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First Name    

Last Name    
Date             

1= No Experience   2= Intermittent Experience   3=Experienced

Levels of Experience

 1 2 3

I. Special Therapeutic Nursing Care
Administration of Rectal Suppositories
Application of Leg Bag
Application of Polyurethane Dressing for Partial Thickness Wound
Application of Transparent Wound Dressings
Application of Unna Boot
Arteriovenous Fistula & Shunt Dressing Change
Assessment & Management of Open Wounds
Blood Glucose Testing Devices
Care of Gastrostomy Tube
Catheter Care
Catheterization
Cleansing Enema
Colostomy Irrigation
Condom Cath. Application
Continuous Bladder Irrigation
Dry Sterile Dressing
Enteral Feedings
Fleets Enema
Insertion of Rectal Tube
Insertion of Gastrostomy Tube
Insertion of Suprapubic Catheter
Intermittent Bladder Irrigation or Instillation
Manual Removal of Fecal Impaction
Nasogastric Tube Placement
Oil Retention Enema
Oral and Nasopharyngeal Suction
Ostomy Care
Patency Assessment of Arteriovenous Fistula
Seizure Precautions
Specific Gravity
Sterile Scrub Sponges
Suprapubic Catheter Care
Suctioning of the Tracheotomy Tube
Suture Removal
Tracheotomy Care
Vaginal Irrigation
Vaginal Pack Removal
Wet Sterile Dressing
Catherization for PVR
Wound Irrigation

II.  Line Therapy
Administration of Medications through Groshong Catheter
Application of Extension Tubing to Hickman or Broviac Catheter
Blood Administration
Cap Change for Hickman or Broviac Catheter
Central Line Dressing
Dressing Change to Groshong Catheter Site
Hickman or Broviac Catheter Irrigation
Home Antibiotic Therapy
Home Chemotherapy Administration
Injection Cap to Groshong Catheter
IV Therapy
Irrigation of Heparin Lock
Irrigation of Groshong Catheter
IV Gamma Globulin Administration
Medication Administration via Epidural Catheter
Obtaining Blood Specimens from a Hickman or Broviac Catheter
PICC Lines
Port A Cath System
Refill of Insaid Pump
Total Parenteral Nutrition and Lipids
Use of Groshong Catheter
Withdrawal of Blood Samples from Groshong Catheter

III.  Eyes, Ears, and Throat
Instillation of Ear Drops
Instillation of Eye Drips
Instillation of Nose Drops
Irrigation of the Ear
Irrigation of the Eye

IV.  Orthopedic Care
Application of Arm Sling
Care following  total hip replacement
Care following total knee replacement

V.  Medications
Abdominal Subcutaneous Injection of Heparin
Administration of Medication via NG Gastrointestinal Tube
Administration of Potassium via IV Infusion
Aerosolized Pentamidine for Treat and Prophylaxis
Intermittent Intravenous Medications
Intramuscularly Injections
Intramuscularly Injections Compatibility
Medication Errors
Z-Track Intramuscularly Injections

VI.  Diagnostic Test
Collection of Clean Cath Midstream Urine Specimen
Collection of Culture Specimen from Wound or Orifice
Collection of Sterile Urine Specimen from A Foley Catheter
Collection of Urine from Urostomy
Gastric Analysis
Intermittent Self Catherization Using a clean technique
Specific Gravity
Testing for Occult Blood
Urine Testing for Glucose and Ketones
Venipuncture for Blood Specimen
VII. Oxygen Therapies in the Home
Home Respiratory Therapy Program Arterial Blood Gas Samples
Intermittent Positive Pressure Breathing Therapy
Oxygen Safety
Oxygen Therapy
Postural Drainage
VIII.  Miscellaneous
Bedside Commode
Bladder Training
Bowel Training
Care of Patient with Angina Pectoris
Care of Patient with Artificial Pacemaker
Care of Patient with CHF
Care of Patient Hearing Impairment
Care of Patient with Plaster Cast
Care of Patient with Visual Impairment
Care of Diabetic Patient
Care of the Hemodialysis Patient
Care of the Patient with Acute Myocardial Infarction
Care of the Patient with Hypertension
Collection of stool specimen
Collection of sputum specimen
Patient Safety
Perineal Care Procedure
Prevention and Care of Decubitus Ulcers
Prevention of Pressure Ulcers
Solutions for Dilutions, Reconstitutions, and Irrigations
Storage of Pharmaceuticals or Other Chemicals
Teaching Self Injections of Insulin
Universal Precautions
Management of Soiled Linen
Additional Skills & Comments