Dialysis RN Skills Checklist           

 
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This profile is for use by Dialysis RN nurses with more than one year experience in their discipline and specialty. 

Please enter your full legal name as it appears on your Social Security Card.

First name*

_______________________________________
Last name*

__________________________

Social Security number

______ - ______ - ______ 

 Date

______ / ______ / ______

 

Email: _________________________________________
Please indicate your level of experience by checking the applicable box below.
A. Theory, no practice C. One - two years experience
B. Intermittent experience D. Two plus years experience
A. RENAL/GENITOURINARY
    1. Assessment of Renal / GU System | A |     | B |     | C |     | D |
    2. Insertion of foley | A |     | B |     | C |     | D |
    3. Care of the Patient With:  
        a. Nephrostomy tube | A |     | B |     | C |     | D |
        b. AV Fistula/ AV Graft | A |     | B |     | C |     | D |
        c. Tunneled/Non-Tunneled Catheter | A |     | B |     | C |     | D |
        d. Ileal Conduit | A |     | B |     | C |     | D |
        e. Supra-Pubic Catheter | A |     | B |     | C |     | D |
        f. Chronic Renal Failure | A |     | B |     | C |     | D |
        g. Acute Renal Failure | A |     | B |     | C |     | D |
        h. Nephrectomy | A |     | B |     | C |     | D |
        i. Turp | A |     | B |     | C |     | D |
        j. Peritoneal Dialysis | A |     | B |     | C |     | D |
        k. Hemodialysis | A |     | B |     | C |     | D |

B. HEMODIALYSIS SKILLS/PROCEDURES
    1. Experience  
        a. Acute/Inpatient Dialysis | A |     | B |     | C |     | D |
        b. Chronic/Outpatient Dialysis | A |     | B |     | C |     | D |
        c. Dialysis Home Care | A |     | B |     | C |     | D |
        d. Pediatric Dialysis | A |     | B |     | C |     | D |
        e. Predialysis Nursing Assessment | A |     | B |     | C |     | D |
        f. Teaching the Dialysis Patient and Family | A |     | B |     | C |     | D |
    2. Set Up/Initiate Dialysis Treatment  
        a. Bicarbonate Dialysate | A |     | B |     | C |     | D |
        b. Conductivity Testing | A |     | B |     | C |     | D |
        c. Priming Dialyzer | A |     | B |     | C |     | D |
        d. Checks for Machine/Alarm Settings | A |     | B |     | C |     | D |
        e. Prep Vascular Access | A |     | B |     | C |     | D |
        f. Fistula Gortex/Bovine Graft | A |     | B |     | C |     | D |
        g. Dialysis | A |     | B |     | C |     | D |
        h. Collect Blood Specimens | A |     | B |     | C |     | D |
        i. Anticoagulation | A |     | B |     | C |     | D |
    3. Assess Patient and Equipment During Dialysis  
        a. Systems Assessment of Patient | A |     | B |     | C |     | D |
        b. Volume Status | A |     | B |     | C |     | D |
        c. Vascular Access Function | A |     | B |     | C |     | D |
        d. Arterial and Venous Pressures | A |     | B |     | C |     | D |
        e. Blood Flow Rate | A |     | B |     | C |     | D |
        f. Subjective Response to Treatment | A |     | B |     | C |     | D |
        g. Management of Anticoagulation | A |     | B |     | C |     | D |
        h. Conductivity | A |     | B |     | C |     | D |
        i. Ultrafiltration Calculation | A |     | B |     | C |     | D |
        j. Operation of Myron L. Meter | A |     | B |     | C |     | D |
        k. Administration of Blood and Blood Products | A |     | B |     | C |     | D |
        l. Administration of Mannitol | A |     | B |     | C |     | D |
        m. Sequential Ultrafiltration/PUF | A |     | B |     | C |     | D |
        n. Documentation of Dialysis Treatment | A |     | B |     | C |     | D |
    4. Management of the Patient With:  
        a. Fluid Overload | A |     | B |     | C |     | D |
        b. Hypertension | A |     | B |     | C |     | D |
        c. Hypotension | A |     | B |     | C |     | D |
        d. Disequilibrium syndrome | A |     | B |     | C |     | D |
        e. Hyperkalemia | A |     | B |     | C |     | D |
        f. Seizures | A |     | B |     | C |     | D |
        g. Muscle Cramps | A |     | B |     | C |     | D |
        h. Clotted Access/Poor Blood Flow Rate From
            Catheter 		| A |     | B |     | C |     | D |
        i. Pyrogenic Reaction | A |     | B |     | C |     | D |
        j. Hemolysis | A |     | B |     | C |     | D |
        k. Air Embolus | A |     | B |     | C |     | D |
        l. Chest Pain | A |     | B |     | C |     | D |
        m. Anemia | A |     | B |     | C |     | D |
        n. Neuropathy | A |     | B |     | C |     | D |
        o. Pericarditis | A |     | B |     | C |     | D |
        p. Filter Blood Leak | A |     | B |     | C |     | D |
        q. Cardiopulmonary Arrest | A |     | B |     | C |     | D |
    5. Machine Alarm Troubleshooting Procedures  
        a. Blood Leak Alarm | A |     | B |     | C |     | D |
        b. Arterial Pressure Alarm | A |     | B |     | C |     | D |
        c. Venous Pressure Alarm | A |     | B |     | C |     | D |
        d. Conductivity Alarm | A |     | B |     | C |     | D |
        e. Ultrafiltration Alarm | A |     | B |     | C |     | D |
        f. High Temperature Alarm | A |     | B |     | C |     | D |
        g. Air/Foam Detector Alarm | A |     | B |     | C |     | D |
        h. Power Failure Alarm | A |     | B |     | C |     | D |
        i. Blood Pump Alarm | A |     | B |     | C |     | D |
    6. Discontinue Dialysis  
        a. Dialysis Catheter | A |     | B |     | C |     | D |
        b. Fistula/ Vein Graft | A |     | B |     | C |     | D |
        c. Return of Blood | A |     | B |     | C |     | D |
        d. Post Treatment Access Care | A |     | B |     | C |     | D |
        e. Equipment Clean Up | A |     | B |     | C |     | D |
        f. Sterilization Procedures | A |     | B |     | C |     | D |

AGE SPECIFIC PRACTICE CRITERIA
Please check the boxes below for each age group for which you have expertise in providing age-appropriate nursing care.

A. Newborn/Neonate (birth - 30 days)
F. Adolescents (12 - 18 years)
B. Infant (30 days - 1 year) G. Young adults (18 - 39 years)
C. Toddler (1 - 3 years) H. Middle adults (39 - 64 years)
D. Preschooler (3 - 5 years) I. Older adults (64+)
E. School age children (5 - 12 years)  
EXPERIENCE WITH AGE GROUPS: A B C D E F G H I
Able to adapt care to incorporate normal growth and development.
Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.
Can ensure a safe environment reflecting specific needs of various age groups.

Certification:
Please check the boxes below and indicate the expiration date for each certificate that you have. If you do not know the exact date, please use the last date of the specific month (e.g., 08/31/2003).
BCLS
Exp. date:
 _________ (mm/dd/yyyy)
BTLS
Exp. date:
 _________ (mm/dd/yyyy)
CNRN
Exp. date:
 _________ (mm/dd/yyyy)
TNCC
Exp. date:
 _________ (mm/dd/yyyy)
ACLS
Exp. date:
 _________ (mm/dd/yyyy)
CCRN
Exp. date:
 _________ (mm/dd/yyyy)
Other (type): ____________________
Exp. date:
 _________ (mm/dd/yyyy)
Computerized charting system: ____________________
Exp. date:
 _________ (mm/dd/yyyy)
Medication administration system: ____________________
Exp. date:
 _________ (mm/dd/yyyy)
Arrhythmia course: ____________________
Exp. date:
 _________ (mm/dd/yyyy)
Critical care course: ____________________
Exp. date:
 _________ (mm/dd/yyyy)

The information I have given is true and accurate to the best of my knowledge.

Signature:_______________________________ Date: _______________