Dialysis Care Skills Checklist Form

Items in red are REQUIRED fields.

Personal Information:
First Name:        Middle Initial:
Last Name:
Address:
City:
State:        ZIP:
Phone:
E-mail Address:
Years of Experience:

Directions for completing Skills Checklist:

The following is a list of equipment and/or procedures performed in rendering care to patients. Please indicate the level of experience/proficiency with each and, where applicable, the types of equipment and/or systems with which you are familiar. Use the following KEY as a guideline:
A) Theory Only/No Experience - Didactic instruction only, no hands-on experience.
B) Limited Experience - Knows procedure/has used equipment, but has done so infrequently or not within the last six months.
C) Moderate Experience - Able to demonstrate equipment/procedure, performs the task/skill independently with only resource assistance needed.
D) Proficient/Competent - Able to demonstrate/perform the task/skill proficiently without any assistance and can instruct/teach.



A. RENAL / GENITOURINARY    A        B        C        D
   1. Assessment of Renal/GU System         
   2. Insertion/Care of Foley Catheter         
   3. Care of the Patient with:  
      (a) Nephrostomy Tube         
      (b) AV Fistula/ AV Graft         
      (c) Tunneled/ Non-tunneled Catheter         
      (d) Ileal Conduit         
      (e) Supra-Pubic Catheter         
      (f) Chronic Renal Failure         
      (g) Acute Renal Failure         
      (h) Nephrectomy         
      (i) Turp         
      (j) Peritoneal Dialysis         
      (k) Hemodialysis         


B. HEMODIALYSIS SKILLS/PROCEDURES    A        B        C        D
   1. Experience  
      (a) Acute/Inpatient Dialysis         
      (b) Chronic/Outpatient Dialysis         
      (c) Dialysis Home Care         
      (d) Pediatric Dialysis         
      (e) Peritoneal Dialysis         
      (f) Predialysis Nursing Assessment         
      (g) Educating Patient and Patient's Family         
      (h) CVVH         
      (i) CAPD         
      (j) Cycled PD         
   2. Set Up/Initiate Dialysis Treatment  
      (a) Bicarbonate Dialysate         
      (b) Conductivity/pH Testing         
      (c) Priming Dialyzer         
      (d) Checks for Machine/Alarm Settings         
      (e) Prep Vascular Access         
      (f) Catheter Vascular Access         
      (g) Fistula or Graft Vascular Access         
      (h) Dialysis         
      (i) Collect Blood Specimins         
      (j) Anticoagulation         
      (k) Set up for Cycler PD Machine         
      (l) Set up for CVHD         
   3. Assess Patient and Equipment During Dialysis  
      (a) Systems Assessment of the Patient         
      (b) Volume Status         
      (c) Vascular Access Function         
      (d) Arterial and Venous Pressures         
      (e) Blood Flow Rate         
      (f) Subjective Assessment of Response to Treatment         
      (g) Management of Anticoagulation         
      (h) Conductivity Meters         
      (i) Ultrafiltration Calculation         
      (j) Knowledge of Peritoneal Dialysis Solutions         
      (k) Administration of Blood and Blood Products         
      (l) Administration of Mannitol         
      (m) Sequential Ultrafication/PUF         
      (n) Documentation of Dialysis Treatment         
      (o) Administration of IV Push and IX Pump Medications         
      (p) Epogen         
      (q) Vitamin D Derivatives         
      (r) Iron Replacement         
      (s) Antibiotics         
      (t) Administration of Antibiotics         
   4. Management of the Patient with:  
      (a) Fluid Overload         
      (b) Hypertension         
      (c) Hypotension         
      (d) Disequilibrium Syndrome         
      (e) Hyperkalemia         
      (f) Seizures         
      (g) Muscle Cramps         
      (h) Clotted Access/Poor Blood Flow Rate From Catheter         
      (i) Pyrogenic Reaction         
      (j) Hemolysis         
      (k) Air Emboli         
      (l) Chest Pain         
      (m) Anemia         
      (n) Neuropathy         
      (o) Pericarditis         
      (p) Filter Blood Leak         
      (q) Cardiopulmonary Arrest         
      (r) Infiltration of an AV Access         
   5. Machine Alarm Troubleshooting Procedures  
      (a) Blood Leak Alarm         
      (b) Arterial Pressure Alarm         
      (c) Venous Pressure Alarm         
      (d) Conductivity Alarm         
      (e) Ultrafiltration Alarm         
      (f) High Temperature Alarm         
      (g) Air/Foam Detector Alarm         
      (h) Power Failure Alarm         
      (i) Blood Pump Alarm         
   6. Discontinue Dialysis  
      (a) Dialysis Catheter         
      (b) Fistula/Vein Graft         
      (c) Return of Blood         
      (d) Post Treatment Access Care         
      (e) Equipment Clean Up         
      (f) Sterilization         
   7. Skilled Nursing Care  
      (a) Airway Management         
      (b) Oxygen Therapy         
      (c) Oral/Nasotracheal Suctioning         
      (d) Pulse Oximetry         
      (e) Venipuncture         
      (f) Saline Lock/Peripheral Intravenous Insertion         
      (g) Assessment of Circulation/Peripheral Pulses         
      (h) Blood Glucose Monitoring         
      (i) NG Tube Insertion/Maintenance         
      (j) Management of Fluid/Electrolyte Balance         
      (k) Intake/Output         
      (l) Seizure Precautions         
      (m) Cardiac Arrest/CPR         
      (n) Knowledge of Lab Values for ESRD Patients         
      (o) Knowledge of ESRD Dietary Recommendations         


C. MISCELLANEOUS    A        B        C        D
   1. AMA procedures Yes     No

Please check the boxes for each age group for which you have expertise in providing age-appropriate nursing care.

AGE SPECIFIC PRACTICE:
A) Newborn.Neonate (Birth - 30 days) D) Preschooler (3-5 years) G) Young Adults (18-39 years)
B) Infant (30 days-1 year) E) School Age Children (5-12 years) H) Middle Adults (39-64 years)
C) Toddler (1-3 years) F) Adolescents (12-18 years) I) Older Adults (64+)

EXPERIENCE WITH AGE GROUPS:
Able to adapt care to incorporate normal growth and development:
A         B         C         D         E         F         G         H         I
Able to adapt method and terminology of patient instruments to their age comprehension and maturity level:
A         B         C         D         E         F         G         H         I
Can ensure a safe environment reflecting specific needs of various age groups:
A         B         C         D         E         F         G         H         I

The information I have given is true and accurate to the best of my knowledge. I hereby authorize Professional Nursing Service to release my Dialysis Care Skills Checklist to Client facilities of PNS in relation to consideration of employment as a Traveler with those facilities.

Yes, I agree and consent to the statement above         Date: