Dialysis Skills Checklist

First name:	Last name:
Phone:	Email:
SSN (last 4 only):	Date: (MM/DD/YYYY)

Key - for each box mark:

Limited or no experience
Somewhat experienced but may need review
Can function independently
Competent to supervise

	1	2	3	4
RENAL/GENITOURINARY
Assessment of Renal / GU System
Insertion of foley
Care of the Patient With:
Nephrostomy tube
AV Fistula/ AV Graft
Tunneled/Non-Tunneled Catheter
Ileal Conduit
Supra-Pubic Catheter
Chronic Renal Failure
Acute Renal Failure
Nephrectomy
Turp
Peritoneal Dialysis
Hemodialysis
HEMODIALYSIS SKILLS/PROCEDURES
Experience
Acute/Inpatient Dialysis
Chronic/Outpatient Dialysis
Dialysis Home Care
Pediatric Dialysis
Predialysis Nursing Assessment
Teaching the Dialysis Patient and Family
Set Up/Initiate Dialysis
Bicarbonate Dialysate
Conductivity Testing
Priming Dialyzer
Checks for Machine/Alarm Settings
Prep Vascular Access
Fistula Gortex/Bovine Graft
Dialysis
Collect Blood Specimens
Anticoagulation
Assess Patient and Equipment During Dialysis
Systems Assessment of Patient
Volume Status
Vascular Access Function
Arterial and Venous Pressures
Blood Flow Rate
Subjective Response to Treatment
Management of Anticoagulation
Conductivity
Ultrafiltration Calculation
Operation of Myron L. Meter
Administration of Blood and Blood Products
Administration of Mannitol
Sequential Ultrafiltration/PUF
Documentation of Dialysis Treatment

	1	2	3	4
Management of the Patient With:
Fluid Overload
Hypertension
Hypotension
Disequilibrium syndrome
Hyperkalemia
Seizures
Muscle Cramps
Clotted Access/Poor Blood Flow Rate From Catheter
Pyrogenic Reaction
Hemolysis
Air Embolus
Chest Pain
Anemia
Neuropathy
Pericarditis
Filter Blood Leak
Cardiopulmonary Arrest
Machine Alarm Troubleshooting Procedures
Blood Leak Alarm
Arterial Pressure Alarm
Venous Pressure Alarm
Conductivity Alarm
Ultrafiltration Alarm
High Temperature Alarm
Air/Foam Detector Alarm
Power Failure Alarm
Blood Pump Alarm
Discontinue Dialysis
Dialysis Catheter
Fistula/ Vein Graft
Return of Blood
Post Treatment Access Care
Equipment Clean Up
Sterilization Procedures
EQUIPMENT
Cycler
Althin
Baxter
Cobe
Fresenius H K
Phoenix
Braun

Age Specific Experiences and Certifications

Age Specific Experiences	Infants and Toddlers (birth-2 years)	Children (3-12 years)	Adolescent (13-18 years)	Young Adult (19-39 years)	Middle Adults (40-64 years)	Older Adult (65+ years)
1. Knows the normal growth and development for each age group and adapts care accordingly.
2. Knows the different communication needs for each age group and changes communication methods and terminology accordingly.
3. Knows the different safety risks for each age group and alters the environment accordingly.
4. Knows the different medications, dosages, and possible side effects for each age group and administers medications accordingly.

Certifications

Arrhythmia Course:	Expiration Date (mm/yyyy)
Critical Care Course:	Expiration Date (mm/yyyy)
Computerized charting system:	Expiration Date (mm/yyyy)
Medication administration system:	Expiration Date (mm/yyyy)
ACLS	Expiration Date (mm/yyyy)
BCLS	Expiration Date (mm/yyyy)
BTLS	Expiration Date (mm/yyyy)
CCRN	Expiration Date (mm/yyyy)
CNRN	Expiration Date (mm/yyyy)
TNCC	Expiration Date (mm/yyyy)
Other:	Expiration Date (mm/yyyy)

The information I have provided in this skills checklist is true and accurate to the best of my knowledge. I hereby authorize Fortus Group to release this information to client facilities in relation to consideration of my employment.