Pediatric Care Skills Checklist Form

Items in red are REQUIRED fields.

Personal Information:
First Name:        Middle Initial:
Last Name:
State:        ZIP:
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. CARDIOVASCULAR    A      B      C      D
   1. Assessment  
      (a) Auscultation (rate/rhythm)         
      (b) Blood pressure/non-invasive         
      (c) Doppler         
      (d) Heart sounds/murmurs         
      (e) Perfusion         
   2. Interpretation of lab results  
      (a) Arterial blood gases         
      (b) Hemoglobin and hematocrit         
   3. Equipment & Procedures  
      (a) Basic EKG interpretation         
      (b) Non-invasive cardiac monitoring         
   4. Care of the child with  
      (a) Bacterial endocarditis         
      (b) Cardiac arrest         
      (c) Cardiomyopathy         
      (d) Congenital heart defects/disease         
      (e) Congestive heart failure         
      (f) Myocarditis         
      (g) Pericarditis         
      (h) Post cardiac cath         
      (i) Post cardiac surgery         
      (j) Rheumatic fever         
      (k) Shock         
   5. Medication - Digoxin (Lanoxin)         

B. PULMONARY    A      B      C      D
   1. Assessment  
      (a) Chest/lungs: Inspection, palpation, percussion, auscultation         
      (b) Breathing patterns/rate/SOB/Inspiration         
      (c) Cough/secretions/hemoptysis         
      (d) Pains - chest         
      (e) Skin - color         
   2. Equipment & Procedures  
      (a) Airway management devices/suctioning  
         (I) Bulb syringe         
         (II) Endotracheal tube/suctioning         
         (III) Nasal airway/suctioning         
         (IV) Oropharyngeal/suctioning         
         (V) Sputum specimen collection         
         (VI) Tracheostomy/suctioning         
      (b) Apnea monitor         
      (c) Chest physiotherapy         
      (d) Chest tubes         
      (e) End tidal CO2         
      (f) Oximetry         
      (g) O2 therapy & medication delivery systems  
         (I) Bag and mask         
         (II) Hood         
         (III) Inhalers         
         (IV) Nasal cannula         
         (V) Portable O2 tank         
         (VI) Trach collar         
      (e) Water seal drainage system         
   3. Care of the child with  
      (a) Asthma         
      (b) Bronchiolitis (RSV)         
      (c) Bronchopulmonary dysplasia (BPD)         
      (d) Cystic fibrosis         
      (e) Epiglottitis         
      (f) LTB/croup         
      (g) Pertussis         
      (h) Pneumonia         
      (i) Tonsillitis         
      (j) Tuberculosis         
   4. Medications  
      (a) Alpupent (Meraproteranol)         
      (b) Aminophylline (Theophylline)         
      (c) Isuprel (Isopreterenol)         
      (d) Ventolin (Albuterol)         

   1. Assessment - level of consciousness         
   2. Equipment & Procedures  
      (a) Application of splints         
      (b) Assist with lumbar puncture         
      (c) Cast         
      (d) ICP monitoring         
      (e) Pinned fractures         
      (f) Traction         
   3. Care of the child with  
      (a) Battered child syndrome/span>         
      (b) Closed head trauma         
      (c) Clubfoot         
      (d) Encephalitis         
      (e) Febrile seizures         
      (f) Meningitis         
      (g) Multiple sclerosis         
      (h)Multiple trauma         
      (i) Near drowning         
      (j) Neuromuscular disease         
      (k) Osteogenic sarcoma         
      (l) Osteomyelitis         
      (m) Spinal cord injury         
   4. Medications  
      (a) Clonazepam (Klonopin)         
      (b) Corticosteroids         
      (c) Dilantin (Phenytoin)         
      (d) Phenobarbital         
      (e) Tegretol (Carbemazepine)         
      (f) Valium (Diazepam)         

D. GASTROINTESTINAL    A      B      C      D
   1. Assessment  
      (a) Abdominal/bowel sounds/inspections         
      (b) Nutrition - diet/fluid balance/ht/wt         
   2. Interpretation of lab results - serum electrolytes         
   3. Equipment & Procedures  
      (a) Feedings  
         (I) Bottle         
         (II) Breast         
         (III) Central hyperalimentation         
         (IV) Gavage         
         (V) Peripheral hyperalimentation         
      (b) Gastrostomy/button         
      (c) I-tubes         
      (d) Jejunal feeding         
      (e) NG and sump tubes to suction         
      (f) Penrose drains         
      (g) Placement of naso/orogastric tube         
      (h) Wound irrigations/dressing change         
   4. Care of the child with  
      (a) Anal fissure         
      (b) Cleft lip/palate         
      (c) Colostomy         
      (d) Diaphragmatic hernia         
      (e) Failure to thrive (FTT)         
      (f) Gastroenteritis/dehydration         
      (g) GE reflux         
      (h) GI Bleeding         
      (i) Ileostomy         
      (j) Intestinal parasites         
      (k) Necrotizing enterocolitis (NEC)         
      (l) Pyloric stenosis         
      (m) Surgical abdomen         
      (n) Ulcerative colitis         

E. RENAL/GENITOURINARY    A      B      C      D
   1. Assessment - fluid balance         
   2. Interpretation of lab results  
      (a) BUN & creatine         
      (b) Urinalysis         
   3. Equipment & Procedures  
      (a) Assist with suprapubic tap         
      (b) Catheter insertion  
         (I) Catheter care         
         (II) Female         
         (III) Indwelling         
         (IV) Maile         
         (V) Straight         
      (c) Collection of urine specimen         
   4. Care of the child with  
      (a) Circumcision         
      (b) Glomerularnephritis         
      (c) Hemodialysis         
      (d) Hemolytic uremic syndrome (HUS)         
      (e) Hypospadias         
      (f) Ileal conduit uretal         
      (g) Infantile polycystic disease         
      (h) Kidney transplant         
      (i) Nephrotic syndrome         
      (j) Peritoneal dialysis         
      (k) Renal failure         
      (l) Urinary tract infection         
      (m) Wilm's tumor         

F. ENDOCRINE/METABOLIC    A      B      C      D
   1. Assessment         
   2. Interpretation of lab results  
      (a) Blood glucose         
      (b) Thyroid studies         
   3. Equipment & Procedures  
      (a) Blood glucose testing: type
   4. Care of the child with  
      (a) Adrenal disorders         
      (b) Cushing's syndrome         
      (c) Juvenile diabetes         
      (d) Pituitary disorders         
      (e) Thyroid malfunction         
   5. Medications  
      (a) Growth hormone         
      (b) Insulin         
      (c) Thyroid         

G. HEMATOLOGY/ONCOLOGY    A      B      C      D
   1. Assessment of nutritional status         
   2. Interpretation of lab results  
      (a) Blood chemistry         
      (b) Blood counts         
   3. Equipment & Procedures - reverse isolation         
   4. Care of the child with  
      (a) Anemia         
      (b) Bone marrow transplant         
      (c) Depressed immune system         
      (d) Desseminated intravascular coagulation (DIC)         
      (e) Hemophilia         
      (f) Hodgekin's disease         
      (g) Infectious mononeucleosis         
      (h) Leukemia         
      (i) Malignant tumors         
      (j) Sickle cell anemia         
      (k) Spleen trauma/splenectomy         
   5. Medications  
      (a) Chemotherapy certification? Yes   No
      (b) Prednisone         

   1. Calculation of pediatric doses         
   2. Eye/ear installations         
   3. Knowledge of emergency drugs         
   4. Knowledge of routine pediatric drugs         
   5. Metered dose inhaler         

I. PHLEBOTOMY/IV THERAPY    A      B      C      D
   1. Equipment & Procedures  
      (a) Administration of blood/blood products  
         (I) Cryoprecipitate         
         (II) Packed red blood cells         
         (III) Whole blood         
      (b) Drawing blood from central line         
      (c) Drawing venous blood         
      (d) Starting IVs  
         (I) Angiocath         
         (II) Butterfly         
         (III) Heparin lock         
   2. Care of the child with  
      (a) Central line/catheter/dressing  
         (I) Broviac         
         (II) Groshong         
         (III) Hickman         
         (IV) Portacath         
         (V) Quinton         

J. INFECTIOUS DISEASES    A      B      C      D
   1. Interpretation of lab results - blood count         
   2. Equipment & Procedures  
      (a) Fever management         
      (b) Isolation         
   3. Care of the child with  
      (a) AIDS         
      (b) Common childhood - communicable diseases         
      (c) Cytomegalo virus (CMV)         
      (d) Hepatitis         
      (e) Kawasaki disease         
      (f) Lyme disease         

K. MISCELLANEOUS    A      B      C      D
   1. Assessment  
      (a) Normal growth and development         
      (b) Normal laboratory values         
      (c) Recognize signs of abuse or neglect         
   2. Medication - immunization schedule         
   3. Care of the child with  
      (a) Anorexia/bulemia         
      (b) Craniofacial reconstruction         
      (c) Depression         
      (d) ENT surgery         
      (e) Eye surgery         
      (f) Ingestion of foreign body         
      (g) Ingestion of poisons or toxins         
      (h) Plastic surgery         
      (i) Suicidal threats/actions         

L. WOUND MANAGEMENT    A      B      C      D
   1. Assessment  
      (a) Skin for impending breakdown         
      (b) Stasis ulcers         
      (c) Surgical wound healing         
   2. Equipment & Procedures  
      (a) 1st degree burns (throughout body)         
      (b) 2nd degree burns         
      (c) 3rd degree burns         
      (d) Pressure sores         
      (e) Staged decubitus ulcers         
      (f) Sterile dressing changes         
      (g)Surgical wounds with drain(s)         
      (h) Traumatic wound care         
      (i) Use of air fluidized, low airloss beds         
      (j) Wound care/irrigations         

M. PAIN MANAGEMENT    A      B      C      D
   1. Assessment of pain level/tolerance         
   2. Care of the child with  
      (a)Epidural anesthesia/analgesia         
      (b)IV conscious sedation         
      (c)Narcotic analgesia         

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

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+)

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

MY EXPERIENCE IS PRIMARILY IN (Please indicate number of years):
 Medical    year(s)  Cardiothoracic    year(s)  Neuro    year(s)
 Neurological    year(s)  Cardiovascular    year(s)  Burn    year(s)
 Trauma    year(s)  Coronary Care    year(s)  PACC    year(s)
 Other       year(s)

The information I have given is true and accurate to the best of my knowledge. I hereby authorize Professional Nursing Service to release my Pediatric 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: