LICENSED PRACTICAL NURSE

KNOWLEDGE & SKILLS CHECKLIST

NAME:       7. IV additives & IV piggy backs
ID #:       8. Chemo-therapy
DATE:      
DIRECTIONS: Please indicate your level of
experience by placing a check (√) in the
This Skills Checklist is for use by nurses box. Experience level:
with more than one year experience in 1 NO EXPERIENCE
their discipline and specialty. Please be 2 MINIMAL EXPERIENCE-requires
accurate with your assessment.
supervision/assistance
3 MODERATELY EXPERIENCED-requires
initial review, then performs
DESCRIPTION 1 2 3 4 independently
PRECAUTIONS / INFECTION CONTROL 4 VERY EXPERIENCED- proficient
1. Knowledge of universal
precautions
2. Knowledge of waste disposal DESCRIPTION 1 2 3 4
3. Proper disposal of sharps 9. Platelets
4. Management of patient in 10. Packed RBC
respiratory 11. Regulate Flow
isolation 12. Maintain IV site
5. Isolation, regular 13. Hyper alimentation
6. Isolation, reverse 14. CVP lines & dressing changes
7. Enteric isolation 15. Arterial blood gases:
8. Respiratory isolation interpretation
9. Sterile dressing changes ASSESSMENT / DIAGNOSIS OF PROBLEMS
MEDICATIONS ADMINISTRATION 1. Perform neurological
1. Oral medications assessment
2. Subcutaneous injections 2. Management of the patient
3. Intramuscular injections with drug
4. Vaginal suppositories interaction/allergic reaction
5. Ophthalmic drops 3. Management of patient with
6. Nasal drops cardio-
7. Inhalers pulmonary arrest
8. Rectal suppositories 4. Perform cardiovascular
9. Emergency meds-crash cart assessment
10. Unit dose 5. Perform gastrointestinal
11. Pass medication: 1-10 patients assessment
12. Pass medication: 10-20 6. Perform genitourinary
patients assessment
13. Pediatric conversions 7. Perform respiratory
INTRAVENOUS assessment
1. IV Certified 8. Fresh MI
2. Heparin locks 9. GI bleed
3. Initiating IV 10. Drug OD
4. Change IV tubing 11. Care of lung
5. Discontinuing IV 12. Emphysema & Asthma
6. IV push drugs 13. Renal failure
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 LICENSED
KNOWLEDGE & SKILLS CHECKLIST
14. Psychiatric
NAME:       disorders
15.#:
ID Diabetes
     
16.
DATE:       of liver
Cirrhosis
17. Hepatic Encephalopathy
18. Femoral bypass (vascular)
procedures
19. COPD
20. Hypothyroidism
21. Hyperthyroidism
22. Ulcers
23. Gunshot wounds
24. Stab wounds
DESCRIPTION
ASSESSMENT / DIAGNOSIS OF PROBLEMS
(CONT)
25. Impending DTs
BODY MECHANICS / TRANSFER
1. Lifting and pulling
2. Transfer to chair
3. Turning and positioning
4. Transfer patient to and from
gurney
RESTRAINTS
1. Application of restraints
2. Observation of patient in
restraints
3. Knowledge of safety
guidelines for
patient in restraints
EQUIPMENT
1. Hemovac/Davol suction pump
2. Use of wall suction
3. Alternate pressure mattress
4. Infusion devices (volumetric
pump)
5. Venturi Mask
6. Management of trach collar
7. Knowledge of use of incentive
spirometer
8. Knowledge of use of bed scale
9. Knowledge of use of heating
pad
10. Assist with/set-up of water
seal suction
11. Pleurevac/Emersion suction
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PRACTICAL NURSE
12. Enteral pump
13. Management of oxygen mask
14. Management of nasal cannula
15. Use of ambu-bag
16. Humidifiers
17. Application of TED hose
18. Use of heat lamp
19. Use of blood glucose monitors
20. Ventilators
21. Endotracheal tubes
22. G.I. Tubes
a. Nasogastric tube care
b. Miller-Abbott
c. Blakemore (Minnesota)
1 2 3 4 DESCRIPTION 1 2 3 4
SPECIMEN COLLECTION
1. Obtain urine for specific
gravity
2. Obtain urine culture
3. Obtain Foley catheter
specimen
4. Obtain stool specimen
5. Perform straight
catheterization
6. Obtain sputum specimen
7. Collect 24 hour urine
specimen
PROCEDURES
1. Perform personal hygiene/oral
care
2. Perform wound irrigation
3. Perform catheterization/Foley
(female)
4. Perform catheterization/Foley
(male)
5. Perform Suprapubic
catheterization
6. Administer tap/saline enema
7. Administer soap suds enema
8. Administer oil retention enema
9. Administer post-mortem care
10. Insert Foley catheter
11. Insert NGT
12. Perform wet to dry dressings
13. Perform sterile dressing
changes
14. Perform bladder irrigation
 LICENSED PRACTICAL NURSE
KNOWLEDGE & SKILLS CHECKLIST
15. Perform
NAME:      ostomy care EXPERIENCE WITH AGE GROUPS:
16.#:
ID Perform
      NG tube feeding 1. Able to assess age appropriate
17.
DATE:      gastrostomy tube
Perform behavior, motor skills and physiological
feeding norms.
18. Administer douches
19. Management of nephrostomy A B C D E F G H I
catheter
20. Management of jejunostomy
tube 2. Able to adapt care according to normal
21. Management of chest tube growth and development.
22. Perform nasal suctioning
23. Perform oral suctioning A B C D E F G H I
MISCELLANEOUS SKILLS
1. Orthopedics
a. Circo-electric bed 3. Able to communicate and instruct
b. Crutchfield traction patient according to their age, maturity
c. Balanced traction and comprehension ability.
d. Cast care
e. Neurological checks A B C D E F G H I
2. Oncology
a. Care of oncology patient
b. Care of Hickman catheter 4. Able to provide a safe environment
according to the specific needs of various
3. Arrhythmia interpretation
age groups.
4. Set-up & run 12-lead EKG
A B C D E F G H I

MY EXPERIENCE IS PRIMARILY IN:

DESCRIPTION 1 2 3 4
MISCELLANEOUS SKILLS (CONT)
NEUROLOGY       years
5. Arrests – initial resuscitation
PULMONARY       years
(CPR)
SURGICAL       years
MEDICAL       years
Please check the boxes below for each
age group for which you have expertise in CARDIAC CARE       years
providing age-appropriate nursing care.
I HAVE CURRENT CERTIFICATIONS FOR:
A. Newborn/Neonatal (birth – 30 days)
TYPE EXPIRATION
B. Infant (30 days – 1 year)
DATE (MM/DD/YY)
C. Toddler (1 – 3 years)
ARRHYTHMIA      
D. Preschool (3 – 5 years)
BLS      
E. School Age Children (5 – 12 years)
Other            
F. Adolescent (12 – 18 years)
Other            
G. Young Adults (18 – 39 years)
Other            
H. Middle Adults (40 – 64 years)
Other            
I. Older Adults (64 + years)

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 LICENSED PRACTICAL NURSE
KNOWLEDGE & SKILLS CHECKLIST
The information I have provided in this
knowledge and skills checklist it true and
accurate to the best of my knowledge.

           
Signature Date
(Written/Electronic)
ID #:      

This skills checklist has been reviewed

and approved by Nicole Bloxham, RN.

           
Signature Date
(Written/Electronic)
ID #:      

Please return to: Northwest Nurse Staffing

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

Email: records@nns-ic.com

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