Neonatal Intensive Care Skills Checklist Form

Items in red are REQUIRED fields.

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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. CARDIOVASCULAR    A        B        C        D
   1. Assessment  
      (a) Auscultation (Rate, Rhythm, Volume)         
      (b) Blood Pressure/ Invasive (Arterial line)         
      (c) Blood Pressure/ Non-Invasive         
      (d) Heart Sounds/ Murmurs         
      (e) Perfusion         
      (f) Pulses         
   2. Equipment & Procedures  
      (a) EKG Interpretation         
      (b) Defibrillation/ Cardioversion         
      (c) Invasive Hemodynamic Monitoring         
      (d) Central Venous Pressure         
   3. Care of the Neonate with  
      (a) Cardiac Arrest         
      (b) Cardiac Transplant         
      (c) Cardiomyopathy         
      (d) Congenital Heart Disease/ Defects         
      (e) Hemodynamic Instability         
      (f) Hypovolemic Shock         
      (g) Post Cardiac Surgery         
      (h) Post Interventional Cardiac Cath         
   4. Medications  
      (a) Dobutamine         
      (b) Dopamine         
      (c) Epinephrine         
      (d) Nipride         
      (e) Sodium Bicarbonate         


B. PULMONARY    A        B        C        D
   1. Assessment  
      (a) Breath Sounds         
      (b) Rate and Work of Breathing         
   2. Interpretation of Lab Results  
      (a) Blood Gases         
      (b) Interpretation of x-ray reports         
   3. Equipment & Procedures  
      (a) Airway Management  
         (I) Assist with Intubation         
         (II) Bulb Syringe         
         (III) CPAP (Nasal Prongs)         
         (IV) Endotracheal Tube Stabilization         
         (V) Endotracheal Tube Suctioning         
      (b) Apnea Monitor         
      (c) Cardiac Resuscitation         
      (d) Apnea Monitor  
         (I) Insertion         
         (II) Removal         
         (III) Set-up         
      (e) ECMO (Extracorporeal Membrane Oxygenation)         
      (f) O2Therapy Delivery Systems  
         (I) Bag (Anesthesia) & Mask         
         (II) Bag (Self-inflating) & Mask         
         (III) Nasal Cannula         
         (IV) Nebulizer         
         (V) Oxyhood         
         (VI) Tent         
         (VII) Trach Collar         
      (g) Obtaining Blood Gases  
         (I) Arterial         
         (II) Heelstick         
         (III) Peripheral         
         (IV) Umbilical Line         
      (h) Thoracentesis         
      (i) Use of Artificial Surfactant         
      (j) Ventilator Care  
         (I) CPAP/PEEP         
         (II) High Frequency Jet Ventilator         
         (III) Home Ventilator         
         (IV) IMV         
         (V) Oscillating         
         (VI) Pressure Ventilator         
         (VII) Volume Ventilator         
      (k) Weaning         
   4. Care of the Neonate with  
      (a) Bronchopulmonary Dysplasia (BPD)         
      (b) Cardiogenic/Hypovolemic Shock         
      (c) Diaphragmatic hernia         
      (d) Fresh Tracheostomy         
      (e) Meconium Aspiration         
      (f) Persistent Pulmonary Hypertention (PPHN)         
      (g) Pneumothorax         
      (h) Respiratory Distress Syndrome (RDS)         
      (i) Respiratory Failure         
   5. Medications  
      (a) Aminophylline         
      (b) Prostaglandin         


C. NEUROLOGICAL    A        B        C        D
   1. Assessment  
      (a) Intracranial Pressure Monitoring         
      (b) Neurological Status         
   2. Care of Neonate with  
      (a) Brain Death/ Organ Procurement         
      (b) Externalized VP Shunt/ Reservoirs         
      (c) Increased Intracranial Pressure         
      (d) Meningitis         
      (e) Seizures         
   3. Medications  
      (a) Anticonvulsant Medication         


D. GASTROINTESTINAL    A        B        C        D
   1. Assessment  
      (a) Abdominal Girth         
      (b) Bowel Sounds         
      (c) Palate         
      (d) Suck/Swallow         
   2. Equipment & Procedures  
      (a) Abdominal Girth         
      (b) Feeding  
         (I) Assist with Breast Feeding         
         (II) Bottle         
         (III) Breast Milk Handling/ Storage         
         (IV) Gavage         
      (c) Hospital Grade Electric Breast Pump         
      (d) Placement of Intestinal Tubes  
         (I) Jejunal Gastro         
         (II) Nasogastric/Orogastric         
      (e) Test for Occult Blood         
   3. Care of the Neonate with  
      (a) Cleft Palate         
      (b) Colostomy/Ileostomy         
      (c) Gastroschisis/Omphalocele         
      (d) GI Bleeding         
      (e) Inguinal Hernia         
      (f) Necrotizing Enterocolitis (NEC)         
      (g) Post Abdominal Surgery         
      (h) Reflux Precautions         
      (i) Tracheoesophageal Fistula (TEF)         


E. ENDOCRINE/METABOLIC    A        B        C        D
   1. Assessment  
      (a) Finnegan         
      (b) Fluid & Electrolyte Balance         
   2. Interpretation of Lab Results  
      (a) Bilirubin         
      (b) Test Urine and Interpret  
         (I) Glucose         
         (II) Labstix         
         (III) Occult Blood         
         (IV) pH         
         (V) Specific Gravity         
   3. Equipment & Procedures  
      (a) Collection of Urine Specimens  
         (I) Assist with Supra Pubic Tap         
         (II) Catheter         
         (III) Diaper/Bag         
      (b) Phototherapy for Jaundice         
      (c) Post Circumcision Care         
   4. Care of the Neonate with  
      (a) Acute Renal Failure         
      (b) DIC (Disseminated Intravascular Coagulation         
      (c) Disorders of Internal/External Organs         
      (d) Drug Addiction/Withdrawal         
      (e) Hypo/Hyperkalemia         
      (f) Hypo/Hypernatremia         
      (g) IDM (Infant of a Diabetic Mother)         
      (h) Malformation of the GU Tract, Kidney         
      (i) Peritoneal Dialysis         


F. INFECTIOUS DISEASES    A        B        C        D
   1. Interpretation of Lab Results  
      (a) CBC/Differential         
      (b) Culture Reports         
      (c) Maternal Lab Results         
   2. Equipment & Procedures  
      (a) Assist with Lumbar Puncture         
      (b) Maternal Lab Results         
      (c) Isolation Techniques         
      (d) Standard (Universal) Precautions         
   3. Care of the Neonate with  
      (a) Hepatitis Surface Antigen+ Mother         
      (b) HIV Positive Mother         
      (c) Neonatal Sepsis         
   4. Medications - Immunizations  
      (a) HBIG         
      (b) HBV         
      (c) HIV         
      (d) Polio         
      (e) DPT         
      (f) RespiGam/Synergis Prophylaxis         


G. PHLEBOTOMY/IV THERAPY    A        B        C        D
   1. Equipment & Procedures  
      (a) Administration of Blood/ Blood Products  
         (I) Cryoprecipitate         
         (II) Packed Red Blood Cells         
         (III) Plasma/Albumin         
         (IV) Whole Blood         
      (b) Delivery Systems  
         (I) IV Pump         
         (II) Syringe Pump         
      (c) Drawing Blood from Central Line         
      (d) Drawing Venous Blood         
      (e) Hyperlimentation/TPN         
      (f) Intralipid         
      (g) Managing IV Therapy  
         (I) Discontinuing         
         (II) Dressing & Tubing Change         
         (III) Rate Calculation         
         (IV) Site & Patency Assessment         
      (h) Starting IVs  
         (I) Angiocath         
         (II) Butterfly         
         (III) Heparin Lock         
   2. Care of Neonate with  
      (a) Central Line/Catheter/Dressing Products  
         (I) Broviac         
         (II) Groshong         
         (III) Hickman         
         (IV) Portacath         
         (V) Quinton         
      (b) Percutanious Arterial Line         
      (c) Percutanious Venous Line         
      (d) Peripheral Line/Dressing         
      (e) PICC (Peripherally Inserted Central Catheter)         
      (f) Umbilical Artery Line         
      (g) Umbilical Venous Line         


H. PAIN MANAGEMENT    A        B        C        D
   1. Assessment of Pain Level         
   2. Care of the Neonate with Sedation, i.e. Morphine         


I. MISCELLANEOUS    A        B        C        D
   1. Assessment  
      (a) Apgar Scoring         
      (b) Eye Exam (r/o Retinopathy)         
      (c) Gestational Age  
         (I) Ballard         
         (II) Dubowitz         
         (III) Other (Specify)
      (d) Maternal History         
      (e) Screen for Hearing Loss         
   2. Equipment & Procedures  
      (a) Bereavement/Postmartum Care         
      (b) Consents  
         (I) Immunization         
         (II) Procedural         
         (III) Treatment         
      (c) Cord Care         
      (d) Neonatal Skin Care         
      (e) Positioning Devices         
      (f) Preparation for Transport/Transfer         
      (g) Thermoregulation  
         (I) Isolette with Humidity         
         (II) Radiant Warmer         
         (III) Temperature (Axillary, rectal, skin)         
         (IV) Weaning to Open Crib/Bassinet         
      (h) Weights  
         (I) Bed Scale         
         (II) Scale         
   3. Medications  
      (a) Calculation of Dosage         
      (b) Emergency Drug Action and Reaction         
      (c) Eye Prophylaxis - Vitamin K         
      (d) Neonatal Drug Action and Reaction         

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

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