GENERAL INFORMATION

Note: * Denotes a required field.

Please enter your full name as it appears on your Social Security Card: First Name   Middle Name   Last Name  * Please enter the Last Four digits of your Social Security Number:  -   -   *       Please check here if you do not hold a valid social security card. Please provide your contact information: Phone Number  * E-mail Address  * Confirm E-mail Address  * Type your e-mail address again above.

This profile is for use by healthcare professionals in the NICU discipline and specialty. It will not be a determining factor for the program.

CHECKLIST INSTRUCTIONS

Please mark your level of experience      1. No theory and/or experience      2. Limited experience/need supervision and/or support      3. Experienced/minimal support needed to perform      4. Proficient/can perform independently

PATIENT TYPES

1

2

3

4

Neonates < 28 Weeks

Neonates 29 - 34 Weeks

Neonates > 34 Weeks

WORK SETTINGS

1

2

3

4

Level II NICU

Level III NICU

Level IV NICU

CARDIOVASCULAR

1

2

3

4

Cardiac Surgery - Pre-op

Cardiac Surgery - Immediate Post-op

Congenital Heart Disease/Defects

CHF/Pulmonary Edema

Hemodynamic Instability

PULMONARY

1

2

3

4

Bronchopulmonary Dysplasia

Diaphragmatic Hernia

Fresh Tracheostomy

Meconium Aspiration

Persistent Pulmonary Hypertension

Pneumonia

Respiratory Distress Syndrome/Failure

Interpretation of ABGs

Assist with Intubation/Extubation

Endotracheal Suctioning

Chest Tube Placement and Management

Modes of Ventilation (AC/PC/SIMV/CPAP/BiPAP)

High Frequency Ventilation

Inhaled NO

ECMO

NEUROLOGIC

1

2

3

4

Ballard/Dubowitz

Reflexes Based on Gestational Age

Hydrocephalus

Intraventricular Hemorrhage

Meningocele/Myelomeningocele

Neonatal Abstinence Score/Syndrome

Seizures

GASTROINTESTINAL

1

2

3

4

Colostomy/Ileostomy

Gastroschisis/Omphalocele

GI Bleeding

Necrotizing Enterocolitis

Post Abdominal Procedure

FEEDINGS

1

2

3

4

Breast Milk Handling/Storage

Breast Pump

Gavage Feedings

NG/OG/NJ Tube Placement and Management

RENAL/ENDOCRINE/GENETIC

1

2

3

4

Circumcision Care

Genetic Disorders

Hypo/Hyperglycemia

Infant of Diabetic Mother

Malformations of the GU Tract/Kidney

Phototherapy

Renal Failure

INFECTIOUS DISEASES

1

2

3

4

Neonatal Sepsis

Septic Work Up

Assist with Lumbar Puncture

MEDICATIONS

1

2

3

4

Calculation of Neonatal Dosages

Antibiotics/Antivirals

Anticonvulsants

Immunizations

Digoxin

IV Vasopressors

Prostaglandin

Bronchodilators

Steroids

Caffeine

Surfactant

Automated Medication Dispensing (i.e. Pyxis, Omnicell)

IV THERAPY

1

2

3

4

Administration of Blood/Blood Products

Central Line Catheter/Dressings

Management of UAC/UVC Lines

Radial Arterial Lines

Start IVs

CARDIAC MONITORING & EMERG. RESPONSE

1

2

3

4

Attend High Risk Deliveries

Preparation for Transport

Transport Neonate

Rhythm Interpretation

Dysrhythmia Management

PROFESSIONAL KNOWLEDGE AND SKILLS

1

2

3

4

National Patient Safety Goals/Core Measures

Bereavement/Postmortem Care

Neonatal Skin Care

Pressure Ulcer Risk Assessment/Prevention

Restraints/Use of Least Restrictive Device

Patient/Family Teaching

Age Specific/Population-Based Care

Isolation Precautions

Infection Prevention

Pain Assessment & Management

Charge Experience

Interpretation and Communication of Lab Values

1

2

3

4

EPIC

Cerner

Eclipsys

McKesson

Meditech

Other Computerized System

Computerized Physician Order Entry

Bar Coding for Medication Administration

EMR Conversion

Yes

No

Certifications

1

2

3

4

BLS

NRP

PALS

S.T.A.B.L.E.

NCC Certification - RNC-NIC

Please read and agree to the statements below by marking the checkbox. You will not be able to submit until you have marked the checkbox. * I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize Hudson Staffing to release this NICU Skills Checklist to the client facilities in relation to consideration of employment as a healthcare professional with those facilities.

Privacy Note: Hudson Staffing will record anonymous electronic information about your connection when you click on the submit button. This information is used for security purposes only. This information will include your IP Address (34.237.51.159) which will be used as a digital signature.