PEDIATRIC NURSING

CLINICAL NURSING SKILLS SELF ASSESSMENT FORM

Name:_______________________________________________ Date:_________________________

Please indicate level of skill and experience in all listed areas.

LEVELS OF PROFICIENCY: 0 = Never Done, 1 = Perform with Supervision, 2 = Perform Independently

  0 1 2   0 1 2
MEDICATION ADMINISTRATION       ISOLATION TECHNIQUES       
Unit Dose       Universal Precautions      
Pouring from Stock Medications       Familiar with Isolation Precautions      
Calculation of Pediatric Doses       Familiar with Isolation Techniques      
Administration of:       CARDIOVASCULAR SYSTEM      
   Oral Medications       Preparation of Emergency Drugs      
   Intramuscular Medications       Apnea monitor      
   IV Push Medications       Cardiac Monitor      
   IV Drip Medications       CPR on Infant      
   Subcutaneous Medications       CPR on Child      
   Aerosol Therapy       Interpretation of EKG Rhythm Strips      
IV THERAPY       Care of Patient with:      
Starting IV’s:          Congestive Heart Failure      
   Angiocath Insertion          PDA Ligation      
   Scalp Veins          Cyanotic Heart Disease      
Mixing IV’s          Septic Shock      
Regulating IV’s          Disseminated Intravascular Coagulation      
Assessment of PAtency / Site              
Discontinuing Peripheral IV’s       Assessment of:      
Discontinuing Subclavian IV’s          Heart Sounds      
Heparin Locks          Pulses      
Hickman Line / Broviac Line Care          Perfusion      
Subclavian Line Care       Blood Pressure:      
Use of Triple Lumen Catheters       Non-Invasive Machine      
Administering Blood Products       Use Of Doppler      
IV Hyperalimentation:        Use of Palpation      
Central       Administration of Cardiac Meds.      
Peripheral       IV      
Dressing       Oral      
Intralipid Infusion       IM      
Infusion Pump       N/G Tube      

PEDIATRIC NURSING

CLINICAL NURSING SKILLS SELF ASSESSMENT FORM, Pg. 2

Name:_______________________________________________ Date:_________________________

Please indicate level of skill and experience in all listed areas.

LEVELS OF PROFICIENCY: 0 = Never Done, 1 = Perform with Supervision, 2 = Perform Independently

  0 1 2   0 1 2
Care of Patient Undergoing Cardiac Surgery       GASTROINTESTINAL SYSTEM      
Interpretation of Normal HCT Values       Assessment of Abdominal Girth      
Assistance with Exchange Transfusion       Assessment of Bowel Sounds      
Parent / Child Teaching of Heart Disease       Stoo