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STUDENT NURSE
PRECEPTORSHIP HEMODIALYSIS SKILLS CHECKLIST

Name: _________________________ Clinic: ___________________

Date Started Training: ________________ Date Completed Training: _____

Instructions for use:

 All hemodialysis procedure skills listed in the first column will be explained and/or demonstrated to the student nurse by the
preceptor. After completion of the demonstration, the trainer will initial and date the second column.

 The student nurse will then explain and demonstrate the procedural skill to the preceptor while being corrected and re-
instructed as needed. After completion, the third column will be initialed and dated by the preceptor.

 After sufficient guidance and practice of the procedure, the student nurse will be rated on the performance of the procedure by
the preceptor. All procedures must receive a satisfactory rating or will be repeated until a satisfactory rating is obtained. After
a satisfactory performance of the skill, the trainer will date and initial the fourth column.

 Skills determined by the _________ as not assigned to the student nurse by the clinic will be indicated by a "N/A" (not
authorized) placed by the procedure in column 2 and initialed and dated by the Facility Manager and a representative of the
school of nursing.

 Upon satisfactory completion of the preceptor program, the student nurse will be eligible to work as a dialysis technician.

Preceptor Name: ____________________________ Preceptor Initials: _________

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
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Date of Preceptor Date of Return Preceptor Date of Preceptor

INFECTION CONTROL Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
UNIVERSAL PRECAUTIONS
1. Demonstrates appropriate use of
barrier precautions
2. Recalls and demonstrates sharp
instrument and needle precautions
3. Recalls high risk procedure
precautions
4. Recalls appropriate use of respiratory
resuscitation equipment during
cardiac and respiratory arrests
5. Properly demonstrates appropriate
cleaning and disinfecting of surfaces
and equipment
6. Properly performs body fluids spill
disinfection procedure
7. Properly disposes of contaminated or
infectious waste
8. Recalls isolation procedure
9. Properly demonstrates appropriate
hand washing technique
10. Properly performs isolation procedure
for patient care during dialysis
11. Properly obtains and handles isolation
blood specimens
12. Properly performs and/or verbalizes
airborne precautions
13. Properly performs and/or verbalizes
contact precautions
14. Properly performs and/or verbalizes

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 3

Date of Preceptor Date of Return Preceptor Date of Preceptor

INFECTION CONTROL Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
UNIVERSAL PRECAUTIONS
general infection control measures
15. Demonstrates aseptic technique
16. Verbalizes understanding of Post
exposure follow up policy
17. Verbalizes understanding TB
Exposure Control Plan

Date of Preceptor Date of Return Preceptor Date of Preceptor

Operation of Delivery System Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
1. Properly performs system start up
procedure
2. Properly performs alarm systems
function test
3. Properly performs manual
conductivity test
4. Properly performs manual
temperature test
5. Properly performs manual pH test
6. Properly performs manual pressure
holding test (IF APPLICABLE)
7. Properly performs basic operator
troubleshooting

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 4

Date of Preceptor Date of Return Preceptor Date of Preceptor

Operation of Delivery System Cont’d Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
8. Properly cleans and disinfects exterior
of machine
9. Properly initiates chemical disinfect
procedure and labels machine with
RTK sign (Right to Know label for
chemical)
10. Properly tests for residual disinfectant
after disinfectant dwell
11. Properly initiates heat disinfect
procedure
12. Properly initiates standard rinse
procedure
13. Properly initiates acetic acid rinse
procedure
14. Properly initiates bleach rinse
procedure
15. Documents procedures performed and
results
16. Properly demonstrates using the
Sodium Variation system
17. Properly demonstrates using the
Ultrafiltration Profiling System

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
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DIALYSIS DELIVERY SYSTEM Date of Preceptor Date of Return Preceptor Date of Preceptor
Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
Properly operates the Fresenius 2008 H
Properly operates the Fresenius 2008 K
Properly operates the Cobe C 3
Properly operates the Baxter 1550
Properly operates the Baxter SPS 550
Properly operates the Althin “Tina”
Other:
Other:

VASCULAR ACCESS PROCEDURES Date of Preceptor Date of Return Preceptor Date of Preceptor
Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
Properly assesses access for function and
lack of pathology
Properly cleans needle site with
appropriate disinfectant
Properly cannulates fistula at 25 angle
Properly cannulates an AV graft at 45
angle
Properly performs pre-dialysis CVC care
(as allowed by state nursing practice)
Properly changes CVC dressing (as
allowed by state nurse practice act)
Properly performs post dialysis vascular
access care

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 6

VASCULAR ACCESS PROCEDURES Cont’d Date of Preceptor Date of Return Preceptor Date of Preceptor
Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
Properly uses safety guard provided on
needles
Properly demonstrates butterfly taping
Properly discontinues dialysis with CVC
(as allowed by state nurse practice
act)
Properly initiates treatment with internal
vascular access
Properly discontinues treatment with
internal vascular access
Properly initiates treatment with CVC (as
allowed by state nurse practice act)
Properly assesses access for function and
cessation of bleeding from needle
sites

ADMINISTRATION OF MEDICATIONS Date of Preceptor Date of Return Preceptor Date of Preceptor

Demonstration by Initials Demonstration by Initials Satisfactory Initials
(AS ALLOWED BY STATE NURSE PRACTICE ACT) Preceptor Trainee Performance by
Trainee
PREPARATION AND ADMINISTRATION OF MEDICATIONS
Properly verifies the medication
prescription and patient
Obtains appropriate supplies/correct
needle and syringe
Properly reads and checks medication
label three times

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 7

ADMINISTRATION OF MEDICATIONS Date of Preceptor Date of Return Preceptor Date of Preceptor

Demonstration by Initials Demonstration by Initials Satisfactory Initials
(AS ALLOWED BY STATE NURSE PRACTICE ACT) Preceptor Trainee Performance by
Trainee
Properly recalls the five rights of
administering medications
Properly documents the administration of
medications on flow sheet
Demonstrates proper aseptic technique
preparing and administering medications
ADMINISTRATION OF LIDOCAINE
Recalls signs and symptoms of adverse
reactions
Properly administers ID xylocaine
Proper angle of needle insertion 15
Aspirates prior to injection
ADMINISTRATION OF HEPARIN
Recalls signs and symptoms of adverse
reactions
Recalls methods of heparin administration
Recalls types of heparin protocols

ADMINISTRATION OF HEPARIN
Properly administers heparin bolus
through venous line
Waits 3 minutes after bolus administration
prior to treatment initiation

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 8

ADMINISTRATION OF MEDICATIONS Date of Preceptor Date of Return Preceptor Date of Preceptor

Demonstration by Initials Demonstration by Initials Satisfactory Initials
(AS ALLOWED BY STATE NURSE PRACTICE ACT) Preceptor Trainee Performance by
Trainee
ADMINISTRATION OF NORMAL SALINE
Recalls indications for use during
hemodialysis
Properly administers normal saline per
procedure
Properly follows precautions during
normal saline administration
Recalls the signs and symptoms of fluid
volume overload
Properly recalls the systemic effects of
normal saline

RISKS AND HAZARDS OF HEMODIALYSIS Date of Preceptor Date of Return Preceptor Date of Preceptor
Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
COMMON OCCURENCES Trainee

Recalls and/or responds properly to

hypotension
Recalls and/or responds properly to
patient complaints of chest pain
Recalls and/or responds properly to
patient cramps
Recalls and/or responds properly to
patient complaints of nausea and vomiting
Recalls and/or responds properly to
pruritis

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 9

RISKS AND HAZARDS OF HEMODIALYSIS Date of Preceptor Date of Return Preceptor Date of Preceptor
Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
UNUSUAL OCCURENCES
Recalls and/or responds properly to an air
embolism
Recalls and/or responds properly to
anaphylactic reactions
Recalls and/or responds properly to
cardiac/resp. arrest
Recalls and/or responds properly to
hemolysis
Recalls and/or properly performs infected
access care
Recalls and/or responds properly to an
allergic reaction due to a medication
Recalls and/or properly performs
identifying fever source
Recalls and/or responds properly to a
pyrogen reaction
Recalls and/or responds properly to
angina
Recalls and/or responds properly to
arrhythmias
Recalls and/or responds properly to back
pain
Recalls and/or responds properly to a
blood loss
Recalls and/or responds properly to
crenation

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 10

RISKS AND HAZARDS OF HEMODIALYSIS Date of Preceptor Date of Return Preceptor Date of Preceptor
Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
UNUSUAL OCCURENCES – Cont’d
Recalls and/or responds properly to
difficulty with needle insertion
Recalls and/or responds properly to
disequilibrium syndrome
Recalls and/or responds properly to
hypertension
Recalls and/or responds properly to
hypoglycemia
Recalls and/or responds properly to a
reaction of undetermined cause
Recalls and/or responds properly to a
rising venous pressure
Recalls and/or responds properly to
shortness of breath
Recalls and/or responds properly to a
dialyzer reaction
Recalls and/or responds properly to
transfusion reaction
Recalls and/or responds properly to a
seizure

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 11

TECHNICAL PROBLEMS Date of Preceptor Date of Return Preceptor Date of Preceptor

Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
1. Recalls and/or properly evaluates a
clotted dialyzer
2. Recalls and/or properly evaluates a
dialyzer blood leak
3. Recalls and/or properly changes an
arterial blood line
4. Recalls and/or properly changes a
venous blood line
5. Recalls and/or properly replaces a
dialyzer
6. Recalls and/or responds properly to
hematoma formation or infiltration
7. Recalls and/or responds properly to
blood flow problems
8. Recalls and/or properly performs the
emergency termination of dialysis
9. Recalls and/or properly performs the
hand crank during a power failure
10. Knows the contents of the emergency
evacuation kit

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 12

Emergency Procedures Date of Preceptor Date of Return Preceptor Date of Preceptor

Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
Recalls and/or responds properly to a
bomb threat
Demonstrates or verbalizes disaster and
emergency readiness
Recalls and/or responds properly to a
disaster
Recalls and/or responds properly to
patient evacuation procedure
Recalls and/or responds properly to the
fire drill procedure
Demonstrates proper use of the fire
extinguisher
Recalls and/or responds properly to a
facility fire
Recalls and/or responds properly to
emergency transfer of patients to the
hospital from the clinic

LABORATORY PROCEDURES Date of Preceptor Date of Return Preceptor Date of Preceptor

Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
Properly obtains blood specimens per
procedure
Properly obtains blood specimens for
URR and KT/V determinations

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 13

LABORATORY PROCEDURES Date of Preceptor Date of Return Preceptor Date of Preceptor

Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
Demonstrates proper basic laboratory
skills:
A. Demonstrates acceptable aseptic
and isolation technique
B. Properly labels specimens
C. Properly fills out forms
D. Demonstrates good technique
collecting specimen
E. Properly obtains specimen from
arterial blood line port
F. Properly obtains specimen from
venous bloodline port
G. Properly obtains specimen from
vascular access port
H. Properly obtains specimen for
blood cultures (as allowed by state
nurse practice act)
I. Properly obtains blood specimen
for transfusion
J. Properly packs and prepares
specimens for transport
Blood glucose monitoring
A. Properly performs blood glucose
QC calibration
B. Properly performs blood glucose
monitoring

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 14

LABORATORY PROCEDURES Date of Preceptor Date of Return Preceptor Date of Preceptor

Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
C. Properly performs operator
maintenance procedures
Demonstrates use of the hemoccult slide
(as allowed by state nurse practice act)

OPERATION AND USE OF ANCILLARY Date of Preceptor Date of Return Preceptor Date of Preceptor
Demonstration by Initials Demonstration by Initials Satisfactory Initials
EQUIPMENT Preceptor Trainee Performance by
Trainee
Properly operates, maintains, and inspects
EKG Machine
Knows location and contents of crash cart
Properly operates, standardizes and
maintains conductivity meter
Properly demonstrates use of the AED

MEDICAL RECORDS
Verbalizes understanding of
confidentiality of medical records
Demonstrates proper documentation in
the medical record
Demonstrates proper completion of the
Incident Reporting system
Verbalizes understanding of release of
information from patient medical record
Properly uses ESRD lab system

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 15

DIALYSATE BATH PROCEDURES Date of Preceptor Date of Return Preceptor Date of Preceptor
Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
Properly prepares bicarbonate concentrate
with bicarbonate mixer
Properly cleans and disinfects bicarbonate
mixer and containers
Familiar with storage and distribution of
acid concentrate
Properly performs manual conductivity
test of dialysate
Properly obtains manual temperature of
dialysate
Properly performs manual pH testing of
dialysate
Properly performs presence test for bleach
Properly performs bacterial culturing of
dialysis delivery system (if applicable)
Properly performs bacterial culturing of
bicarbonate mixer (if applicable)

WATER TREATMENT PROCEDURES Date of Preceptor Date of Return Preceptor Date of Preceptor
Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
1. Properly performs RO System start up
procedure
2. Properly performs the water hardness
test

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 16

WATER TREATMENT PROCEDURES Date of Preceptor Date of Return Preceptor Date of Preceptor
Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
3. Properly performs the
chlorine/chloramine test
4. Properly reads the total dissolved
solutes meter (TDS Test)
5. Properly reads pressure drops
6. Properly records RO rejection and
product flow rates
7. Properly documents performance and
operating parameters
8. Properly performs RO System shut
down procedure
9. Properly performs manual RO bypass
procedure
10. Properly performs bacterial culturing
of water treatment system
11. Properly performs water treatment
system disinfect procedure
12. Properly rinses water treatment
system free of disinfectant
13. Properly reports to the charge
nurse/administrator and technical
water treatment deviations and
abnormal quality test results

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
 17

OTHER PROCEDURES Date of Preceptor Date of Return Preceptor Date of Preceptor

Demonstration by Initials Demonstration by Initials Satisfactory Initials
Preceptor Trainee Performance by
Trainee
Properly endorses over patient assignment
before leaving the floor in a consistent
manner.
Completed extra assignments in a timely
manner.
Completed all inservices.
Effectively communicates with patients,
families, and multidisciplinary team
members.
Refers problems/issues to appropriate
multidisciplinary team member.
The above individual has received training and has Preceptor Signature: Date:
demonstrated competency at performing procedures _______________________________________ ________________
listed above.

___________________________________ has received training in the above procedures satisfactorily as indicated above by a
check.

Signature of Employee: _____________________________ Date: ___________

Signature of Medical Director: _______________________ Date: ___________

Signature of Education Coordinator ___________________ Date: ___________

Signature of Clinic Manager: ________________________ Date: ___________

Copyright 2005, American Nephrology Nurses' Association (ANNA).

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force
recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.