NURSING SKILLSASSESSMENT

NAME_______________________ RN LPN/LVN (CIRCLE AS APPROPRIATE)

DATE OF REVIEW_____________Self-Eval Key1. Training Only, no experience2. Experience, need refresher3. Experience, proficient4. No experience, no training

Procedure Self-Evaluation

Date 1st Performed

Date Observed

Signature of Evaluator

ADMISSION ASSESSMENT

Data CollectionINFECTION CONTROL

Nursing Bag Technique

Handwashing

Bio-hazard Waste Disposal

Care/storage of equipment

OXYGEN THERAPY

Concentrator

Liquid 02

Ventilator

CPAP

PULMINARY

Chest Physiotherapy

Intermittent Nebulizer Rx

Apnea Monitor

Care of Tracheostomy

Change of Outer Cannula

Change of Inner Cannula

Trach Dressing Changee

Care of Chest Tubes

Procedure Self-Evaluation

Date 1st Performed

Date Observed

Signature of Evaluator

ENTERAL

Insertion of TubeCare of Enterostomy tube

Site Dressing Change

ENTERAL TUBE FEEDINGS:

Gravity

Bolus

PumpColostomy care

and Appliance applicationColostomy Irrigation

Colostomy Teaching

URINARY

Foley Insertion - Female

Foley Insertion - Male

External cathetersUrostomy care

and Applicance applicationCAPD

MUSCULOSKELETAL

Assistive Device

Knowledge

Cane Straight/Quad

Crutches

Walker

Wheelchair

Range of Motion:

PROM

AROM

INFUSION

Hickman/Broviac

Groshong

Port-a-cath

PICC

Procedure Self-Evaluation

Date 1st Performed

Date Observed

Signature of Evaluator

Midline

Peripheral cathButterfly

Venipuncture for blood specimen collectionUrokinase/Streptokinase

Chemotherapy

TPN/PPN

Home Hemotransfusion

WOUND CARE

Hyrdrocolloids

Foam Dressings

Calcium Alginates

Transparent

Hydrogel

Wound gels

Unna Boat

Ace wrap

PICC dressing change

DME

Glucometer

(List brand names)

Sequential Compression

Stockings

AMI pump

Infusion pump

(List types)

Enteral Feeding pumps

(List types)

OTHER SKILLS