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*

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*

Do you speak any languages other than English?*
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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.
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Date
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Basic Nursing Care