CYNET_SYSTEMS_MAIN_LOGO.gif   REGISTERED NURSE PICU CHECKLIST
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided to IMCS Group on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

  
       
Rating Stars (Click) WORK SETTINGS 1 2 3 4  
PICU  
Pediatric CVICU  
Pediatric Step Down  
Pediatric PACU  
Rating Stars (Click) CARDIOVASCULAR 1 2 3 4  
Congenital Heart Disease/Repair  
Post Cardiac Surgery (Directly from OR)  
Post Cardiac Surgery (NOT Directly from OR)  
Post Diagnostic/Interventional Cardiac Cath  
Heart Failure/Cardiogenic Shock  
Cardiac Transplant  
Hemodynamic Monitoring  
Arrhythmia Interpretation  
Pacemaker - Temporary/Permanent  
SVO2 Monitoring  
Intra-Aortic Balloon Pump  
Ventricular Assist Device  
ECMO  
Rating Stars (Click) PULMONARY 1 2 3 4  
Respiratory Distress Syndrome/Resp. Failure  
Reactive Airway Disease  
ENT Surgery  
Epiglottis  
Cystic Fibrosis  
Tuberculosis  
Intubation/Extubation  
Endotracheal Tube Management  
Tracheostomy Management  
Modes of Ventilation: AC/PC/SIMV/CPAP  
Modes of Ventilation: Jet/Oscillator  
Nitric Oxide  
Hemo/Pneumothorax  
Rating Stars (Click) NEUROLOGIC/ORTHOPEDIC 1 2 3 4  
Brain Injury  
Craniotomy  
Spinal Cord Injury  
Seizure Disorders  
ICP Monitoring  
VP Shunt  
Meningitis  
Neuromuscular Disease  
Post Vertebral Surgery  
Traction - General  
Traction - Halo  
Rating Stars (Click) GASTROINTESTINAL 1 2 3 4  
Acute Surgical Abdomen  
GI Bleeding  
Pancreatitis  
Hepatic Failure  
Ostomy Management  
Management of Gastric Tubes  
Breast Milk Handling/Storage  
Rating Stars (Click) RENAL/GENITOURINARY 1 2 3 4  
Nephrotic Syndrome  
Renal Transplant  
Renal Replacement Therapy  
Peritoneal Dialysis  
Rating Stars (Click) ENDOCRINE/METABOLIC 1 2 3 4  
Diabetes - Hypo/Hyperglycemic Crisis  
Diabetic Ketoacidosis  
IV Insulin Pumps  
Indwelling Insulin Pumps  
Rating Stars (Click) TRAUMA/OTHER 1 2 3 4  
Blunt/Penetrating Trauma  
Burns  
Craniofacial Reconstruction  
Near Drowning  
Poison Ingestion/Overdose  
Bites-Animal/Snake/Human  
Suicide Precautions  
Wound Management/VAC  
Specialty Beds  
Rating Stars (Click) ONCOLOGY 1 2 3 4  
Bone Marrow Transplant  
Immunosuppressive Disorder  
Hemophilia Crisis  
Sickle Cell Crisis  
Rating Stars (Click) MEDICATIONS 1 2 3 4  
Pediatric Dosage Calculations  
Anti-Arrhythmics  
Anticoagulants (IV, Oral & Injection)  
Anti-Hypertensives  
Anti-Seizure Medications  
Benzodiazepines  
Continuous IV Paralytics  
Continuous IV Sedation  
Procedural Sedation - Administration  
Diuretics  
Emergency Medication  
Inhaled Medications  
Insulin  
IV Vasopressors  
Narcotics/Opioid Analgesics (IV, Oral & Injection)  
Non-Opioid Analgesics (IV, Oral & Injection)  
Reversal Agents  
Steroids (IV, Oral, Inhaled)  
Automated Medication Dispensing (i.e. Pyxis, Omnicell)  
Rating Stars (Click) IV THERAPY 1 2 3 4  
Starting Ivs  
Central Line Blood Draw  
Central Line/Implanted Line Care  
TPN/Lipids  
Blood Product Administration  
Administration of Chemotherapy  
Rating Stars (Click) CARDIAC MONITORING & EMERG. RESPONSE 1 2 3 4  
Dysrhythmia Interpretation  
Dysrhythmia Management  
Management of Cardiac Arrest  
Shock Management  
Malignant Hyperthermia  
Multisystem Organ Failure  
Rating Stars (Click) PROFESSIONAL KNOWLEDGE AND SKILLS 1 2 3 4  
National Patient Safety Goals/Core Measures  
Recognize/Report Signs of Abuse  
EMTALA  
Fall Risk Assessment/Prevention  
Pressure Ulcer Risk Assessment/Prevention  
Restraints/Use of Least Restrictive Device  
Normal Growth and Development  
Age Specific/Population Based Care  
Patient Family Teaching  
Isolation Precautions  
Infection Prevention  
Reporting Communicable Diseases  
Pain Assessment & Management  
Charge Experience  
Interpretation and Communication of Lab Values  
Rating Stars (Click)  Age Specific Competencies 1 2 3 4  
Newborn/Neonatal (birth – 30 days)  
Infant (30 days-1 year)  
Toddler (1-3 years)  
Preschool (3-5 years)  
School Age Children (5-12 years)  
Adolescent (12-17 years)  
Young Adults (18-44 years)  
Middle Adults (45-64 years)  
Older Adults (>65 years)  
MY EXPERIENCE IS PRIMARILY IN:  
Unit No. of Years Unit No. of Years  
BURN POST PARTUM  
CRITICAL UNIT LABOR & DELIVERY  
PACU NEWBORN NURSERY  
NEUROLOGY LEVEL II NICU  
TELEMETRY LEVEL III NICU  
MEDICAL PICU  
SURGICAL  PEDIATRICS  
ONCOLOGY OB/GYN  
ORTHOPEDICS PSYCHIATRY  
OPERATING ROOM RRT  
EMERGENCY ROOM CRT  
TRAUMA CENTER LEVEL 1    
COMMUNITY ER    
RURAL ER    
Rating Stars (Click) EMR 1 2 3 4  
Epic   
Cerner   
Eclipsys   
McKesson   
Meditech   
Other Computerized System  
Computerized Physician Order Entry  
Bar Coding for Medication Administration  
CERTIFICATIONS     Expiry Date :   
BLS  
PALS  
ACLS  
PEARS  
ENPC  
CEN  
TNCC  
  Other: Specify   
  Other: Specify