's Traction
Skeletal / Skin Traction
Amputation
Cervical Collars
Post Harrington Rod Insertion
Balanced Suspension Traction
External Fixation
Osteomyelitis

Immunology / Hematology / Oncology*

Rows	Proficiency	Frequency
Acute Lymphocytic Leukemia
DIC
Spleen Trauma / Splenectomy
Blood Transfusions
Bone Marrow Transplant
Sepsis
Anaphylactic Shock
Dehydration
Hemophilia
Treatment Side Effects Chemo / Radiation
Acetaminophen Toxicity
Depressed Immune System
HIV / AIDS
Immunization Schedule
Cancer
Sickle Cell Anemia
Hematology

Wounds / Integument*

Rows	Proficiency	Frequency
Skin Turgor
Skin Assessment
Burns
S/S Infection
Wounds / Incisions

Genitourinary*

Rows	Proficiency	Frequency
Acute / Chronic Renal Failure
Nephrostomy Tube
BUN & Creatinine
Skin Turgor
Shunts & Fistulas
Measurement of I & O
Genitourinary Trauma
Urinary Tract Infection
Serum Electrolytes
Hemodialysis
Diaper Weights
Urinalysis
Assess Fluid Balance
Nephritis
Fluid Status

Endocrine*

Rows	Proficiency	Frequency
DKA
Thyroid Studies
Pituitary Disorders (SAIDH, DI)
Juvenile Diabetes
Cushing's Syndrome
Thyroid Disorders
Insulin Shock
Blood Glucose

ENT / Plastics*

Rows	Proficiency	Frequency
Cleft Lip / Palate
Craniofacial Reconstruction

General*

Rows	Proficiency	Frequency
Amiodarone
Dobutamine (Dobutrex)
Valium
Aminophylline
Diltiazem (Cardizem)
Insulin Drip
Versed
Atropine
Diprivan (Propofol)
Levophed
Bicarbonate
Epinephrine (Adrenalin)
Verapamil (Calan, Isoptin, Verelan)
Ativan
Dopamine (Intropin)
Paralytics

Medications Administration*

Rows	Proficiency	Frequency
Calculation of Pediatric Doses
Needleless Systems
Eye / Ear Meds
PO Medications
Bladder Irrigation and Instillation
Emergency Meds
NG Medications
IM & SQ Meds
Rectal Medications
Metered Dose Inhaler

IV Therapy*

Rows	Proficiency	Frequency
Adverse Reactions
Butterfly
Insertion of Peripheral IV
Administer IV Drips
Fluid Resuscitation
PCA Pumps
Administer IV Medications
Heparin Locks
IV Insertion Scalp Vein
Infusion Pumps
Syringe Pumps
Assess / Maintain IV
Vascular Access Device - Care / Maintenance
Mix IV Infusion With Additives

Oxygen Administration*

Rows	Proficiency	Frequency
Aerosol Treatments
Isolette
Venti Mask
CPAP / PEEP / IMV
Pressure Ventilator
Tracheostomy
ECMO
Non-Rebreather Mask
Volume Ventilator
Ambu-Bag
Nasal Cannula
Ventilation With Ambu Bag
Hood and Tent
Portable Oxygen

Nutritional Therapy*

Rows	Proficiency	Frequency
Enteral Administration
TPN and Hyperalimentation
Assist With Bottle & Breast Feeding
Procalamine
PEG
NGT Insertion
Dobhoff Insertion
Tube Feeding Pumps

Pain Management*

Rows	Proficiency	Frequency
Narcotic Analgesia
Epidural Anesthesia / Analgesia
Moderate Sedation
Assess Pain Level / Tolerance
Ramsey Scale
Patient Controlled Analgesia

Blood*

Rows	Proficiency	Frequency
Albumin
Administer Blood / Blood Products

Specimen Collection*

Rows	Proficiency	Frequency
Dextrostick
Venipuncture
Assist With Rape Exam
Stool
Butterfly Stick
Diaper A'spiration
Throat Swab
Scalp Vein
Sputum
Central Line Draw
Finger Stick
Cultures
Urine

General*

Rows	Proficiency	Frequency
Chest Physical Therapy
Foley, Male
Infant & Child CPR
Suctioning (Oro-Naso-Pharynx)
Wound Vac
CPM Machine
Drains (JP-Hemovac-Penrose)
Iced Saline Lavage
Specialty Beds
Vaporizer
Doppler
Hyper / Hypothermia Blanket
Isolation
Trach Care and Suctioning
Dressing Changes
Insertion of NGT / Suction
Phototherapy
Use of Bulb Syringe
Chest Tube Drainage Systems
Foley, Female
Incentive Spirometry
Thermoregulators
Wound Care / Irrigations

Assist*

Rows	Proficiency	Frequency
Chest Tube Insertion
Intraosseous Infusion
Bronchoscopy
Halo Traction / Cervical Tongs Placement
Central Line Insertion
ET Intubation and Extubation
Assist With Supra-Pubic Tap
Chest Tub Removal
IV Cutdown
Bedside Invasive Procedures
Emergency Tracheostomy
Lumbar Puncture

Clinical Settings*

Rows	Proficiency	Frequency
Specialty PICU
General ICU

Age Specific Criteria*

Rows	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)

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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