PPR Healthcare Staffing, Inc.
333 1st. St. North -- Suite 200
Jacksonville Beach, FL 32250
Fax:(888)794-5038

GENERAL NURSING SKILLS AND AGE SPECIFIC EXPERIENCES
Name:   Date:  
Instructions: Use the following Answer Key to indicate the extent of your previous experience:
Key - for each box mark:   1 - Limited or no experience, 2 - Somewhat experienced but may need review,
    3 - Can function independently, 4 - Competent to supervise
  1     2     3     4     1     2     3     4
General Nursing Skills   |   Care of Patient with  
IV Therapy   |     Epidural Anesthesia/Analgesia
  Line Insertion/Maintenance   |     IV Conscious Sedation
      Angiocath/Intracath |     PCA pump
      Butterfly | Wound Care/Infectious  
      Heparin Lock | Disease Management  
    Hang Piggyback |   Procedures  
    IV Push |     Collection of Cultures  
    PICC |       Blood
  Blood/Blood Products   |       Sputum
    Administration   |       Stool
      Whole Blood/Packed Cells |       Wound
      Plasma/Extenders |       CSF
      Lipids/Albumin |     Universal Precautions
    Drawing Blood |     Isolation/Reverse Isolation Technique
Medication Administration   |     Infectious Disease Reporting
  Administration Routes   |     Fever Management
    Parenteral   |     Sterile Dressings
      IV |     Decubitus Care
      IM | Other Basic Nursing Skills  
      ID |     Cardioversion/Defibrillation
      Subcutaneous |     Basic 12 Lead Placement  
    Oral |       and Interpretation
    Topical |     Insertion and Care of  
    Rectal |       Urinary Catheters
  Calculation   |     Feeding tubes/G-tubes
    IV Rate Calculation |     Feeding Pumps
    IV Pump |     Glucose Monitoring
    Dosage Calculation |     Oximetry
    Unit Dose System | Documentation  
Pain Management   |     Computer Charting System
  Assessment   |     Multipage Charting Form
    Pain Scales |     Nursing Plan of Care Documentation
    Pain Tolerance |

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2
AGE SPECIFIC EXPERIENCES AND CERTIFICATIONS
Key - for each box mark:   1 - Limited knowledge and experience, 2 - Some knowledge and experience,
    3 - Very knowledgeable and experienced, 4 - Extremely knowledgeable and experienced

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.

My experience is primarily in (Please indicate number of years):

Medical year(s)   Neurology year(s)
Surgical year(s)   Pulmonary year(s)
Telemetry year(s)   Renal/GU year(s)
Orthopedics year(s)   Women's year(s)
Oncology year(s)   Other year(s)
Certifications
BCLS Expiration Date (mm/yyyy)
ACLS 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 PPR to release this information to client facilities of PPR in relation to consideration of my employment to those facilities.
 



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