Skills Checklist – Dialysis

Skills Checklist – Dialysis

• Name
  
  First
  
  Last
• Phone
• Email
  

• Basic Nursing Care

• Basic Nursing Care*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Airway Management

• Basic Nursing Care (Oxygen Therapy Administration)*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Bag & Mask
  ET tube
  Face mask
  Nasal cannula
  Trach Collar
  BiPAP
  Ambu bag

• Basic Nursing Care*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Fluid & Electrolye Balance/Management
  Pulse Oximetry
  Oral Suctioning – Yankauer
  Nasotracheal Suctioning
  IV Insertion
  Venipuncture
  Blood Glucose Monitoring
  Foley Catheter Insertion
  Intake & Output Monitoring
  Seizure Precautions
  CPR
  NG Tube Insertion/Maintenance
  Assess Circulation/Peripheral Pulses
  Interpretation of Labs
  Dietary needs for ESRD patients
  Computer Charting Systems

• CARE OF PATIENTS WITH…*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Air Emboli
  Anemia
  Cardiac Arrest
  Chest Pain
  Clotted Access/Poor Flow Rate
  Disequilibrium Syndrome
  Filter Blood Leak
  Fluid Overload
  Hemolysis
  Hypertension
  Hypotension
  Infiltration of an AV access
  Muscle Cramps
  Neuropathy
  Pericarditis
  Pyogenic Reactions
  Seizures

• DIALYSIS EXPERIENCE – GENERAL*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Acute/Inpatient Dialysis
  Chronic/Outpatient Dialysis
  Pediatric Dialysis
  Peritoneal Dialysis
  Dialysis Home Care
  Predialysis RN Assessment
  Patient/Family Teaching re: Dialysis
  CVVH
  CAPD
  Cycled PD

• INITIATE DIALYSIS*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Bicarbonate Dialysate
  Conductivity and pH Testing
  Priming the Dialyzer
  Check Machine/Alarm Settings
  Prep Vascular Access
  Catheter Vascular Access
  Fistula/Graft Vascular Access
  Collect Blood Specimen
  Anticoagulation
  Set up for Cycler PD Machine
  Set up for CVHD

• MANAGEMENT DURING DIALYSIS*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Patient Assessment by System
  Volume Status Assessment
  Vascular Access Function Assessment
  Arterial/Vascular Function Assessment
  Blood Flow Rate
  Response to Treatment (Subjective)
  Anticoagulant Management
  Conductivity
  Ultra Filtration Calculation
  Administration of Blood/Blood Products
  Epogen
  Vitamin D Derivative
  Iron Replacement
  Antiobiotic Administration
  IV Push Medications
  IV Pump Medications
  Mannitol Administration
  Sequential Ultra Filtration/PUF
  Documentation of Dialysis Treatment

• MACHINE/ALARM TROUBLESHOOTING*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Air/Foam Detector Alarm
  Blood Leak Alarm
  Blood Pump Alarm
  Air/Foam Detector Alarm
  Ultra Filtration Alarm
  High Temperature Alarm
  Conductivity Alarm
  Arterial Pressure Alarm
  Venous Pressure Alarm

• DISCONTINUATION OF DIALYSIS*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Retransfusion Procedure
  Dialysis Catheter Procedure
  Fistual/Graft Procedure
  Post Treatment Access Care
  Equipment Clean Up
  Sterilization Procedure
  Biohazard Procedures

• Age Group Experience*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Newborn (birth – 30 days)
  Infant (30 days – 1 year)
  Toddler (1 – 3 years)
  Preschooler (3 – 5 years)
  School Age (5 – 12 years)
  Adolescents (12 – 18 years)
  Young Adults (18 – 39 years)
  Middle Adults (39-64 years)
  Older Adults (64+ years)

• Do you speak any languages other than English?*
  • No

  If yes, enter languages above, separated by commas.

• Confirmation*
  • 
    I attest that the information I have given is both true and, to the best of my knowledge, represents an accurate self assessment of my professional skills and/or education.
• Signature
• Date
  
  Date Format: MM slash DD slash YYYY