Neonatal Intensive Care Unit Self Assessment
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1 DIRECTIONS Please place a check mark next to each question to provide us and the interested facilities with an assessment of your clinical experience. One box must be checked for each skill listed. Print Name: Date: Last 4 Digits of Social Security Number: ADMISSION/ASSESSMENT Attending High Risk Deliveries APGAR Scoring Gestational Age Ballard Dubowitz Eye Exam Hearing Screen Thermoregulation Isolette with humidity Radiant warmer Bed Scale Care of Extremely Low Birthweight Care of Infant Under Phototherapy CARDIOVASCULAR Auscultation of heart sounds Perfusion, pulses Non-invasive BP monitoring (Dinamap) Invasive hempdynamic monitoring Cardiac Arrest/ CPR Emergency drug preparation and administration (NRP) Defibrillation/cardioversion Congenital Heart Disease Hemodynamic instability Hypovolemic shock Post Cardiac Surgery GASTROINTESTINAL Abdominal Girth Bowel Sounds
2 GASTROINTESTINAL (Continued) Suck/Swallow Pattern Feeding Intolerance Feeding Bottle Assist with breastfeeding Breastmilk handling and storage Gavage Reflux precautions Placement of OGT/NGT/NJT NG Tubes Gastrostomy Tubes Colostomy/Ileostomy Care Test for Occult Blood Tracheoesophogeal fistula (TEF) Cleft lip/palate Necrotizing enterocolitis (NEC) Gastroschisis/Omphalocele Inguinal Hernia Post abdominal surgery GENTIO-URINARY Test and Interpret Urine Abnormalities Insertion of Urinary Catheter Collection of Urine Specimen Peritoneal Dialysis Assist with Circumcision Post Circumcision Care Acute renal failure Malformations of GU Tract MEDICATION ADMINISTRATION Vasoactive Drips NaHCO3 Epinephrine Prostaglandin Aminophiylline/Caffine Insulin Drip Steroids NEUROLOGICAL Neurological assessment and LOC Drug withdrawal and abstinence scoring NICU Page 2
3 NEUROLOGICAL (Continued) Seizures Meningitis External VP shunt/reservoirs ICP monitoring Spinal disorders Neurological development and positioning NUTRITIONAL SUPPORT Gastroenteric Feeding Tubes OG-NG Feedings Feeding Pump Intralipids Total Parenteral Nutrition PAIN MANAGEMENT of Pain Level pre and post procedure Post Operative Pain Management Care of Neonate with sedation PHLEBOTOMY/IV THERAPY Starting IV Site and patency assessment TPN Drawing specimen via venipuncture Drawing specimen from central line Administration of Blood and/or Blood products Assist with insertion and care of Neonate with: (PAL) Percutaneous arterial line PICC UAC UVC PIV Care of infant with: Broviac/Hickman/Croshong Catheters Use of Syringe/IV Pumps PULMONARY Chest exam and auscultation Obtaining Blood Gases Capillary UAC PAL (Peripheral arterial line) Interpretation of blood gases suctioning ETT inline catheter NICU Page 3
4 PULMONARY (Continued) Open ETT catheter sx Nasal/Oral airway Tracheostomy Oxygen Therapy Nasal cannula Oxyhood Trach collar Pulse oximeter Transcutaneous monitoring Intubation Assist with intubation Stabilization of ETT Planned extubation Care of Neonate on ventilator CPAP/PEEP High frequency jet vent IMV Oscillator Nitric Oxide therapy Use/administration of artificial surfactant ECMO BPD Diaphragmatic Hernia MAS (Meconium aspiration syndrome) Fresh tracheostomy PPHN RDS Pneunothorax AGE SPECIFIC PRACTICE CRITERIA Please circle the letter for each age group for which you have expertise in providing age-appropriate nursing care. A. Newborn/Neonate (Birth 30 Days) F. Adolescents (12-18 years) B. Infant ( 30 days - 1 year) G. Young adults (18-39 years) C. Toddler (1-3 years) H. Middle adults (39-64 years) D. Preschooler (3-5 years) I. Older adults (64 years+) E. School age children (5-12 years) WITH AGE GROUPS: Able to adapt care to incorporate growth and development A B C D E F G H I Able to adapt method and terminology to patient instructions to their age, comprehension and maturity level. A B C D E F G H I Can ensure a safe environment reflecting specific needs of various age. A B C D E F G H I NICU Page 4
5 Credentialing and Expiration Dates Are you BCLS Certified? YES NO Exp Date: Are you ACLS Certified? YES NO Exp Date: Are you NRP Certified? YES NO Exp Date: Are you PALS Certified? YES NO Exp Date: Are you CCRN Certified? YES NO Exp Date: Additional Certifications: Certification: Certification: Exp Date: Exp Date: Have had ONE year of experience in this area within the last THREE years. YES NO Nurse Signature Agency (Name/Title) Date Date NICU Page 5
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