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LPN
LPN
Name
First
Last
Date
MM slash DD slash YYYY
Self-Assessment Rating Scale
No Experience
Theory or observation only during the past 12 months
Limited Experience
Performed less than 12 times within the past 12 months and may need a review
Experienced
Performed at least once per month within the past 12 months and may need minimal assistance
Highly Skilled
Performed on at least a weekly basis over the past 12 months; proficient
Age Specific Care
No Experience
Limited Experience
Experienced
Highly Skilled
Newborn/neonatal (Birth-30 days)
Infant (30 days-1 yr)
Toddler (1-3 yrs)
Preschool (3-5 yrs)
School Age Children (5-12 yrs)
Adolescent (12-18 yrs)
Young Adults (19-39 yrs)
Middle Adults (39-64 yrs)
Older Adults (64+ yrs)
Clinical Areas
No Experience
Limited Experience
Experienced
Highly Skilled
Burn unit
Cardiac care
Emergency department
Intensive care unit
Step down
Gynecology
Labor and delivery
Medical
Mother/baby
Neurology
Nursery
Obstetrics
OR
Oncology
Orthopedics
Pediatrics
Post partum
Psychiatry
Rehabilitation
Renal/dialysis
Respiratory
Surgical
Telemetry
Doctor's office
Health department
Corrections
Home health
Long term care
Hospice
Respite care
Outpatient clinic
Nursing home
Core Skills
No Experience
Limited Experience
Experienced
Highly Skilled
Admissions of a patient
Transfer of a patient
Discharge of a patient
Assist with emergency situations/codes
Vital signs
Post mortem care
Assist with defibrillation
Assist with cardioversion
Documentation
Patient and family education
Assessment of abuse
Restraints
Body mechanics
Aseptic technique
Isolation precautions
Cardiovascular - Care of Patient With:
No Experience
Limited Experience
Experienced
Highly Skilled
Auscultation (rate, rhythm)
Blood pressure/non-invasive
Doppler
Heart sounds/mumurs
Abdominal aortic aneurysm/bypass
Angina
Cardiac arrest
Cardiomyopathy
Carotid endarterectomy
Congestive heart failure
Femoral-popliteal bypass
Myocarditis
Status post MI
Post angioplasty
Post cardiac cath
Thrombophlebitis
Temporary pacemaker
Permanent pacemaker
Cardiac enzymes
Blood chemistries
Basic arrhythmia interpretation
Lead placement
Pulmonary - Care of Patient With:
No Experience
Limited Experience
Experienced
Highly Skilled
Ventilator/weaning
Breath sounds
Rate and work of breathing
Arterial blood gases (ABG)
Asthma
COPD
Tracheostomy
Lobectomy
Pneumonectomy
Pneumonia
Pulmonary embolism
Thoracotomy
Tuberculosis
pulmonary edema
Pneumothorax
Laryngospasm
Endotracheal tube/suctioning
NAsal airway/suctioning
Oropharyngeal/suctioning
Sputum specimen collection
Tracheostomy/suctioning
Assist with intubation
Assist with thoracentesis
Chest tube management
Chest physiotherapy
Incentive spirometry
Pulse oximetry
Bag and mask
Face mask
Nasal cannula
Portable O2 tank
Neurological - Care of Patient With:
No Experience
Limited Experience
Experienced
Highly Skilled
Glascow coma scale
Level of consciousness
Assist with lumbar puncture
Use of hypo/hyperthermia blanket
Aneurysm precautions
Basal skull fracture
Closed head injuries
Coma
CVA
TIA
Delirium tremens
Encephalitis
Meningitis
Neuromuscular disorders
Psychiatric disorders
Seizures
Overdose
Guillain-Barre syndrome
Externalized VP shunts
Post Craniotomy
Spinal cord injuries
Orthopedics - Care of Patient With:
No Experience
Limited Experience
Experienced
Highly Skilled
Circulation checks
Gait
Range of motion
Skin
Wheelchair use
Cane/crutches/walker use
Amputation
Arthroscopic surgery
Cast
Splint
Knee immobilizer
Osteoporosis
Pinned fractures
Total joint replacements
Continuous Passive Motion devices
Cervical collar
Prosthetics
Traction - Bucks/skeletal
Auto transfuser
Gastrointestinal - Care of Patient With:
No Experience
Limited Experience
Experienced
Highly Skilled
Abdominal/bowel sounds
Fluid balance
Placement of NG tube
Placement of flexible feeding tube
Administration of tube feeding
Feeding pumps
Gravity feeding
Salem sump to suction
Care of gastrostomy tube
Colostomy care
Bowel obstruction
GI bleeding
GI surgery
Hepatits
Inflammatory bowel disease
Liver failure
Liver transplant
Paralytic ileus
Colostomyileostomy
Abdominal trauma
Renal/Genitourinary - Care of Patient With:
*
No Experience
Limited Experience
Experienced
Highly Skilled
Fluid balance
Urinary output
BUN and Creatinine
Catheter care
Specimen collection - Routine
Specimen collection - 24 hours
Specimen collection - Clean catch
Insertion and care of straight and Foley catheters - Female
Insertion and care of straight and Foley catheters - Male
Hemodialysis
Nephrectomy
Peritoneal dialysis
Renal failure
Renal transplant
TURP
Ileal conduit
Bladder irrigations
Urinary tract infections
Gyn surgery
Renal trauma
Endocrine/Metabolic - Care of Patient With:
No Experience
Limited Experience
Experienced
Highly Skilled
S/S diabetic coma
S/S insulin coma
Blood glucose monitoring
Performing finger/heel stick
Sliding scale insulin protocols
Adrenal disorders (Addison's)
Diabetes mellitus
Diabetes insipidus (pituitary disorder)
Diabetic ketoacidosis
Hyperthyroidism
Hypothyroidism
Thyroidectomy
Wound Management
No Experience
Limited Experience
Experienced
Highly Skilled
Assess skin for impending breakdown
Surgical wound healing
Sterile dressing change
Wound vac
Wet to dry dressings
Burns - 1st degree
Burns - 2nd degree
Burns - 3rd degree
Decubitus ulcers
Surgical wounds with drain(s)
Traumatic wounds
Wound care irrigations
Multiple abdominal wounds and drains
Gunshot wound
Stab wound
Lacerations
Abrasions
Oncology - Care of Patient With:
No Experience
Limited Experience
Experienced
Highly Skilled
Bone marrow transplant
Inpatient chemotherapy
Leukemia
Radiation implant
Lymphoma
Depressed immune system
Radiation therapy
Fresh oncology surgery
Infections Disease - Care of Patient With:
No Experience
Limited Experience
Experienced
Highly Skilled
HIV
MRSA
C. Difficile
VRE
Hepatitis
Influenza
Isolation precautions
Intravenous therapy
No Experience
Limited Experience
Experienced
Highly Skilled
Site assessment
Administration of blood/blood products
Drawing blood from a central line
IV insertion
Heplock flushes
Administration of IV fluid
Administration of IV piggy back
Administration of IV push medications
Access VAD
Central line
Peripheral line
Administration - TPN/lipids
Pain Management
No Experience
Limited Experience
Experienced
Highly Skilled
Assessment of pain level/tolerance
Administration of narcotic analgesia
PCA pumps
IV conscious sedation
Epidural anesthesia
Miscellaneous
*
No Experience
Limited Experience
Experienced
Highly Skilled
Computerized charting
Automated med. dispensing systems
Safe needle devices
PO medications
IM injections
Z-track injections
Rectal suppositories
Nasal sprays
Ear drops
Eye drops
Inhalers
Assist with emergency drugs/code cart
Signature
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