PICU

Pediatric ICU

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 of Patients Cared For

	No Experience	Limited Experience	Experienced	Highly Skilled
Newborn/neonate (birth-30 days)
Infant (1 mo-1 yr)
Toddler (1-3 yrs)
Preschooler (3-5 yrs)
School age child (5-12 yrs)
Adolescents (12-18 yrs)
Young adults (18-39 yrs)

General Skills

	No Experience	Limited Experience	Experienced	Highly Skilled
Standard precautions
Isolation precautions
Pediatric respiratory/cardiac arrest
Adult respiratory/cardiac arrest
Crash carts
Defibrillators
Care of patient in restraints
Automated med dispensing systems
Care planning and patient discharge
Family/patient education
Electronic documentation
Patient head to toe assessment

Cardiovascular General Skills
No Experience Limited Experience Experienced Highly Skilled
Auscultation (rate, rhythm, volume)
Blood pressure/invasive (arterial line)
Heart sounds/murmers
Perfusion
Central venous pressure
Invasive Hemodynamic Monitoring
No Experience Limited Experience Experienced Highly Skilled
Interpretation of lab results - CBC/electrolytes
Defibrillation/cardioversion
EKG interpretation (basic & advanced)

Cardiovascular - Care of the child with:

	No Experience	Limited Experience	Experienced	Highly Skilled
Bacterial endocarditis
Congenital heart disease/defects
Cardiac arrest
Cardiac transplant
Cardiogenic shock
Cardiomyopathy
Hypovolemic shock
Myocarditis
Post cardiac surgery
Post interventional cardiac cath

Medications - Knowledge and Use Of:

	No Experience	Limited Experience	Experienced	Highly Skilled
Dobutamine (Dobutrex)
Dopamine (Intropin)
Epinephrine (Adrenaline)
Nipride (Nitroprusside)
Nitroglycerine (Tridil)
Sodium Bicarbonate
Antiarrhythmics
Steroids
Bronchodilators
Racemic epinephrine
Mannitol
Sedatives
Anticonvulsants
Antiemetics
Growth Hormone
Insulin
Thyroid Medications
Chemotherapeutic Agents
Sedatives
Reversal Agents
Analgesics

Respiratory General Skills
No Experience Limited Experience Experienced Highly Skilled
Breath sounds/work of breathing
Obtaining Blood Gases
No Experience Limited Experience Experienced Highly Skilled
Arterial
Heelstick
Peripheral
Interpretation of ABG's
Oximeter
Airway Management
No Experience Limited Experience Experienced Highly Skilled
Assist with intubation
Assist with extubation

	No Experience	Limited Experience	Experienced	Highly Skilled
Breath sounds/work of breathing

Suctioning

	No Experience	Limited Experience	Experienced	Highly Skilled
Bulb syringe
Nasal airway/suctioning
Oral airway/suctioning
In-line suction
Open ET catheter suction
Tracheostomy/suctioning
Apnea monitor
Chest physiotherapy

Chest Tube (Assist with):
No Experience Limited Experience Experienced Highly Skilled
Insertion
Removal
ECMO (Extracorporeal Membrane Oxygenation)
End Tidal CO2
O2 Therapy
No Experience Limited Experience Experienced Highly Skilled
Nasal cannula
Bag and mask
Isolette
Oxyhood
Tent
Trach collar
Thoracentesis
Ventilators
No Experience Limited Experience Experienced Highly Skilled
CPAP/PEEP/BIPAP
High frequency jet ventilator
Home ventilator
IMV
Pressure ventilator
Volume ventilator
Weaning

Respiratory - Care of child with:

	No Experience	Limited Experience	Experienced	Highly Skilled
Bronchiolitis (RSV)
Pneumonia
Croup
Chronic respiratory disease
Status asthmaticus
Lung transplant
Epiglottitis
Fresh tracheostomy
Foreign body aspiration
Flail chest
Hemothorax
Pneumothorax
Respiratory distress syndrome (RDS)
Respiratory failure

Neuro General Skills
No Experience Limited Experience Experienced Highly Skilled
Glasgow coma scale
Neurological status
Assist with lumbar puncture
Seizure precautions
Intracranial pressure monitoring

Neuro - Care of Child With:

	No Experience	Limited Experience	Experience	Highly Skilled
Head trauma
Post neurosurgery
Spinal cord injury
Status epilepticus
Coma
Brain death/organ procurement
Encephalitis
Meningitis
Externalized VP shunt/reservoirs
Neuromuscular disease

Gastrointestinal General Skills
No Experience Limited Experience Experienced Highly Skilled
Abdominal assessment
Interpretation of lab results - Serum electrolytes
Feedings (storage and prep of)
Bottle
Breast
Gavage
TPN
PPN
Gastrostomy/Button
No Experience Limited Experience Experienced Highly Skilled
J-tubes
NG to suction
Placement of naso-orogastric tube
Test for occult blood

Gastrointestinal - Care of Child With:

	No Experience	Limited Experience	Experienced	Highly Skilled
Anal fissure
Cleft lip/palate
New colostomy
New ileostomy
Diaphragmatic hernia
Severe failure to thrive (FTT)
Pyloric stenosis repair
GE reflux
GI bleeding
Crohn's disease
Ulcerative colitis
Severe gastroenteritis/dehydration
Intestinal parasites
Necrotizing enterocolitis
Surgical abdomen
Liver transplant
Small bowel transplant

Renal/Genitourinary General Skills
No Experience Limited Experience Experienced Highly Skilled
Interpretation of lab results (UA/BUN/Creatinine)
Test urine and interpret
Glucose
Labstix
Occult blood
pH
Specific gravity
Collection of Urine Specimens
No Experience Limited Experience Experienced Highly Skilled
Catheter
Diaper/bag
Insertion and care of straight and Foley catheter
Suprapubic

Renal/Genitourinary - Care of Child With:

	No Experience	Limited Experience	Experienced	Highly Skilled
Acute renal failure
CAVH
Peritoneal dialysis
Hemodialysis
Hemolytic uremic syndrome (HUS)
Nephritis
Nephrotic syndrome
Renal transplant
Syndrome inappropriate ADH (SIADH)

Endocrine/Metabolic General Skills
No Experience Limited Experience Experienced Highly Skilled
Electrolyte balance
Blood glucose testing
Knowledge of lab work - Thyroid studies
Endocrine/Metabolic - Care of Child With:
No Experience Limited Experience Experienced Highly Skilled
Diabetes mellitus
Diabetic ketoacidosis
Diabetic coma
Hyper/hypocalcemia
Hyperbilirubinemia
Thyroid dysfunction
Orthopedics General Skills
No Experience Limited Experience Experienced Highly Skilled
Specialized Orthopedic Bed
Orthopedics - Care of Child With:
No Experience Limited Experience Experienced Highly Skilled
Cervical traction
Pinned fractures
Post vertebral surgery

	No Experience	Limited Experience	Experienced	Highly Skilled
Specialized Orthopedic Bed

Wound Management

	No Experience	Limited Experience	Experienced	Highly Skilled
Assessment of skin status
Stasis ulcers
Surgical wound healing
Air fluidized, low air loss bed
Sterile dressing changes
Wound care/irrigations
JP
Penrose
Hemovac

Burns
No Experience Limited Experience Experienced Highly Skilled
1st degree
2nd degree
3rd degree
Pressure sores
Staged decubitis ulcers
Surgical wounds with drain(s)
Traumatic wounds
Oncology General Skills
No Experience Limited Experience Experienced Highly Skilled
Reverse isolation
Nutritional status
Interpretation of Lab Result
No Experience Limited Experience Experienced Highly Skilled
Blood chemistry
Blood counts

Oncology - Care of Child With:

	No Experiene	Limited Experience	Experienced	Highly Skilled
Malignant tumors
Fresh oncologic surgery
Acute tumor lysis syndrome
Leukemia
Bone marrow transplant
Disseminated intravascular coagulation
Inpatient chemotherapy
Radiation implant

Infectious Diseases - General Skills
No Experience Limited Experience Experienced Highly Skilled
Interpretation of lab results
Cultures (including sensitivites)
CBC/differential (shift)
Obtain culture specimens
No Experience Limited Experience Experienced Highly Skilled
Blood
Swab
Urine
Sputum
Infection Diseases - Care of Child With:
No Experience Limited Experiencce Experienced Highly Skilled
Cytomegalovirus (CMV)
HIV/AIDS
Septic shock
Tuberculosis
Hepatitis
Common childhood communicable diseases

Phlebotomy/IV Therapy

	No Experience	Limited Experience	Experienced	Highly Skilled
Peripheral IV insertion, care, and maintenance
Central line care and maintenance
PICC line care and maintenance
Drawing blood from central line/PICC line
Drawing venous blood
Administration of blood/blood products
Cryoprecipitate
Packed red blood cells
Whole blood

Phlebotomy/IV - Care of Child With:
No Experience Limited Experience Experienced Highly Skilled
Central line
Port-a-cath
PICC
Cutdown line
Peripheral line
Arterial line
Pain Management - General Skills
No Experience Limited Experience Experienced Highly Skilled
Assessment- Pain Level Using Age Appropriate Scales
Pain Management - Care of Child With:
No Experience Limited Experience Experienced Highly Skilled
Epidural Analgesia
PCA
IV conscious sedation
Miscellaneous
No Experience Limited Experience Experineced Highly Skilled
Normal growth and development
Normal laboratory values
Recognize signs of abuse or neglect

	No Experience	Limited Experience	Experienced	Highly Skilled
Assessment- Pain Level Using Age Appropriate Scales

Miscellaneous - Care of Child With:

	No Experience	Limited Experience	Experienced	Highly Skilled
Anorexia/bulimia
Craniofacial reconstruction
Depression
HEENT surgery
Ingestion of foreign body
Ingestion of poison or toxins
Plastic surgery
Suicide attempt
Multiple trauma
Near drowning

Medication Administration for Children

	No Experience	Limited Experience	Experienced	Highly Skilled
Calculation of pediatric doses
Titration of IV drips
Eye/ear installations
Metered dose inhaler
Intravenous medications (IV)
Subcutaneous injections (SQ)
Z track injections
Knowledge of emergency drug action and reaction
Pediatric drug action and reaction

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	No Experience	Limited Experience	Experienced	Highly Skilled
Auscultation (rate, rhythm, volume)
Blood pressure/invasive (arterial line)
Heart sounds/murmers
Perfusion
Central venous pressure

	No Experience	Limited Experience	Experienced	Highly Skilled
Interpretation of lab results - CBC/electrolytes
Defibrillation/cardioversion
EKG interpretation (basic & advanced)

	No Experience	Limited Experience	Experienced	Highly Skilled
Assist with intubation
Assist with extubation

	No Experience	Limited Experience	Experienced	Highly Skilled
Insertion
Removal
ECMO (Extracorporeal Membrane Oxygenation)
End Tidal CO2