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					NEONATAL INTENSIVE CARE SKILLS CHECKLIST




This profile is for use by Neonatal Intensive Care nurses with more than one-year experience in their discipline and specialty. It
will not be a determining factor for the Around The Globe RN program. This document must be completed in its entirety;
each page initialed, the last page signed, and then returned to Around The Globe RN by any of the following methods:
         Email: Save, then email completed document to forms@atgrn.com
         Fax:   Print and fax completed document toll free to 1.877.332.6701.
         Mail:  Mail to Around The Globe RN, ATTN: Forms Processing. Our mailing address is at the bottom of each form!

Please enter your full legal name as it appears on your Social Security Card.

First Name:                                                     Last Name:

Social Security Number:                                         Date:                                Email:

Please indicate your level of experience by checking 1 box in each of the category below (1-less experience  4-more experience):
    1. Theory, or only prior observation                                           2. Less than one-year current experience or any previous experience
    3. One - Two years current experience or need minimal assistance               4. Two plus years experience or functions independently


A. CARDIOVASCULAR                                                                    B. PULMONARY (cont…)

  1. Assessment                                      1    2    3       4                  2. Interpretation of lab results                   1     2     3   4
       a. Auscultation (rate, rhythm, volume)                                                  a. Blood gases
       b. Blood pressure, invasive (arterial line)                                             b. Interpretation of x-ray reports
       c. Blood pressure, non-invasive
       d. Heart sounds/murmurs                                                            3. Equipment & procedures
       e. Perfusion                                                                            a. Airway management                          1     2     3   4
       f. Pulses                                                                                    Assist with intubation
                                                                                                    Bulb syringe
  2. Equipment & procedures                          1    2    3       4                            CPAP (nasal prongs)
       a. EKG interpretation                                                                        Endotracheal tube stabilization
       b. Defibrillation/cardioversion                                                              Endotracheal tube suctioning
       c. Invasive hemodynamic monitoring                                                                (a) In-line suction
       d. Central venous pressure                                                                        (b) Open ET catheter suction
                                                                                                    Extubation
  3. Care of the patient with:                       1    2    3       4                            Intubation
      a. Cardiac arrest                                                                             Nasal airway/suctioning
      b. Cardiac transplant                                                                         Oral airway/suctioning
      c. Cardiomyopathy                                                                             Tracheostomy/suctioning
      d. Congenital heart disease/defects                                                      b. Apnea monitor
      e. Hemodynamic instability                                                               c. Caridac resuscitation
      f. Hypovolemic shock                                                                     d. Chest tube (assist with)
      g. Post cardiac surgery                                                                       Insertion
      h. Post interventional cardiac cath                                                           Removal
                                                                                                    Set up
  4. Medications                                     1    2    3       4                       e. ECMO (extracorporeal membrane
      a. Dobutamine                                                                                  oxygenation)
      b. Dopamine                                                                              f. O2 therapy delivery systems                1     2     3   4
      c. Epinephrine                                                                                Bag (anesthesia) and mask
      d. Nipride                                                                                    Bag (self-inflating) and mask
      e. Sodium bicarbonate                                                                         Nasal cannula
                                                                                                    Nebulizer
B. PULMONARY                                                                                        Oxyhood
                                                                                                    Tent
  1. Assessment                                      1    2    3       4                            Trach collar
       a. Breath sounds
       b. Rate and work of breathing

                                                                                                                                                 Initials:
87605e40-85c1-4c12-8c9e-d02a0407e6bd.doc                                   Confidential                                                          Page 1 of 4
 7723 Tylers Place Blvd. Suite 276         West Chester, Ohio 45069-4684                  877.331.9660          877.332.6701          www.atgrn.com
NEONATAL INTENSIVE CARE SKILLS CHECKLIST



B. PULMONARY (cont…)                                                            D. GASTROINTESTINAL (cont…)

  3. Equipment & procedures (cont…)                                                  2. Equipment & procedures                          1     2     3   4
       g. Obtaining blood gases                      1   2    3   4                       a. Care of gastrostomy tube
            Arterial                                                                      b. Feedings
            Heelstick                                                                          Assist with breast feeding
            Peripheral                                                                         Bottle
            Umbilical line                                                                     Breast milk handling/storage
       h. Thoracentesis                                                                        Gavage
       i. Use of artificial surfactant                                                    c. Hospital grade electric breast pump
       j. Ventilator care                                                                 d. Placement of intestinal tubes
            CPAP/PEEP                                                                          Jejunal gastro
            High frequency jet ventilator                                                      Nasogastirc/orogastric
            Home ventilator                                                               e. Test for occult blood
            IMV
            Oscillating                                                              3. Care of the neonate with:                       1     2     3   4
            Pressure ventilator                                                          a. Cleft palate
            Volume ventilator                                                            b. Colostomy/ileostomy
       k. Weaning                                                                        c. Gastroschisis/omphalocele
                                                                                         d. GI bleeding
  4. Care of the neonate with:                       1   2    3   4                      e. Inguinal hernia
      a. Bronchoplumonary dysplasia (BPD)                                                f. Necrotizing enterocolitis (NEC)
      b. Cardiogenic/hypovolemic shock                                                   g. Post abdominal surgery
      c. Diaphragmatic hernia                                                            h. Relflux precautions
      d. Fresh tracheostomy                                                              i. Tracheoesophageal fistula (TEF)
      e. Meconium aspiration
      f. Persistent pulmonary hypertension                                      E. ENDOCRINE/METABOLIC
           (PPHN)
      g. Pneumothorax                                                                1. Assessment                                      1     2     3   4
      h. Respiratory distress syndrome (RDS)                                              a. Finnegan
      i. Respiratory failure                                                              b. Fluid & electrolyte balance

  5. Medications                                     1   2    3   4                  2. Interpretation of lab results                   1     2     3   4
      a. Aminophylline                                                                    a. Bilirubin
      b. Prostaglandin                                                                    b. Test urine and interpret
                                                                                               Glucose
C. NEUROLOGICAL                                                                                Labstix
                                                                                               Occult blood
  1. Assessment                                      1   2    3   4                            pH
       a. Intracranial pressure monitoring                                                     Specific gravity
       b. Neurological status
                                                                                     3. Equipment & procedures
  2. Care of the neonate with:                       1   2    3   4                       a. Collection of urine specimens              1     2     3   4
      a. Brain death/organ procurement                                                         Assist with supra pubic tap
      b. Externalized VP shunt/reservoirs                                                      Catheter
      c. Increased intracranial pressure                                                       Diaper/bag
      d. Meningitis                                                                       b. Phototherapy for jaundice
      e. Seizures                                                                         c. Post circumcision care
                                                     1   2    3   4
  3. Medication - Anticonvulsant medication                                          4. Care of the neonate with:                       1     2     3   4
                                                                                         a. Acute renal failure
D. GASTROINTESTINAL                                                                      b. Disseminated intravascular coagulation
  1. Assessment                                      1   2    3   4                           (DIC)
       a. Abdominal girth                                                                c. Disorders of internal/external organs
       b. Bowel sounds                                                                   d. Drug addiction/withdrawal
       c. Palate                                                                         e. Hypo/hyperkalemia
       d. Suck/swallow                                                                   f. Hypo/hypernatremia


                                                                                                                                            Initials:
87605e40-85c1-4c12-8c9e-d02a0407e6bd.doc                              Confidential                                                          Page 2 of 4
 7723 Tylers Place Blvd. Suite 276          West Chester, Ohio 45069-4684            877.331.9660          877.332.6701          www.atgrn.com
NEONATAL INTENSIVE CARE SKILLS CHECKLIST



E. ENDOCRINE/METABOLIC (cont…)                                               G. PHLEBOTOMY/IV THERAPY (cont…)

4. Care of the neonate with: (cont…)                                              2. Care of the neonate with:
       g. IDM (infant of a diabetic mother)                                           a. Central line/catheter/dressing                 1     2     3   4
            Hyperglycemia                                                                  Broviac
            Hypoglycemia                                                                   Groshong
       h. Malformations of the GU tract, kidney                                            Hickman
       i. Peritoneal dialysis                                                              Portacath
                                                                                           Quinton
F. INFECTIOUS DISEASES                                                                b. Percuntaneous arterial line
                                                                                      c. Percuntaneous venous line
  1. Interpretation of lab results                 1   2   3   4                      d. Peripheral line/dressing
       a. CBC/differential                                                            e. Peripherally inserted central catheter
       b. Culture reports                                                                  (PICC)
       c. Maternal lab results                                                        f. Umbilical artery line
                                                                                      g. Umbilical venous line
  2. Equipment & procedures                        1   2   3   4
       a. Assist with lumbar puncture                                        H. PAIN MANAGEMENT                                         1     2     3   4
       b. Collect culture specimens
       c. Isolation techniques                                                    1. Assessment of pain level
       d. Standard (universal) precautions                                        2. Care of the neonate with sedation(morphine)

  3. Care of the neonate with:                     1   2   3   4             I. MISCELLANEOUS
      a. Hepatitis surface antigen+mother
      b. HIV positive mother                                                      1. Assessment                                         1     2     3   4
      c. Neonatal sepsis                                                               a. Apgar scoring
                                                                                       b. Eye exam
  4. Medications - Immunizations                   1   2   3   4                       c. Gestational age
      a. HBIG                                                                               Ballard
      b. HBV                                                                                Dubowitz
      c. HIB                                                                                Other (specify)
      d. Polio                                                                         d. Maternal history
      e. DPT                                                                           e. Screen for hearing loss
      f. RespiGam/synergis prophylaxis
                                                                                  2. Equipment & procedures                             1     2     3   4
G. PHLEBOTOMY/IV THERAPY                                                               a. Bereavement / postmortem care
                                                                                       b. Consents
  1. Equipment & procedures                                                                 Immunization
       a. Administration of blood/blood products   1   2   3   4                            Procedural
            Cryoprecipitate                                                                 Treatment
            Packed red blood cells                                                     c. Cord care
            Plasma / albumin                                                           d. Neonatal skin care
            Whole blood                                                                e. Positioning devices
       b. Delivery systems                                                             f. Preparation for transport/transfer
            IV pump                                                                    g. Thermoregulation
            Syringe pump                                                                    Isolette with humidity
       c. Drawing blood from central line                                                   Radiant warmer
       d. Drawing venous blood                                                              Temperature (axillary, rectal, skin)
       e. Hyperalimentation/TPN                                                             Weaning to open crib/bassinet
       f. Intralipid                                                                   h. Weights
       g. Managing IV therapy                                                               Bed scale
            Discontinuing                                                                   Scale
            Dressing & tubing change
            Rate calculation                                                      3. Medications                                        1     2     3   4
            Site & patency assessment                                                 a. Calculation of dosage
       h. Starting IVs                                                                b. Emergency drug action & reaction
            Angiocath                                                                 c. Eye prophylaxis - Vitamin K
            Butterfly                                                                 d. Neonatal drug action& reactions
            Heparin lock
                                                                                                                                            Initials:
87605e40-85c1-4c12-8c9e-d02a0407e6bd.doc                           Confidential                                                             Page 3 of 4
 7723 Tylers Place Blvd. Suite 276      West Chester, Ohio 45069-4684             877.331.9660           877.332.6701            www.atgrn.com
NEONATAL INTENSIVE CARE SKILLS CHECKLIST



AGE SPECIFIC PRACTICE CRITERIA

Please check the boxes below for each age group for which you have expertise in providing age-appropriate nursing care.

A. Newborn/Neonate (birth – 30 days)         D. Preschooler (3 - 5 years)                 G. Young adults (18 – 39 years)
B. Infant (30 days – 1 year)                 E. School age children (5 – 12 years)        H. Middle adults (39 - 64 years)
C. Toddler (1 – 3 years)                     F. Adolescents (12 – 18 years)               I. Older adults (64+ years)

Experience with Age Groups:
                                                                                                    A    B    C   D    E     F   G    H    I
Able to adapt care to incorporate normal growth and development.

Able to adapt method and terminology of patient instructions to their age,                          A    B    C   D    E     F   G    H    I
comprehension and maturity level.

                                                                                                    A    B    C   D    E     F   G    H    I
Can ensure a safe environment reflecting specific needs of various age groups.


MY EXPERIENCE IS PRIMARILY IN (Please indicate number of years)

   Level II Nursery                                                 year(s)
   Level III Nursery                                                year(s)

   Other (specify)           ________________________________________________                             __________ year(s)

CERTIFICATION

Please check the boxes below and indicate the expiration date for each certificate that you have. If you do not know the exact
date, please use the last date of the specific month (e.g., 05/31/2004).

   BCLS                    Exp.   Date:                         (mm/dd/yyyy)
   NCC                     Exp.   Date:                         (mm/dd/yyyy)
   NRP                     Exp.   Date:                         (mm/dd/yyyy)
   PALS                    Exp.   Date:                         (mm/dd/yyyy)

   Computerized charting system:                                                          Date:              _________ (mm/dd/yyyy)
   Medication administration system:                                                      Date:              _________ (mm/dd/yyyy)

   Other (type):                                                                          Exp. Date:                  __ (mm/dd/yyyy)

The information I have given is true and accurate to the best of my knowledge. I am the individual completing this form.
I hereby authorize Around The Globe RN to release this Neonatal Intensive Care Skills Checklist to client facilities in relation to
consideration of my employment with those facilities.



Print Name                                                                        Date


Signature

DON’T FORGET TO SIGN ABOVE, INITIAL ALL OTHER PAGES, AND SEND THE FORM BACK TO YOUR POINT OF CONTACT!
         Email: Save, then email completed document to forms@atgrn.com
         Fax:   Print and fax completed document toll free to 1.877.332.6701.
         Mail:  Mail to Around The Globe RN, ATTN: Forms Processing. Our mailing address is at the bottom of each form!
87605e40-85c1-4c12-8c9e-d02a0407e6bd.doc                          Confidential                                                       Page 4 of 4
 7723 Tylers Place Blvd. Suite 276       West Chester, Ohio 45069-4684           877.331.9660        877.332.6701          www.atgrn.com

				
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