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IV THERAPY KNOWLEDGE & SKILLS

CHECKLIST
6. Hand Washing
NAME:       7. Infectious / Hazardous Waste
ID #:       Disposal
DATE:       8. Supply / Equipment Disposal
9. Use of Disposable
This Skills Checklist is for use by nurses Thermometer
with more than one year experience in 10. Use of CPR Mask / Bag
their discipline and specialty. Please be 11. AIDS
accurate with your assessment.
DIRECTIONS: Please indicate your level of
experience by placing a check (√) in the
DESCRIPTION 1 2 3 4 box. Experience level:
PATIENT RIGHTS 1 NO EXPERIENCE
1. Communicates and obtains 2 MINIMAL EXPERIENCE-requires
information while respecting supervision/assistance
the rights, privacy, and 3 MODERATELY EXPERIENCED-requires
confidentiality of information in initial review, then performs
accordance with the Health independently
Insurance Portability and
4 VERY EXPERIENCED- proficient
Accountability Act of 1996
(HIPPA)
2. Involves the patient and DESCRIPTION 1 2 3 4
family and 12. Hepatitis B
respects their role in VITAL SIGNS AND WEIGHTS
determining the nature of care 1. Recognizing Cardiac Arrest
to be provided, including 2. Activating Code Team
Advance Directives. 3. Initiating CPR
3. Complies with nursing staff 4. Bringing Emergency
responsibility included in the Equipment to
hospital policy related to Organ Room
Donation. 5. Providing Appropriate Code
4. Meets patient’s and families’ Support
needs 6. Use of Electronic VS
regarding communication, Equipment
including interpreter services. a. Automatic BP Machine
5. Provides accurate information (Dynamap)
to b. Electronic Thermometer
patient and families in a timely c. Applying Oximeter
manner. SAFETY AND ACTIVITY
INFECTION CONTROL 1. Determining Patient ID
1. Proper Use of Specific Barrier Methods: 2. Identifying Safety Hazards
a. Gloves 3. Determining Need for
b. Gown Additional Help
c. Mask / Goggles 4. Assessing Safety and ADL
2. Protective / Reverse Isolation Needs and Restraints
3. Body Substance Isolation 5. Maintaining Orderly Work
4. TB Precautions Area
5. MRSA Precautions 6. Disposing of Sharps
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IV THERAPY KNOWLEDGE & SKILLS
CHECKLIST
7. Handling Hazardous Materials
8. Proper Body Mechanics
9. Reporting Broken Equipment
10. Responding to Safety Hazards
11. Use of Wheel Locks
12. Use of Call Light
13. Application of Restraints
SPECIMENS
1. Venipuncture
2. Arterial Draw
3. Line Draw
4. Culture Specimens
5. Labeling Specimens and
Preparing for
Transport

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IV THERAPY KNOWLEDGE & SKILLS
CHECKLIST

Name:       DESCRIPTION 1 2 3 4


EQUIPMENT AND TROUBLESHOOTING
ID #:       1. CADD Pumps
DESCRIPTION 1 2 3 4 2. IVAC Pumps
SKIN HYGIENE 3. Blood Warmer
1. Risk Factors for Skin 4. Needleless Systems
Breakdown 5. Pressure Lines
2. Observing Sites for Redness 6. Bard Pumps
or 7. PCA Pumps
Breakdown 8. Repair PICC Line
3. Treatment of Infiltrates 9. Declotting Peripheral Site
4. Reducing Pressure and 10. Declotting Central Lines
Friction 11. Sterile Dressing Change, One
PROCEDURES Person
1. Insertion of: 12. Sterile Dressing Change, Two
a. Peripheral IV – Adult Person
b. Peripheral IV – Child COMPUTERIZED CHARTING
c. Peripheral IV – Neonate 1. Cerner
d. PICC Line 2. Eclipsys
e. Interosseous Needles 3. Epic
CARE OF AND DRESSING CHANGE TO: 4. McKesson
1. Interosseous Line 5. Meditech
2. Subcutaneous Needles 6. Other:
3. Groshong
4. Portacath
5. Hickman
6. Access Ports
7. Vascath
8. Multilumen Catheters
9. Scalp Vein
10. Heparin Lock
11. Subclavian Line
12. Interjugular Line
FLUIDS / MEDICATIONS
1. Chemotherapy
2. Dopamine
3. Heparin
4. Lidocaine
5. Regitine
6. Streptokinase
7. TpA
8. TPN / Lipids
9. Wydase
10. Blood Products

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IV THERAPY KNOWLEDGE & SKILLS
CHECKLIST

Name:       MY EXPERIENCE IS PRIMARILY IN:

Please check the boxes below for each NEUROLOGY       years
age group for which you have expertise in PULMONARY       years
providing age-appropriate nursing care. SURGICAL       years
MEDICAL       years
A. Newborn/Neonatal (birth – 30 days) CARDIAC CARE       years
B. Infant (30 days – 1 year) TELEMETRY       years
C. Toddler (1 – 3 years)
D. Preschool (3 – 5 years) I HAVE CURRENT CERTIFICATIONS FOR:
E. School Age Children (5 – 12 years)
F. Adolescent (12 – 18 years) TYPE COURSE
G. Young Adults (18 – 39 years) DATE (MM/DD/YY)
H. Middle Adults (40 – 64 years) ARRHYTHMIA      
I. Older Adults (64 + years) CRITICAL CARE      
ACLS      
EXPERIENCE WITH AGE GROUPS: BLS      
1. Able to assess age appropriate TNCC      
behavior, motor skills and physiological NRP      
norms. PALS      
NALS      
A B C D E F G H I Other            
Other            
Other            
2. Able to adapt care according to normal Other            
growth and development.
The information I have provided in this
A B C D E F G H I knowledge and skills checklist it true and
accurate to the best of my knowledge.

3. Able to communicate and instruct            


patient according to their age, maturity Signature Date
and comprehension ability. (Written/Electronic)
ID #:      
A B C D E F G H I
This skills checklist has been reviewed
and approved by Nicole Bloxham, RN.
4. Able to provide a safe environment
according to the specific needs of various            
age groups. Signature Date
(Written/Electronic)
A B C D E F G H I ID #:      

Please return to: NORTHWEST NURSE STAFFING


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

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IV THERAPY KNOWLEDGE & SKILLS
CHECKLIST
Email: records@nns-ic.com

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