SELF EVALUATION
NURSING SKILLS PROFICIENCY CHECKLIST
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NAME: _____________________________________
             Last                 First                             M.I.		 o RN Years Experience:    _____
o LPN Years Experience:  _____

DIRECTIONS: Place an x in the box that best describes your level of proficiency for each of the skills presented.

LEVELS OF PROFICIENCY KEY:
HP = Highly Proficient.
Extensively experienced; able to supervise and/or train others.

VE = Very Experienced.
Can perform well, without assistance or supervision.

EX = Experienced.
Competent; Can perform independently; may need initial review or supervision.

 SE = Some Experience;
Need review and assistance or supervision.

NE = No Experience.
PROFICIENCY LEVEL PROFICIENCY LEVEL
GENERAL SKILLS: HP VE EX SE NE HP VE EX SE NE
Physical Assessments o o o o o Med. Administration-Rectal o o o o o
Principles of Body Mechanics o o o o o Med. Administration-Otic o o o o o
Universal Precautions o o o o o Med. Administration-Vaginal o o o o o
Patient Transfer- Bed To Chair o o o o o Ear Irrigation o o o o o
Patient Transfer- Bed To Cart o o o o o Eye Irrigation o o o o o
Patient Transfer- Chair To Chair o o o o o Admin.-Packed Red Blood Cells o o o o o
Patient Transfer- Horizontal Lift o o o o o Admin.-Whole Blood o o o o o
Range of Motion Exercises o o o o o Admin.-Cryoprecipitate o o o o o
Post Mortum Care o o o o o Admin.-Platelets o o o o o
Opening A Sterile Pack o o o o o Admin.-Fresh Frozen Plasma o o o o o
Adding Items To A Sterile Field o o o o o Admin.-Albumin o o o o o
Sterile Dressing Changes o o o o o Admin.-Hyperalimentation/T.P.N. o o o o o
Wound Irrigation o o o o o Preoperative Care o o o o o
Decubitus Ulcer Care o o o o o Postoperative Care o o o o o
Immunization Requirements o o o o o Obtaining Urine Cultures o o o o o
Insertion of IV Catheter o o o o o Obtaining Wet Cultures o o o o o
Care of Central IV Lines o o o o o Obtaining Dry Cultures o o o o o
Insertion of Pic Catheter o o o o o Testing For Occult Blood o o o o o
IV Medication Administration o o o o o Assisting-Bone Marrow Biopsy o o o o o
Intradermal Injections o o o o o Assisting-Lumbar Punctures o o o o o
Intramuscular Injections o o o o o Assisting-Liver Biopsy o o o o o
Intramuscular Z-Track Technique o o o o o Assisting-Paracentesis o o o o o
Subcutaneous Injections o o o o o Assisting-Thoracentesis o o o o o
Med. Administration-Nasal o o o o o Knowledge of Normal Lab Values o o o o o
Med. Administration-Ophthalmic o o o o o Urine Testing-Glucose & Ketones o o o o o

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CARDIOPULMONARY: HP VE EX SE NE HP VE EX SE NE
EKG Interpretation o o o o o Incentive Spirometry o o o o o
Placement of Telemetry Leads o o o o o Chest Percussion o o o o o
Cardiopulmonary Resuscitation o o o o o O2 Admin.-Nasal Cannula o o o o o
Clearing Airway Obstructions o o o o o O2 Admin.-Face Mask o o o o o
Placement-Nasopharageal Airway o o o o o O2 Admin.-Venti Mask o o o o o
Use of Ambu Bag o o o o o O2 Admin.-Rebreather Mask o o o o o
Nasopharygeal Suctioning o o o o o O2 Admin.-Tent o o o o o
Tracheal Suctioning o o o o o Admin.-Hand Nebulizer Treatment o o o o o
Care of Tracheostomy o o o o o Collection of Sputum Specimens o o o o o
Monitor & Use-Pulse Oximeter o o o o o

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GU/GI: HP VE EX SE NE HP VE EX SE NE
Enema Administration o o o o o Urostomy Care o o o o o
Placement of NG Tube o o o o o Urinary Straight Catheterazation o o o o o
Gastric Lavage o o o o o Foley Cath Insertion-Male o o o o o
NGT-Irrigation/Meds Admin. o o o o o Foley Cath Insertion-Female o o o o o
Gastric Tube-Irrigation/Meds Admin. o o o o o Foley Cath Care o o o o o
Gastric Tube Care o o o o o Foley Cath Irrigations o o o o o
T-Tube Care o o o o o Foley Cath-Continuous Irrigations o o o o o
JP Tube Care o o o o o Foley Cath-Obtaining Specimens o o o o o
Hemovac Care o o o o o Suprapubic Cath Care o o o o o
Colostomy Care o o o o o Removal of Fecal Impactions o o o o o
Ileostomy o o o o o Assisting-Peritoneal Lavage o o o o o
Care after Ileostomy o o o o o

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LABOR & DELIVERY: HP VE EX SE NE HP VE EX SE NE
Assessment of Labor Patient o o o o o Obtaining Fundal Height o o o o o
Intrauterine Monitor Placement o o o o o Management-Pitocin Induced-
Vag.Exam-Determine Dilation o o o o o                           Labor o o o o o
Vag.Exam-Station & Presentation o o o o o Management-Premature Labor o o o o o
Leopold's Maneuver o o o o o Management-Placenta Previa o o o o o
Fetal Monitor Strip Interpretation o o o o o Management-Placenta Abruptio o o o o o
Fetoscope-Obtaining Fetal- Management-Preeclampsia o o o o o
                         Heart Rate o o o o o Circulate for Cesarean Section o o o o o
Doppler-Obtaining Fetal- Assisting-Cesarean Section o o o o o
                         Heart Rate o o o o o Applying Fundal Pressure o o o o o
pH Test-Rupture of Amniotic- Assisting-Forceps Delivery o o o o o
                          Membrane o o o o o Assisting-Vacuum Extraction o o o o o
Fern Test-Rupture of Amniotic- Precipitous Delivery o o o o o
                         Membrane o o o o o Epidural Infusions o o o o o
Assisting-Fetal Scalp- Epidural Catheter Removal o o o o o
                          Blood Sampling o o o o o Internal Fetal Monitor Placement o o o o o

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PEDIATRICS: HP VE EX SE NE HP VE EX SE NE
Age Specific Assessments o o o o o Central IV Line Care o o o o o
Calculation of Drug Doses o o o o o Admin.-Intravenous Fluids o o o o o
Cardiac Monitoring o o o o o Admin.-Oxygen Via Oxihood o o o o o
Apnea Monitoring o o o o o Admin.-Phototherapy o o o o o
Restrain a Child for Procedures o o o o o Care of Child in Isolette o o o o o
Insertion of Peripheral IV Catheter o o o o o Care of Child in Croup Tent o o o o o
Insertion of Scalp Vein IV Catheter o o o o o Interpret Pediatric Lab Values o o o o o
Safety Precautions o o o o o

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ORTHOPEDICS: HP VE EX SE NE HP VE EX SE NE
Assisting-Cast Application o o o o o Reverse Spiral Dressings o o o o o
Cast Bivalving & Windowing o o o o o Ankle Wrapping o o o o o
Continuous Passive Movement Use o o o o o Application of Heat & Cold o o o o o
Maintaining Skeletal Traction o o o o o Circulation Checks o o o o o
Skeletal Pin Site Care o o o o o Rotorest Beds o o o o o
Skin Traction-Apply & Maintain o o o o o Stryker Frame Beds o o o o o
Stump Dressings o o o o o Crutch Walking o o o o o
Figure 8 Dressings o o o o o Blood Autotransfusion o o o o o
Circular Dressings o o o o o

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ONCOLOGY: HP VE EX SE NE HP VE EX SE NE
Admin.-Chemotherapy IVP o o o o o Groshong Catheter-Care & Use o o o o o
Admin.-Chemotherapy Via- Port-A-Cath-Care & Use o o o o o
             Continuous Infusion o o o o o Broviac Catheter o o o o o
Side Effects of Chemo Agents o o o o o Care of Patient Receiving-
             Radiation Therapy o o o o o

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CRITICAL CARE/
EMERGENCY DEPT: 		HP VE EX SE NE HP VE EX SE NE
Triage o o o o o Obtaining Cardiac Outputs o o o o o
EMS Communications o o o o o LA Lines-Care & Readings o o o o o
Obtaining 12 Lead EKG o o o o o Balloon Pump Use o o o o o
Interpreting 12 Lead EKG o o o o o Assisting-Chest Tube Placement o o o o o
Use of Cardiac Monitors o o o o o Maintaining Chest Tube o o o o o
Defibrillation o o o o o Suctioning of ETT & Trach o o o o o
Cardioversion o o o o o Care of ETT & Trachs o o o o o
Permanent Pacemaker o o o o o Use & Type of Ventilators o o o o o
Temporary Pacemaker o o o o o Peep Trials o o o o o
Hemodynamic Monitoring o o o o o Vent Weaning o o o o o
Care & Reading of CVP Line o o o o o Obtaining Arterial Blood Sample o o o o o
Reading, Sampling, & Care of- Interpretation of ABG's o o o o o
              Arterial Line o o o o o Epidural Infusions o o o o o
Swan Ganz-Care & Readings o o o o o o o o o o

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