General Patient Care
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Admission |
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Advanced Directives |
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Charge Nurse Experience |
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Collect Appropriate Data |
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Discharge Teaching |
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Organ/Tissue Donation |
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Patient and Family Teaching |
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Cardiac
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Abnormal Heart Sounds/Murmurs |
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Apical Pulse |
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Auscultation (Rate/Rhythm) |
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Capillary Refill |
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Color |
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Pulses/Circulation Checks |
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Abdominal Aortic |
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Aneurysm |
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Acute MI |
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Angina |
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Cardiac Tamponade |
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Cardiac Teaching |
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Cardiomyopathy |
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Cardiopulmonary Arrest |
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Carotid Endarterectomy |
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Congestive Heart Failure |
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Endocarditis |
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EP Study & Ablation |
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Femoral Popliteal Bypass |
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Heart Transplant |
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Hypertension |
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Hypovolemic Shock |
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Multi-System Organ Failure |
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Myocardial Contusion |
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Pacemaker-External |
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Pacemaker-Permanent |
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Pacemaker-Temporary |
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Pacemaker-Transthoracic (Epicardial) |
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Pericarditis |
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Post AICD Insertion |
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Pre/Post Cardiac Cath |
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Pre/Post Cardiac Surgery |
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Pre/Post PTCA/Stents |
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Valve Replacement |
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Pulmonary
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Adventitious Breath Sounds |
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Assess Lung Sounds |
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Oxygenation Status |
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Rate and Work of Breathing |
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Acute Pneumonia |
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ARDS |
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Asthma |
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Chest Trauma |
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Chest Tube |
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COPD |
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Inhalation Injuries |
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Neurological
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Glasgow Coma Scale |
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Level of Consciousness |
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Reflex/Motor Deficits |
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Visual/Communication Deficits |
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Acute Head Injury |
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Alzheimer’s Disease |
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CNS Infection |
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Coma |
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CVA |
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DTS |
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Encephalitis |
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Halo Traction/Cervical Tongs |
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Increased ICP |
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Gastrointestinal
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Bowel Sounds |
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Colostomy Care |
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G.I. Assessment |
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Abdominal Wounds and Surgeries |
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Blunt Trauma |
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Bowel Obstruction |
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Colostomy |
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Esophageal Bleeding |
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GI Bleeding Hepatitis |
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Ileostomy |
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Inflammatory Bowel Diseases |
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Jejunostomy Tube |
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Liver Cancer |
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Liver Failure |
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Renal/Genitourinary
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Skin Tugor |
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Acute Renal Failure |
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End Stage Renal Disease |
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Hemodialysis |
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Nephrectomy |
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Nephrostomy Tube |
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Peritoneal Dialysis |
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Renal Transplant |
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Suprapubic Cath |
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V Fistula/Shunt |
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Fluid Balance Monitoring |
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Measurement I & O Monitoring |
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Bun & Creatinine Lab |
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Serum Electrolytes Lab |
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Endocrine/Metabolic
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Diabetic |
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Diabetic Ketoacidosis |
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Drug Overdoes |
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Insulin Shock |
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Blood Glucose Lab |
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Thyroid Studies Lab |
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Musculoskeletal
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Cast Care |
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Circulation/Pulse Checks |
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Amputation |
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External Fixation |
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Joint Replacements |
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Multiple Trauma |
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Paraplegia |
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Rheumatoid Arthritic Disease |
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Immunology/Hematology/Oncology
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Rating Stars (Click)
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Blood Transfusions |
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Acute Leukemia |
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Cancer |
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Disseminated Intravascular Coagulation |
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HIV/Aids |
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Treatment Side Effects Chemo/Radiation |
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Sepsis |
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Hematology Lab |
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Wounds/Integument
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S/S Infection Assessment |
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Skin Assessment |
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Burns |
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Staged Decubitus Ulcers |
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Stasis Ulcers |
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Surgical Wounds with Drains |
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Skin Breakdown Monitoring |
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Medications Administration
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Administer IM and SQ Meds |
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Administer PO Medications |
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Bladder Irrigation and Instillation |
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Needleless Systems |
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IV Therapy
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Assess/Maintain IV Insertion Site |
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PICCS |
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Inserting IVs |
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Multi-Lumen Central Venous Catheters |
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Blood
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Administer Blood/Blood Products |
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Albumin |
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Nutritional Therapy
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Rating Stars (Click)
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Dobhoff Insertion |
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Enteral Administration |
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Gravity/Bolus Tube Feedings |
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J-Tube |
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NGT Insertion |
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PEG |
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TPN and Hyperalimentation |
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Oxygen Administration
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Ambu-Bag |
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Nasal Cannula |
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Nebulizer Treatments |
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Non-Rebreather Mask |
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Portable Oxygen |
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Tracheostomy Tube |
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Venti Mask |
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Pain Management
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Rating Stars (Click)
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Assess Pain Level/Tolerance |
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Epidural Anesthesia/Analgesia |
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Moderate Sedation |
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Patient Controlled Analgesia |
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Ramsey Scale |
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Procedures/Equipment
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Chest Tube Drainage Systems |
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Doppler |
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Drains (JP-Hemovac-Penrose) |
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Dressing Changes |
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Establish/Protect Airway |
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Femoral Artery Sheath Removal |
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Foley |
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Hyper/hypothermia Blanket |
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Incentive Spirometry |
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Isolation |
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Specialty Beds |
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Sterile Dressing Changes |
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Suction (ET-Oral-Trach-Nasal) |
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Universal Precautions |
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Wound Care/Irrigations |
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Wound Vac |
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Specimen Collection |
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Age Specific Practice Criteria
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Newborn/Neonate (birth - 30 days) |
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Infant (30 days - 1 year) |
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Toddler (1 - 3 years) |
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Preschooler (3 - 5 years) |
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School age children (5 - 12 years) |
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Adolescents (12 - 18 years) |
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Young adults (18 - 39 years) |
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Middle adults (39 - 64 years) |
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Older adults (64+ years) |
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Critical Care Settings
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Interventional Unit |
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PCU |
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Stepdown |
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Tele |
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EMR
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AllScripts |
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ARIA |
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Canopy |
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Epic |
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Cerner |
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Eclipsys |
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McKesson |
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Meditech Other Computerized System |
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Computerized Physician Order Entry |
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EMR Conversion |
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Bar Coding for Medication Administration |
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