Neonatal Intensive Care Checklist

Name *

Telephone *		--

Who is your recruiter? *

Who referred you? *

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

1 = Never Performed 2 = Limited Experience 3 = Comfortable Performing 4 = Proficient

CARE OF PATIENTS WITH	1	2	3	4
Periventricular Leukomalacia (PVL)
Seizures
Spina Bifida
Anal Atresia
Cleft Lip/Palate
Cystic Kidney Disease
Esophageal Atresia
Fetal Hydronephrosis
Gastroschisis/Omphalocele
IDM Hyperglycemia
IDM Hypoglycemia
Inguinal Hernia
Intestinal Obstruction
Jaundice/Hyperbilirubinemia
Necrotizing Enterocolitis (NEC)
Post Abdominal Surgery
Pyloric Stenosis
Tracheoesphogeal Fistula (TEF)
Birth Injuries
Congenital Hip Dislocation
Drug Addiction/Exposure
Fetal Alcohol Syndrome
HIV Positive Mother
HBsAg Positive Mother
Retinopathy of Prematurity (ROP)
Sepsis
Brain Death/Organ Procurement

MEDICATION ADMINISTRATION	1	2	3	4
Aminophylline/Caffeine
Anticoagulants
Anticonvulsant Medications
Dobutamine (Dobutrex)
Dopamine (Intropin)
Epinephrine
Eye Prophylaxis
Immunizations
Insulin Drip
NaHCO3

MEDICATION ADMINISTRATION	1	2	3	4
Prostaglandin
Respigam/Synergis Prophylaxis
Steroids
Vitamin K
Pain Medications
IM Meds
IV drips
IV push
Eye Instillations
Dosage calculations for neonates

PROCEDURES/SKILLS	1	2	3	4
Airway Management
a. Bulb Syringe
b. CPAP (nasal prongs)
c. Endotracheal Tube
- assist with insertion
- stabilization of ETT
- extubation
d. Suctioning
- ETT
- Nasal
- Oral
- Tracheostomy
Cardiac Resuscitation
Chest Physiotherapy
Chest tube & drainage system
a. Set up
b. Assist with insertion
c. Care & maintenance
d. Troubleshooting
e. Removal
Continuous Bladder Irrigation
EKG Intrepretation
Exchange Transfusion
Extracorporeal Membrane Oxygenation
Hemodynamic Monitoring, non-invasive
a. Auscultation
b. Doppler
c. Automatic BP cuff
d. Palpation
Hemodynamic Monitoring - Invasive
Feedings
a. Breastfeeding - assist
b. Breastmilk handling/storage
c. Bottle
d. Continuous tube feeding
e. Gavage
f. Reflux precautions
g. Placement of Tubes
- orogastric tube
- nasogastric tube
- nasojejunal tube
h. Assessing Feeding Tolerance
Gastric Suctioning - Intermittent
Gastric Suctioning - Continuous
Interpretation of Lab Results
a. Blood gases
b. Bilirubin
c. CBC/Diff
d. Cultures
e. Maternal lab results
f. Urine (test & interpret)
- Glucose
- Labstix
- pH
- Specific Gravity
- Occult Blood

PROCEDURES/SKILLS	1	2	3	4
Intracranial Pressure Monitoring
IV's
a. Starting IV
b. Site & Patency Assessment
c. Administration Blood/Blood Products
d. Maintenance/Discontinuation of:
- Broviac
- Hickman
- Heparin/Saline Lock
- Percutaneous Arterial Line
- Peripheral IV
- PICC
- Umbilical Arterial Catheter
- Umbilical Venous Catheter
e. Hyperalimenation
Lumbar Puncture (assist with)
Nitric Oxide Therapy
Orthopedic Devices - casts, splints, etc
Oxygen Therapy Administration
a. Bag & mask
b. ET tube
c. Oxyhood
d. Nasal CPAP
e. Nebulizer
f. Trach Collar
Skin
a. Skin breakdown prevention
b. Wound healing
c. Color change
- mottling
- petechiae
- cyanosis
- jaundice
Specimen Collection
a. Blood
- arterial stick
- heel stick
- peripheral
- Umbilical
b. Cultures
- blood
- wound
- sputum
Stool Testing
Temperature
a. Rectal
b. Skin
c. Axillary
Transillumination
Wound/Ostomy Care
a. Colostomy care/bag change
b. Ileostomy care/bag change
c. Irrigations
d. Sterile Dressing changes
e. Surgical wounds with drains

EQUIPMENT	1	2	3	4
Cardiac Monitor
Centrifuge
Defibrillator
Glucometer
Infusion Pumps (specific brands)
-
-
O2 Analyzer
Oxygen Flow Meter
Oxyhood
Phototherapy Equipment
a. Bili blanket
b. Bili lights
c. Bili meter
Computer Charting Systems

EQUIPMENT	1	2	3	4
Positioning Devices
Pulse Oximeter
Thermoregulation
a. Isolette with Humidity
b. Radiant Warmer
c. Warming Lights
Transport Incubator
Ventilator
a. CPAP/PEEP
b. High frequency jet
c. IMV
d. Transport
e. Oscillating
f. Home Ventilator

ASSESSMENT/OTHER	1	2	3	4
Experience in:
a. Level II Nursery
b. Level III Nursery
Abdominal Girth Measurement
Admission of patients to unit
APGAR Scoring
Assess Breath Sounds
Assess Heart Sounds
Ballard Score
Bereavement support
Breastfeeding Teaching
Care Planning
Charge Nurse responsibilities
Circulation Checks
Computerized Charting

ASSESSMENT/OTHER	1	2	3	4
Developmental Intervention/Assessment
Dubowitz Score
Fontanel Assessment
Head circumference measurement
Isolation Procedures
Neurological Assessments
Pain Assessment
Pain Management
Parent Teaching of Normal Infant
Patient Teaching
ROM exercises
Sedation
Use of Restraints
Vital Signs

Do you speak any languages other than English?	Yes	No

If yes, which language(s)?

AGE SPECIFIC CARE

Mark whether or not you have expertise in providing age-appropriate care for the following:

	Yes	No
1. Understands the different communication needs for the parental age group and changes communication methods and terminology accordingly
2. Understands the different medications, dosages and possible side effeccts for neonates and administers medications appropriately
3. Understands the different safety risks for neonates and alters the environment accordingly
4. Understands the normal growth and development of neonates and adapts care accordingly

I hereby certify that ALL information I have provided to Emerald, on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.