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Skills Assessment - Pediatric
 
The following checklist will be used to match your skills and interests with available assignments. Please enter your information, and we will store this information with your application/profile. Please indicate your level of proficiency by marking the appropriate number.
 
First Name:
Middle Initial:
Last Name:
SSN: - -
E-mail Address:
Home Phone: - -
Work Phone: - -
Cell Phone: - -
City:
State:
 
 
0. Theory, no practice  1. Limited   2. Confident   3. Very Confident
 
General: Experience:
Care for the Infant 0   1   2   3  
Care for the Toddler 0   1   2   3  
Care for the Pre-schooler 0   1   2   3  
Care for the School-ager 0   1   2   3  
Care for the Adolescent 0   1   2   3  
Assess pediatric patient head-to-toe 0   1   2   3  
Knowledge of age-appropriate vital signs 0   1   2   3  
Knowledge of normal serum values 0   1   2   3  
Use of radiant warmers 0   1   2   3  
Use of phototherapy 0   1   2   3  
Care for the patient with sepsis 0   1   2   3  
Care for the patient with failure to thrive 0   1   2   3  
Care for the patient who is near drowning 0   1   2   3  
Care for the patient with hyperbilirubinemia 0   1   2   3  
Care for the patient who has overdosed or been poisoned 0   1   2   3  
Care for the patient who is post Harrington Rod insertion 0   1   2   3  
 
Cardiovascular:
Assess heart sounds and peripheral pulses 0   1   2   3  
Interpret arrhythmias 0   1   2   3  
Intervene appropriately for arrhythmias 0   1   2   3  
Assist with arterial line insertion 0   1   2   3  
Care for patients with arterial line 0   1   2   3  
Draw blood samples from arterial line 0   1   2   3  
Interpret arterial line waveform/pressures 0   1   2   3  
Remove arterial line 0   1   2   3  
Assist with S/G insertion 0   1   2   3  
Care for patient with S/G catheter 0   1   2   3  
Interpret PA waveforms/pressures 0   1   2   3  
Assist with central line insertion 0   1   2   3  
Draw blood samples from central line 0   1   2   3  
Assist with cardioversion 0   1   2   3  
Care for the patient with acute heart failure 0   1   2   3  
Care for the patient requiring temporary pacing 0   1   2   3  
Care for the post-op cardiac surgery patient 0   1   2   3  
Care for the patient in shock 0   1   2   3  
Care for the pre- and post-cardiac cath patient 0   1   2   3  
Care for the post-op thoracic surgery patient 0   1   2   3  
Care for the patient with PDA Ligation 0   1   2   3  
Care for the patient with Tetralogy of Fallot 0   1   2   3  
Care for the patient with Transposition of Great Vessels 0   1   2   3  
Participate in resuscitation as a team member 0   1   2   3  
Participate in resuscitation by performing defibrillation 0   1   2   3  
Participate in resuscitation by preparing emergency drugs 0   1   2   3  
Participate in resuscitation by performing CPR 0   1   2   3  
 
Pulmonary:
Assess lung sounds 0   1   2   3  
Set up O2 devices 0   1   2   3  
Pulse oximetry monitoring 0   1   2   3  
Open, establish patent airway 0   1   2   3  
Interpret ABG 0   1   2   3  
Suction and care of endotracheal tube 0   1   2   3  
Use Ambu bag 0   1   2   3  
Assist with intubation 0   1   2   3  
Assist with chest tube insertion 0   1   2   3  
Care for the patient with asthma 0   1   2   3  
Care for the patient with mechanical ventilation 0   1   2   3  
Care for the patient with RDS 0   1   2   3  
Care for the patient with chest tubes 0   1   2   3  
Care for the patient with a tracheostomy 0   1   2   3  
Care for the patient with cystic fibrosis 0   1   2   3  
Care for the patient with pulmonary edema 0   1   2   3  
Care for the patient with respiratory distress 0   1   2   3  
Care for the patient with respiratory failure 0   1   2   3  
 
Neurological:
Assess Glasgow Coma Scale 0   1   2   3  
Identify sudden change in LOC 0   1   2   3  
Assess sensory, motor, speech 0   1   2   3  
Reflex assessment (Babinski, gag) 0   1   2   3  
Identify, intervene for seizure 0   1   2   3  
Care for the patient with ICP monitoring 0   1   2   3  
Care for the patient who is post-op neurosurgical 0   1   2   3  
Care for the patient in a comatose state 0   1   2   3  
Care for the patient by assisting with lumbar puncture 0   1   2   3  
Care for the patient with neuromuscular disease 0   1   2   3  
Care for the patient with meningitis 0   1   2   3  
Care for the patient with a brain tumor 0   1   2   3  
 
GI/Renal/Endocrine/Nutrition:
Insert nasogastric tube 0   1   2   3  
Care for the patient with gastroenteritis 0   1   2   3  
Care for the patient with dehydration 0   1   2   3  
Care for the patient with Diabetes mellitus 0   1   2   3  
Care for the patient with a GI bleed 0   1   2   3  
Care for the patient with hemodialysis 0   1   2   3  
Care for the patient with DKA 0   1   2   3  
Care for the patient with TPN 0   1   2   3  
Care for the patient with enteral nutrition 0   1   2   3  
Care for the patient with bowel obstruction 0   1   2   3  
Care for the patient with appendicitis 0   1   2   3  
Care for the patient with pH probe 0   1   2   3  
Care for the patient with gastroesophageal reflux 0   1   2   3  
 
Hematology/Oncology:
Administer blood and blood products 0   1   2   3  
Administer chemotherapeutic agents 0   1   2   3  
Care for the patient with neutropenia 0   1   2   3  
Care for the patient with Sickle Cell Anemia 0   1   2   3  
Care for the patient with HIV 0   1   2   3  
Care for the patient with Leukemia 0   1   2   3  
Care for the patient with Hodgkin's Disease 0   1   2   3  
 
Medications:
Calculate pediatric dosing 0   1   2   3  
Use of Infusion/Syringe pump 0   1   2   3  
Use PCA pumps 0   1   2   3  
Use epidural pumps 0   1   2   3  
Administer IV Dopamine 0   1   2   3  
Administer IV Norepinephrine (Levophed) 0   1   2   3  
Administer IV Epinephrine 0   1   2   3  
Administer IV Nitroglycerine 0   1   2   3  
Administer IV Nitroprusside (Nipride) 0   1   2   3  
Administer IV Dobutamine (Dobutrex) 0   1   2   3  
Administer IV Lidocaine 0   1   2   3  
Administer IV Amiodarone (Cordarone) 0   1   2   3  
Administer IV Atropine 0   1   2   3  
Administer IV Thrombolytics (i.e., TPA, Streptokinase) 0   1   2   3  
Administer IV Heparin 0   1   2   3  
Administer IV Benzodiazepines (i.e., Valium, Versed, Ativan) 0   1   2   3  
Administer IV Propofol (Diprivan) 0   1   2   3  
Administer IV Neuromuscular blocking agents (Pavulon,Norcuron) 0   1   2   3  
Administer IV Morphine 0   1   2   3  
 
Pain Management/Miscellaneous:
Assessment of pain level/tolerance/manage 0   1   2   3  
Care of the child with Epidural anesthesia/analgesia 0   1   2   3  
Admit unstable patient 0   1   2   3  
Transport patient within hospital for testing 0   1   2   3  
Start peripheral IV/scalp vein 0   1   2   3  
Maintain a heparin/saline lock 0   1   2   3  
 
Age-Specific Practice Criteria:
Please check the box corresponding to each age group for which you have expertise in providing age-appropriate nursing care. Newborn/Neonate (birth - 30 days)  
Infant (30 days-1year)  
Toddler (1 - 3 years)  
Preschooler (3 - 5 years)  
School age children (5-12 years)  
Adolescents (12-18 years)  
Young adults (18-39 years)  
Middle adults (39-64 years)  
Older adults (65+)  
 
Experience With Age Groups:
Calculate body weight to verify correct dosing of medication 0   1   2   3  
Assess immunization status for pediatric, and adolescent 0   1   2   3  
Set age-appropriate short-term and long-term goals in care planning 0   1   2   3  
Provide age-appropriate education 0   1   2   3  
 
 
 
 


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