Pediatric Skills Checklist Name* First Last Date* MM slash DD slash YYYY Please use the following key: 1 = Done Frequently; well skilled 2 = Occasionally Done; moderately skilled 3 = Rarely Done; skill limited 4 = Observed only; never doneBlood / Blood Product Administration / Precautions* 1 2 3 4 Calculation of Rates* 1 2 3 4 Mcg / min* 1 2 3 4 Mcg / kg / min* 1 2 3 4 Mg / min* 1 2 3 4 Hang IV Piggyback* 1 2 3 4 Heparin Lock* 1 2 3 4 Hyperalimentation* 1 2 3 4 Peripheral / Central Line* 1 2 3 4 Knowledge of Solution* 1 2 3 4 Insertion of Central Line* 1 2 3 4 Use of Broviac / Hickman / Groshong Catheters* 1 2 3 4 Lab Assessment* 1 2 3 4 Implanted Venous Access Ports* 1 2 3 4 Dressing Changes* 1 2 3 4 Insertion of Peripheral Line* 1 2 3 4 Dressing Change* 1 2 3 4 D / C Line* 1 2 3 4 Universal Precautions* 1 2 3 4 Isolation Procedures* 1 2 3 4 Airborne Isolations* 1 2 3 4 Wound / Blood Isolations* 1 2 3 4 Specimen Collection* 1 2 3 4 Arterial Line Blood Draw* 1 2 3 4 Blood Culture* 1 2 3 4 Capillary Blood Draw* 1 2 3 4 Central Line Blood Draw* 1 2 3 4 PICC Line Blood Draw* 1 2 3 4 Sputum* 1 2 3 4 Stool* 1 2 3 4 Urine Culture* 1 2 3 4 Urinalysis* 1 2 3 4 Venipuncture* 1 2 3 4 Wound Culture* 1 2 3 4 Normal Anatomy of the Heart* 1 2 3 4 Left Side* 1 2 3 4 Right Side* 1 2 3 4 Resuscitation* 1 2 3 4 Team Member* 1 2 3 4 Perform Defibrillation* 1 2 3 4 Perform / Set Up Emergent Cardioversion* 1 2 3 4 Prepare and Administer Meds* 1 2 3 4 Set Up and Interpret 12 Lead EKG* 1 2 3 4 Administer Oxygen* 1 2 3 4 Use of Apnea Monitor* 1 2 3 4 Assess Lung Sounds* 1 2 3 4 Incentive Spirometer* 1 2 3 4 Nebulizer* 1 2 3 4 Normal Physiology of Pulmonary Vascular System* 1 2 3 4 Obtain Arterial Blood Gas* 1 2 3 4 Result Interpretation* 1 2 3 4 Pavulonized Patient* 1 2 3 4 Pulse Oximetry* 1 2 3 4 Suctioning* 1 2 3 4 Use of Emergency Equipment* 1 2 3 4 Insulin Preparation and Administration* 1 2 3 4 Blood Glucose Monitoring* 1 2 3 4 Equipment Used* 1 2 3 4 Jejunostomy Care* 1 2 3 4 NG Tube Insertion / Lavage* 1 2 3 4 Normal Physiology of Renal and GI System* 1 2 3 4 Ostomy / Stoma Care* 1 2 3 4 Peritoneal Lavage* 1 2 3 4 Poison Control* 1 2 3 4 Wound Care Irrigations* 1 2 3 4 Consent for Treatment of a Minor* 1 2 3 4 Procedure for Patient Signing AMA* 1 2 3 4 Disaster Protocols* 1 2 3 4 Assist with Peritoneal Lavage* 1 2 3 4 Misc. Trays / Instruments* 1 2 3 4 Pelvic Tray* 1 2 3 4 Cut Down Tray* 1 2 3 4 Procto Tray* 1 2 3 4 CVP Tray* 1 2 3 4 Culdocentesis Tray* 1 2 3 4 Thoracentesis Tray* 1 2 3 4 Pediatrics* 1 2 3 4 Administration of Medication* 1 2 3 4 Oral* 1 2 3 4 Subcutaneous* 1 2 3 4 Intramuscular* 1 2 3 4 Pediatric Nursing* 1 2 3 4 Anorexic Patient Care* 1 2 3 4 Assist with Lumbar Puncture* 1 2 3 4 Respiratory Distress Syndrome* 1 2 3 4 Broncho-pulmonary Dysplasia* 1 2 3 4 Croup* 1 2 3 4 Epiglottitis* 1 2 3 4 Asthma* 1 2 3 4 Cystic Fibrosis* 1 2 3 4 Pneumonia* 1 2 3 4 Near Drowning* 1 2 3 4 Near SIDS* 1 2 3 4 Chest Tubes* 1 2 3 4 Reye's Syndrome* 1 2 3 4 Meningitis* 1 2 3 4 Hydrocephalus* 1 2 3 4 Spina Bifida* 1 2 3 4 Lead Play Therapy* 1 2 3 4 Care of the Child with Seizures* 1 2 3 4 Sickle Cell* 1 2 3 4 Equipment* 1 2 3 4 Apnea Monitor* 1 2 3 4 Cardiac Monitor* 1 2 3 4 Ventilator* 1 2 3 4 ECMO* 1 2 3 4 Care of the Child with* 1 2 3 4 Child Abuse* 1 2 3 4 Failure to Thrive* 1 2 3 4 Cleft Palate* 1 2 3 4 Post Tonsillectomy* 1 2 3 4 Dying Infant / Child* 1 2 3 4 Diabetes Mellitus* 1 2 3 4 Psych Patients* 1 2 3 4