Pediatric Intensive Care

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Name*

First Last

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Email*

Age Specific Care

Proficiency Rating

Frequency Rating

Newborn/Neonate (birth - 30 days) *

Newborn/Neonate (birth - 30 days) proficiency*

Newborn/Neonate (birth - 30 days) frequency*

Infant (30 days - 1 year) *

Infant (30 days - 1 year) proficiency*

Infant (30 days - 1 year) frequency*

Toddler (1 - 3 years) *

Toddler (1 - 3 years) proficiency*

Toddler (1 - 3 years) frequency*

Preschooler (3 - 5 years) *

Preschooler (3 - 5 years) proficiency*

Preschooler (3 - 5 years) frequency*

School Age Child (5 - 12 years) *

School Age Child (5 - 12 years) proficiency*

School Age Child (5 - 12 years) frequency*

Adolescents (12 - 18 years) *

Adolescents (12 - 18 years) proficiency*

Adolescents (12 - 18 years) frequency*

Young Adults (18 - 39 years) *

Young Adults (18 - 39 years) proficiency*

Young Adults (18 - 39 years) frequency*

General Skills

Proficiency Rating

Frequency Rating

Standard Precautions *

Standard Precautions proficiency*

Standard Precautions frequency*

Isolation Precautions *

Isolation Precautions proficiency*

Isolation Precautions frequency*

Pediatric Respiratory / Cardiac Arrest *

Pediatric Respiratory / Cardiac Arrest proficiency*

Pediatric Respiratory / Cardiac Arrest frequency*

Adult Respiratory / Cardiac Arrest *

Adult Respiratory / Cardiac Arrest proficiency*

Adult Respiratory / Cardiac Arrest frequency*

Crash Carts *

Crash Carts proficiency*

Crash Carts frequency*

Defibrillators *

Defibrillators proficiency*

Defibrillators frequency*

Care of Patient in Restraints *

Care of Patient in Restraints proficiency*

Care of Patient in Restraints frequency*

Pain Management *

Pain Management proficiency*

Pain Management frequency*

Automated Med Dispensing Systems *

Automated Med Dispensing Systems proficiency*

Automated Med Dispensing Systems frequency*

Care Planning & Discharge Planning *

Care Planning & Discharge Planning proficiency*

Care Planning & Discharge Planning frequency*

Patient / Family Education *

Patient / Family Education proficiency*

Patient / Family Education frequency*

Electronic Documentation *

Electronic Documentation proficiency*

Electronic Documentation frequency*

Patient Head to Toe Assessment *

Patient Head to Toe Assessment proficiency*

Patient Head to Toe Assessment frequency*

Cardiovascular General Skills

Proficiency Rating

Frequency Rating

Auscultation (rate, rhythm, volume) *

Auscultation (rate, rhythm, volume) proficiency*

Auscultation (rate, rhythm, volume) frequency*

Blood Pressure / Invasive (arterial line) *

Blood Pressure / Invasive (arterial line) proficiency*

Blood Pressure / Invasive (arterial line) frequency*

Heart Sounds / Murmurs *

Heart Sounds / Murmurs proficiency*

Heart Sounds / Murmurs frequency*

Perfusion *

Perfusion proficiency*

Perfusion frequency*

Central Venous Pressure *

Central Venous Pressure proficiency*

Central Venous Pressure frequency*

Invasive Hemodynamic Monitoring:

Proficiency Rating

Frequency Rating

Interpretation of Lab Results - CBC / Electrolytes *

Interpretation of Lab Results - CBC / Electrolytes proficiency*

Interpretation of Lab Results - CBC / Electrolytes frequency*

Defibrillation / Cardioversion *

Defibrillation / Cardioversion proficiency*

Defibrillation / Cardioversion frequency*

EKG Interpretation (Basic & Advanced) *

EKG Interpretation (Basic & Advanced) proficiency*

EKG Interpretation (Basic & Advanced) frequency*

Cardiovascular - Care of the Child with:

Proficiency Rating

Frequency Rating

Bacterial Endocarditis *

Bacterial Endocarditis proficiency*

Bacterial Endocarditis frequency*

Congenital Heart Disease / Defects Cardiac Arrest *

Congenital Heart Disease / Defects Cardiac Arrest proficiency*

Congenital Heart Disease / Defects Cardiac Arrest frequency*

Cardiac Transplant *

Cardiac Transplant proficiency*

Cardiac Transplant frequency*

Cardiogenic Shock *

Cardiogenic Shock proficiency*

Cardiogenic Shock frequency*

Cardiomyopathy *

Cardiomyopathy proficiency*

Cardiomyopathy frequency*

Hypovolemic Shock *

Hypovolemic Shock proficiency*

Hypovolemic Shock frequency*

Myocarditis *

Myocarditis proficiency*

Myocarditis frequency*

Post Cardiac Surgery *

Post Cardiac Surgery proficiency*

Post Cardiac Surgery frequency*

Post Interventional Cardiac Cath *

Post Interventional Cardiac Cath proficiency*

Post Interventional Cardiac Cath frequency*

Medications Knowledge and Use of

Proficiency Rating

Frequency Rating

Dobutamine (Dobutrex) *

Dobutamine (Dobutrex) proficiency*

Dobutamine (Dobutrex) frequency*

Dopamine (Intropin) *

Dopamine (Intropin) proficiency*

Dopamine (Intropin) frequency*

Epinephrine (Adrenalin) *

Epinephrine (Adrenalin) proficiency*

Epinephrine (Adrenalin) frequency*

Nipride (Nitroprusside) *

Nipride (Nitroprusside) proficiency*

Nipride (Nitroprusside) frequency*

Nitroglycerine (Tridil) *

Nitroglycerine (Tridil) proficiency*

Nitroglycerine (Tridil) frequency*

Sodium Bicarbonate *

Sodium Bicarbonate proficiency*

Sodium Bicarbonate frequency*

Antiarrhythmics *

Antiarrhythmics proficiency*

Antiarrhythmics frequency*

Respiratory General Skills

Proficiency Rating

Frequency Rating

Breath Sounds / Work of Breathing *

Breath Sounds / Work of Breathing proficiency*

Breath Sounds / Work of Breathing frequency*

Obtaining Blood Gases:

Proficiency Rating

Frequency Rating

Arterial *

Arterial proficiency*

Arterial frequency*

Heelstick *

Heelstick proficiency*

Heelstick frequency*

Peripheral *

Peripheral proficiency*

Peripheral frequency*

Interpretation of ABGs *

Interpretation of ABGs proficiency*

Interpretation of ABGs frequency*

Oximeter *

Oximeter proficiency*

Oximeter frequency*

Airway Management:

Proficiency Rating

Frequency Rating

Assist with Intubation *

Assist with Intubation proficiency*

Assist with Intubation frequency*

Assist with Extubation *

Assist with Extubation proficiency*

Assist with Extubation frequency*

Suctioning:

Proficiency Rating

Frequency Rating

Bulb Syringe *

Bulb Syringe proficiency*

Bulb Syringe frequency*

Nasal Airway / Suctioning *

Nasal Airway / Suctioning proficiency*

Nasal Airway / Suctioning frequency*

Oral Airway / Suctioning *

Oral Airway / Suctioning proficiency*

Oral Airway / Suctioning frequency*

In - Line Suction *

In - Line Suction proficiency*

In - Line Suction frequency*

Open ET Catheter Suction *

Open ET Catheter Suction proficiency*

Open ET Catheter Suction frequency*

Tracheostomy / Suctioning *

Tracheostomy / Suctioning proficiency*

Tracheostomy / Suctioning frequency*

Apnea Monitor *

Apnea Monitor proficiency*

Apnea Monitor frequency*

Chest Physiotherapy *

Chest Physiotherapy proficiency*

Chest Physiotherapy frequency*

Chest Tube (Assist with):

Proficiency Rating

Frequency Rating

Insertion *

Insertion proficiency*

Insertion frequency*

Removal *

Removal proficiency*

Removal frequency*

ECMO (Extracorporeal Membrane Oxygenation) *

ECMO (Extracorporeal Membrane Oxygenation) proficiency*

ECMO (Extracorporeal Membrane Oxygenation) frequency*

End Tidal CO2 *

End Tidal CO2 proficiency*

End Tidal CO2 frequency*

O2 Therapy:

Proficiency Rating

Frequency Rating

Nasal Cannula *

Nasal Cannula proficiency*

Nasal Cannula frequency*

Bag & Mask *

Bag & Mask proficiency*

Bag & Mask frequency*

Isolette *

Isolette proficiency*

Isolette frequency*

Oxyhood *

Oxyhood proficiency*

Oxyhood frequency*

Tent *

Tent proficiency*

Tent frequency*

Trach Collar *

Trach Collar proficiency*

Trach Collar frequency*

Thoracentesis *

Thoracentesis proficiency*

Thoracentesis frequency*

Ventilators:

Proficiency Rating

Frequency Rating

CPAP / PEEP / BIPAP *

CPAP / PEEP / BIPAP proficiency*

CPAP / PEEP / BIPAP frequency*

High Frequency Jet Ventilator *

High Frequency Jet Ventilator proficiency*

High Frequency Jet Ventilator frequency*

Home Ventilator *

Home Ventilator proficiency*

Home Ventilator frequency*

IMV *

IMV proficiency*

IMV frequency*

Pressure Ventilator *

Pressure Ventilator proficiency*

Pressure Ventilator frequency*

Volume Ventilator *

Volume Ventilator proficiency*

Volume Ventilator frequency*

Weaning *

Weaning proficiency*

Weaning frequency*

Respiratory - Care of Child with:

Proficiency Rating

Frequency Rating

Bronchiolitis (RSV) *

Bronchiolitis (RSV) proficiency*

Bronchiolitis (RSV) frequency*

Pneumonia *

Pneumonia proficiency*

Pneumonia frequency*

Croup *

Croup proficiency*

Croup frequency*

Chronic Respiratory Disease *

Chronic Respiratory Disease proficiency*

Chronic Respiratory Disease frequency*

Status Asthmaticus *

Status Asthmaticus proficiency*

Status Asthmaticus frequency*

Lung Transplant *

Lung Transplant proficiency*

Lung Transplant frequency*

Epiglottitis *

Epiglottitis proficiency*

Epiglottitis frequency*

Fresh Tracheostomy *

Fresh Tracheostomy proficiency*

Fresh Tracheostomy frequency*

Foreign Body Aspiration *

Foreign Body Aspiration proficiency*

Foreign Body Aspiration frequency*

Flail Chest *

Flail Chest proficiency*

Flail Chest frequency*

Hemothorax *

Hemothorax proficiency*

Hemothorax frequency*

Pneumothorax *

Pneumothorax proficiency*

Pneumothorax frequency*

Respiratory Distress Syndrome (RDS) *

Respiratory Distress Syndrome (RDS) proficiency*

Respiratory Distress Syndrome (RDS) frequency*

Respiratory Failure *

Respiratory Failure proficiency*

Respiratory Failure frequency*

Medications Knowledge and Use of

Proficiency Rating

Frequency Rating

Steroids *

Steroids proficiency*

Steroids frequency*

Bronchodilators *

Bronchodilators proficiency*

Bronchodilators frequency*

Racemic Epinephrine *

Racemic Epinephrine proficiency*

Racemic Epinephrine frequency*

Neuro General Skills

Proficiency Rating

Frequency Rating

Glasgow Coma Scale *

Glasgow Coma Scale proficiency*

Glasgow Coma Scale frequency*

Neurological Status *

Neurological Status proficiency*

Neurological Status frequency*

Assist with Lumbar Puncture *

Assist with Lumbar Puncture proficiency*

Assist with Lumbar Puncture frequency*

Seizure Precautions *

Seizure Precautions proficiency*

Seizure Precautions frequency*

Intracranial Pressure Monitoring *

Intracranial Pressure Monitoring proficiency*

Intracranial Pressure Monitoring frequency*

Neuro - Care of Child with:

Proficiency Rating

Frequency Rating

Head Trauma *

Head Trauma proficiency*

Head Trauma frequency*

Post Neurosurgery *

Post Neurosurgery proficiency*

Post Neurosurgery frequency*

Spinal Cord Injury *

Spinal Cord Injury proficiency*

Spinal Cord Injury frequency*

Status Epilepticus *

Status Epilepticus proficiency*

Status Epilepticus frequency*

Coma *

Coma proficiency*

Coma frequency*

Brain Death / Organ Procurement *

Brain Death / Organ Procurement proficiency*

Brain Death / Organ Procurement frequency*

Encephalitis *

Encephalitis proficiency*

Encephalitis frequency*

Meningitis *

Meningitis proficiency*

Meningitis frequency*

Externalized VP Shunt / Reservoirs *

Externalized VP Shunt / Reservoirs proficiency*

Externalized VP Shunt / Reservoirs frequency*

Neuromuscular Disease *

Neuromuscular Disease proficiency*

Neuromuscular Disease frequency*

Medications Knowledge and Use of

Proficiency Rating

Frequency Rating

Mannitol *

Mannitol proficiency*

Mannitol frequency*

Sedatives *

Sedatives proficiency*

Sedatives frequency*

Anticonvulsants *

Anticonvulsants proficiency*

Anticonvulsants frequency*

Gastrointestinal General Skills

Proficiency Rating

Frequency Rating

Abdominal Assessment *

Abdominal Assessment proficiency*

Abdominal Assessment frequency*

Interpretation of Lab Results - Serum Electrolytes *

Interpretation of Lab Results - Serum Electrolytes proficiency*

Interpretation of Lab Results - Serum Electrolytes frequency*

Feedings (Storage and Prep of) *

Feedings (Storage and Prep of) proficiency*

Feedings (Storage and Prep of) frequency*

Bottle *

Bottle proficiency*

Bottle frequency*

Breast *

Breast proficiency*

Breast frequency*

Gavage *

Gavage proficiency*

Gavage frequency*

TPN *

TPN proficiency*

TPN frequency*

PPN *

PPN proficiency*

PPN frequency*

Gastrostomy / Button:

Proficiency Rating

Frequency Rating

J-Tubes *

J-Tubes proficiency*

J-Tubes frequency*

NG to Suction *

NG to Suction proficiency*

NG to Suction frequency*

Placement of Naso / Orogastric Tube *

Placement of Naso / Orogastric Tube proficiency*

Placement of Naso / Orogastric Tube frequency*

Test for Occult Blood *

Test for Occult Blood proficiency*

Test for Occult Blood frequency*

Gastrointestinal - Care of Child with:

Proficiency Rating

Frequency Rating

Anal Fissure *

Anal Fissure proficiency*

Anal Fissure frequency*

Cleft Lip / Palate *

Cleft Lip / Palate proficiency*

Cleft Lip / Palate frequency*

New Colostomy *

New Colostomy proficiency*

New Colostomy frequency*

New Ileostomy *

New Ileostomy proficiency*

New Ileostomy frequency*

Diaphragmatic Hernia *

Diaphragmatic Hernia proficiency*

Diaphragmatic Hernia frequency*

Severe Failure to Thrive (FTT) *

Severe Failure to Thrive (FTT) proficiency*

Severe Failure to Thrive (FTT) frequency*

Pyloric Stenosis Repair *

Pyloric Stenosis Repair proficiency*

Pyloric Stenosis Repair frequency*

GE Reflux *

GE Reflux proficiency*

GE Reflux frequency*

GI Bleeding *

GI Bleeding proficiency*

GI Bleeding frequency*

Crohn’s Disease *

Crohn’s Disease proficiency*

Crohn’s Disease frequency*

Ulcerative Colitis *

Ulcerative Colitis proficiency*

Ulcerative Colitis frequency*

Severe Gastroenteritis / Dehydration *

Severe Gastroenteritis / Dehydration proficiency*

Severe Gastroenteritis / Dehydration frequency*

Intestinal Parasites *

Intestinal Parasites proficiency*

Intestinal Parasites frequency*

Necrotizing Enterocolitis (NEC) *

Necrotizing Enterocolitis (NEC) proficiency*

Necrotizing Enterocolitis (NEC) frequency*

Surgical Abdomen *

Surgical Abdomen proficiency*

Surgical Abdomen frequency*

Liver Transplant *

Liver Transplant proficiency*

Liver Transplant frequency*

Small Bowel Transplant *

Small Bowel Transplant proficiency*

Small Bowel Transplant frequency*

Medications Knowledge and Use of

Proficiency Rating

Frequency Rating

Antiemetics *

Antiemetics proficiency*

Antiemetics frequency*

Renal / Genitourinary General Skills

Proficiency Rating

Frequency Rating

Interpretation of Lab Results (UA / BUN / Creatinine) *

Interpretation of Lab Results (UA / BUN / Creatinine) proficiency*

Interpretation of Lab Results (UA / BUN / Creatinine) frequency*

Test Urine and Interpret *

Test Urine and Interpret proficiency*

Test Urine and Interpret frequency*

Glucose *

Glucose proficiency*

Glucose frequency*

Labstix *

Labstix proficiency*

Labstix frequency*

Occult Blood *

Occult Blood proficiency*

Occult Blood frequency*

pH *

pH proficiency*

pH frequency*

Specific Gravity *

Specific Gravity proficiency*

Specific Gravity frequency*

Collection of Urine Specimens:

Proficiency Rating

Frequency Rating

Assist with Suprapubic Tap *

Assist with Suprapubic Tap proficiency*

Assist with Suprapubic Tap frequency*

Catheter *

Catheter proficiency*

Catheter frequency*

Diaper / Bag *

Diaper / Bag proficiency*

Diaper / Bag frequency*

Insertion & Care of Straight And Foley Catheter *

Insertion & Care of Straight And Foley Catheter proficiency*

Insertion & Care of Straight And Foley Catheter frequency*

Suprapubic *

Suprapubic proficiency*

Suprapubic frequency*

Renal / Genitourinary - Care of Child with:

Proficiency Rating

Frequency Rating

Acute Renal Failure *

Acute Renal Failure proficiency*

Acute Renal Failure frequency*

CAVH *

CAVH proficiency*

CAVH frequency*

Peritoneal Dialysis *

Peritoneal Dialysis proficiency*

Peritoneal Dialysis frequency*

Hemodialysis *

Hemodialysis proficiency*

Hemodialysis frequency*

Hemolytic Uremic Syndrome (HUS) *

Hemolytic Uremic Syndrome (HUS) proficiency*

Hemolytic Uremic Syndrome (HUS) frequency*

Nephritis *

Nephritis proficiency*

Nephritis frequency*

Nephrotic Syndrome *

Nephrotic Syndrome proficiency*

Nephrotic Syndrome frequency*

Renal Transplant *

Renal Transplant proficiency*

Renal Transplant frequency*

Syndrome Inappropriate ADH (SIADH) *

Syndrome Inappropriate ADH (SIADH) proficiency*

Syndrome Inappropriate ADH (SIADH) frequency*

Endocrine / Metabolic General Skills

Proficiency Rating

Frequency Rating

Electrolyte Balance *

Electrolyte Balance proficiency*

Electrolyte Balance frequency*

Blood Glucose Testing *

Blood Glucose Testing proficiency*

Blood Glucose Testing frequency*

Knowledge of Lab work - Thyroid Studies *

Knowledge of Lab work - Thyroid Studies proficiency*

Knowledge of Lab work - Thyroid Studies frequency*

Endocrine/Metabolic- Care of Child with:

Proficiency Rating

Frequency Rating

Diabetes Mellitus *

Diabetes Mellitus proficiency*

Diabetes Mellitus frequency*

Diabetic Ketoacidosis *

Diabetic Ketoacidosis proficiency*

Diabetic Ketoacidosis frequency*

Diabetic Coma *

Diabetic Coma proficiency*

Diabetic Coma frequency*

Hyper / Hypocalcemia *

Hyper / Hypocalcemia proficiency*

Hyper / Hypocalcemia frequency*

Hyperbilirubinemia *

Hyperbilirubinemia proficiency*

Hyperbilirubinemia frequency*

Thyroid Dysfunction *

Thyroid Dysfunction proficiency*

Thyroid Dysfunction frequency*

Medications Knowledge and Use of

Proficiency Rating

Frequency Rating

Growth Hormone *

Growth Hormone proficiency*

Growth Hormone frequency*

Insulin *

Insulin proficiency*

Insulin frequency*

Thyroid Medications *

Thyroid Medications proficiency*

Thyroid Medications frequency*

Orthopedics General Skills

Proficiency Rating

Frequency Rating

Specialized Orthopedic Bed *

Specialized Orthopedic Bed proficiency*

Specialized Orthopedic Bed frequency*

Orthopedics - Care of Child with:

Proficiency Rating

Frequency Rating

Cervical Traction *

Cervical Traction proficiency*

Cervical Traction frequency*

Pinned Fractures *

Pinned Fractures proficiency*

Pinned Fractures frequency*

Post Vertebral Surgery *

Post Vertebral Surgery proficiency*

Post Vertebral Surgery frequency*

Wound Management

Proficiency Rating

Frequency Rating

Assessment of Skin Status *

Assessment of Skin Status proficiency*

Assessment of Skin Status frequency*

Stasis Ulcers *

Stasis Ulcers proficiency*

Stasis Ulcers frequency*

Surgical Wound Healing *

Surgical Wound Healing proficiency*

Surgical Wound Healing frequency*

Air Fluidized, Low Airloss Beds *

Air Fluidized, Low Airloss Beds proficiency*

Air Fluidized, Low Airloss Beds frequency*

Sterile Dressing Changes *

Sterile Dressing Changes proficiency*

Sterile Dressing Changes frequency*

Wound Care / Irrigations *

Wound Care / Irrigations proficiency*

Wound Care / Irrigations frequency*

JP *

JP proficiency*

JP frequency*

Hemovac *

Penrose proficiency*

Penrose frequency*

Hemovac *

Hemovac proficiency*

Hemovac frequency*

Burns

Proficiency Rating

Frequency Rating

First Degree *

First Degree proficiency*

First Degree frequency*

Second Degree *

Second Degree proficiency*

Second Degree frequency*

Third Degree *

Third Degree proficiency*

Third Degree frequency*

Pressure sores *

Pressure sores proficiency*

Pressure sores frequency*

Staged Decubitus Ulcers *

Staged Decubitus Ulcers proficiency*

Staged Decubitus Ulcers frequency*

Surgical Wounds with Drain(s) *

Surgical Wounds with Drain(s) proficiency*

Surgical Wounds with Drain(s) frequency*

Traumatic Wounds *

Traumatic Wounds proficiency*

Traumatic Wounds frequency*

Oncology General Skills

Proficiency Rating

Frequency Rating

Reverse Isolation *

Reverse Isolation proficiency*

Reverse Isolation frequency*

Nutritional Status *

Nutritional Status proficiency*

Nutritional Status frequency*

Interpretation of Lab Result

Proficiency Rating

Frequency Rating

Blood Chemistry *

Blood Chemistry proficiency*

Blood Chemistry frequency*

Blood Counts *

Blood Counts proficiency*

Blood Counts frequency*

Oncology - Care of Child with

Proficiency Rating

Frequency Rating

Malignant Tumors *

Malignant Tumors proficiency*

Malignant Tumors frequency*

Fresh Oncologic Surgery *

Fresh Oncologic Surgery proficiency*

Fresh Oncologic Surgery frequency*

Acute Tumor Lysis Syndrome *

Acute Tumor Lysis Syndrome proficiency*

Acute Tumor Lysis Syndrome frequency*

Leukemia *

Leukemia proficiency*

Leukemia frequency*

Bone Marrow Transplant *

Bone Marrow Transplant proficiency*

Bone Marrow Transplant frequency*

Disseminated Intravascular Coagulation *

Disseminated Intravascular Coagulation proficiency*

Disseminated Intravascular Coagulation frequency*

Inpatient Chemotherapy *

Inpatient Chemotherapy proficiency*

Inpatient Chemotherapy frequency*

Radiation Implant *

Radiation Implant proficiency*

Radiation Implant frequency*

Medications Knowledge and Use of

Proficiency Rating

Frequency Rating

Chemotherapeutic Agents *

Chemotherapeutic Agents proficiency*

Chemotherapeutic Agents frequency*

Infectious Diseases General Skills

Proficiency Rating

Frequency Rating

Interpretation of Lab Results *

Interpretation of Lab Results proficiency*

Interpretation of Lab Results frequency*

Cultures (Including Sensitivities) *

Cultures (Including Sensitivities) proficiency*

Cultures (Including Sensitivities) frequency*

CBC / differential (shift) *

CBC / differential (shift) proficiency*

CBC / differential (shift) frequency*

Obtain Culture Specimens

Proficiency Rating

Frequency Rating

Blood *

Blood proficiency*

Blood frequency*

Swab *

Swab proficiency*

Swab frequency*

Urine *

Urine proficiency*

Urine frequency*

Sputum *

Sputum proficiency*

Sputum frequency*

Infectious Diseases - Care of Child with

Proficiency Rating

Frequency Rating

Cytomegalovirus (CMV) *

Cytomegalovirus (CMV) proficiency*

Cytomegalovirus (CMV) frequency*

HIV / AIDS *

HIV / AIDS proficiency*

HIV / AIDS frequency*

Septic Shock *

Septic Shock proficiency*

Septic Shock frequency*

Tuberculosis *

Tuberculosis proficiency*

Tuberculosis frequency*

Hepatitis *

Hepatitis proficiency*

Hepatitis frequency*

Common Childhood Communicable Diseases *

Common Childhood Communicable Diseases proficiency*

Common Childhood Communicable Diseases frequency*

Phlebotomy / IV - Care of Child with

Proficiency Rating

Frequency Rating

Central Line *

Central Line proficiency*

Central Line frequency*

Port - A - Cath *

Port - A - Cath proficiency*

Port - A - Cath frequency*

PICC *

PICC proficiency*

PICC frequency*

Cutdown Line *

Cutdown Line proficiency*

Cutdown Line frequency*

Peripheral Line *

Peripheral Line proficiency*

Peripheral Line frequency*

Arterial Line *

Arterial Line proficiency*

Arterial Line frequency*

Pain Management General Skills

Proficiency Rating

Frequency Rating

Assessment - Pain Level Using Age Appropriate Scales *

Assessment - Pain Level Using Age Appropriate Scales proficiency*

Assessment - Pain Level Using Age Appropriate Scales frequency*

Pain Management - Care of Child with

Proficiency Rating

Frequency Rating

Epidural Analgesia *

Epidural Analgesia proficiency*

Epidural Analgesia frequency*

PCA *

PCA proficiency*

PCA frequency*

IV Conscious Sedation *

IV Conscious Sedation proficiency*

IV Conscious Sedation frequency*

Medication Knowledge and Use of

Proficiency Rating

Frequency Rating

Analgesics *

Analgesics proficiency*

Analgesics frequency*

Sedatives *

Sedatives proficiency*

Sedatives frequency*

Reversal Agents *

Reversal Agents proficiency*

Reversal Agents frequency*

Miscellaneous

Proficiency Rating

Frequency Rating

Normal Growth and Development *

Normal Growth and Development proficiency*

Normal Growth and Development frequency*

Normal Laboratory Values *

Normal Laboratory Values proficiency*

Normal Laboratory Values frequency*

Recognize Signs of Abuse or Neglect *

Recognize Signs of Abuse or Neglect proficiency*

Recognize Signs of Abuse or Neglect frequency*

Miscellaneous - Care of Child with

Proficiency Rating

Frequency Rating

Anorexia / Bulimia *

Anorexia / Bulimia proficiency*

Anorexia / Bulimia frequency*

Craniofacial Reconstruction *

Craniofacial Reconstruction proficiency*

Craniofacial Reconstruction frequency*

Depression *

Depression proficiency*

Depression frequency*

HEENT Surgery *

HEENT Surgery proficiency*

HEENT Surgery frequency*

Ingestion of foreign body *

Ingestion of foreign body*

Ingestion of foreign body frequency*

Ingestion of Poison or Toxins *

Ingestion of Poison or Toxins proficiency*

Ingestion of Poison or Toxins frequency*

Plastic Surgery *

Plastic Surgery proficiency*

Plastic Surgery frequency*

Suicide Attempt *

Suicide Attempt proficiency*

Suicide Attempt frequency*

Multiple Trauma *

Multiple Trauma proficiency*

Multiple Trauma frequency*

Near Drowning *

Near Drowning proficiency*

Near Drowning frequency*

Medication Administration for Children

Proficiency Rating

Frequency Rating

Calculation of Pediatric Doses *

Calculation of Pediatric Doses proficiency*

Calculation of Pediatric Doses frequency*

Titration of IV Drips *

Titration of IV Drips proficiency*

Titration of IV Drips frequency*

Eye / Ear Installations *

Eye / Ear Installations proficiency*

Eye / Ear Installations frequency*

Metered Dose Inhaler *

Metered Dose Inhaler proficiency*

Metered Dose Inhaler frequency*

Intravenous Medications (IV) *

Intravenous Medications (IV) proficiency*

Intravenous Medications (IV) frequency*

Subcutaneous (SQ) Injections *

Subcutaneous (SQ) Injections proficiency*

Subcutaneous (SQ) Injections frequency*

Z Track Injections *

Z Track Injections proficiency*

Z Track Injections frequency*

Knowledge of Emergency Drug Action and Reaction *

Knowledge of Emergency Drug Action and Reaction proficiency*

Knowledge of Emergency Drug Action and Reaction frequency*

Pediatric Drug Actions and Reactions *

Pediatric Drug Actions and Reactions proficiency*

Pediatric Drug Actions and Reactions frequency*

Years of Experience in each of the following Pediatric Areas

Medical / Surgical*

Telemetry*

Oncology*

Neurology*

Psychiatry*

Rehabilitation*

Other (Specify)*

Total Years in Pediatric Nursing*

Do you have a Chemotherapy Certificate?*

Yes

Certify your information*

I certify that I have provided true and accurate information about my skills and experience to the best of my ability

Signature*

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Date*

Skills/Competences

Proficiency

Frequency

PEDIATRIC INTENSIVE CARE

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