MEDICAL/SURGICAL KNOWLEDGE & SKILLS CHECKLIST _____

DIRECTIONS: Please indicate your level of experience by

NAME:       placing a check (√) in the box. Experience level:
ID #:       1 NO EXPERIENCE
DATE:       2 MINIMAL EXPERIENCE-requires supervision/assistance
3 MODERATELY EXPERIENCED-requires initial review,
This Skills Checklist is for use by nurses with more than then performs independently
one year experience in their discipline and specialty. 4 VERY EXPERIENCED- proficient
Please be accurate with your assessment.

DESCRIPTION 1 2 3 4 DESCRIPTION 1 2 3 4
1. Charge duties GI TUBES
2. Primary Care 1. Nasogastric
3. Team Nursing 2. Miller – Abbott
PRECAUTIONS 3. Blakemore (MN) (for bleeding varices)
1. Isolation, regular GU
2. Isolation, reverse 1. Catheters – Foley insertion (Male &
3. Enteric isolation Female)
4. Respiratory Isolation 2. 3-way Foley
5. Wound and skin isolation 3. Supra-pubic
6. Sterile dressing changes ORTHOPEDICS
7. Universal precautions 1. Circo-electric bed
MEDICATIONS 2. Crutchfield traction
1. Unit dose 3. Balanced traction
2. Pass meds for 1 – 10 patients 4. Cast care
3. Pass meds for 10 – 20 patients 5. Neurological checks
4. Pediatric Conversions ADDITIONAL NURSING SKILLS
5. IV additives & IVPBs 1. Arrhythmia interpretation
IV THERAPY 2. Set up and run 12-lead EKG
1. Heparin locks 3. Arrests – initial resuscitation (CPR)
2. Initiating IV line 4. Arrests – adminis. Of meds & assist w/ initiation
3. CVP lines & dressing changes 5. Breath sounds
4. Infusion pumps 6. Administration of Chemotherapy
5. Hanging blood and blood products CARING FOR PATIENTS WITH THE FOLLOWING:
6. Care of cutdown 1. IVs:
7. Administration a. Aminophylline
8. Veni-Puncture b. Dopamine
9. Arterial blood gases (obtain samples) c. Lidocaine
10. Arterial blood gases (interpretation) d. Pitressin
RESPIRATORY THERAPY e. Isuprel
1. Suctioning oro-naso-pharynx f. Chemotherapy
2. Tracheostomy care g. Nipride
3. O2 Equipment (mask, cannulas) h. Intralipid administration
4. Endotracheal tubes i. Hyperalimentation administration
5. Chest Tubes 2. IVP Medications:
a. Digoxin

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 MEDICAL/SURGICAL KNOWLEDGE & SKILLS CHECKLIST _____

Name:       ID #:      

DESCRIPTION 1 2 3 4 DESCRIPTION 1 2 3 4
CARING FOR PATIENTS WITH THE FOLLOWING: (CONT) COMPUTERIZED CHARTING
2. IVP Medications: (Cont) 1. Cerner
b. Lasix 2. Eclipsys
c. Bumex 3. Epic
d. Morphine 4. McKesson
e. Demerol 5. Meditech
f. Decadron 6. Other:
g. Valium
h. Librium
i. Dilantin
3. Diagnosis or Problems:
a. Fresh MI
b. GI bleed
c. Drug Overdose
d. Cancer with brain Metastasis
e. Cancer of the lung
f. Leukemia
g. Emphysema and asthma
h. Renal failure
i. Psychiatric disorders
j. Diabetes
k. Cirrhosis of the liver
l. Hepatic encephalopathy
m. Femoral bypass (vascular) procedures
n. COPD
o. Hypothyroidism/Hyperthyroidism
p. Decubitus ulcers
q. Gunshot/Stab wounds
r. Impending DTs
s. Care of transplant patient
t. Care of terminal patient
u. Care of patient on ventilator
4. Hemodialysis:
a. Build
b. Initiate
c. Monitor
d. Discontinue
5. Peritoneal Dialysis

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 MEDICAL/SURGICAL KNOWLEDGE & SKILLS CHECKLIST _____

Name:       ID #:      

Please check the boxes below for each age group for I HAVE CURRENT CERTIFICATIONS FOR:
which you have expertise in providing age-appropriate
nursing care. TYPE COURSE DATE (MM/DD/YY)
ARRHYTHMIA      
A. Newborn/Neonatal (birth – 30 days) CRITICAL CARE      
B. Infant (30 days – 1 year) ACLS      
C. Toddler (1 – 3 years) BLS      
D. Preschool (3 – 5 years) TNCC      
E. School Age Children (5 – 12 years) NRP      
F. Adolescent (12 – 18 years) PALS      
G. Young Adults (18 – 39 years) NALS      
H. Middle Adults (40 – 64 years) Other            
I. Older Adults (64 + years) Other            

EXPERIENCE WITH AGE GROUPS:

1. Able to assess age appropriate behavior, motor skills The information I have provided in this knowledge and
and physiological norms. skills checklist it true and accurate to the best of my
knowledge.
A B C D E F G H I
           
Signature (Written/Electronic) Date
2. Able to adapt care according to normal growth and ID #:      
development.
This skills checklist has been reviewed and approved by
A B C D E F G H I Nicole Bloxham, RN.

           
3. Able to communicate and instruct patient according to Signature (Written/Electronic) Date
their age, maturity and comprehension ability. ID #:      

A B C D E F G H I Please return to: Northwest Nurse Staffing Company, PA

ATTN: Records Dept.
Fax: (866) 352-4338

Email: records@nns-ic.com
4. Able to provide a safe environment according to the
specific needs of various age groups.

A B C D E F G H I

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