WOUND/OSTOMY/CONTINENCE KNOWLEDGE & SKILLS CHECKLIST

DIRECTIONS: Please indicate your level of experience by

NAME:       placing a check (√) in the box. Experience level:
ID #:       1 NO EXPERIENCE
DATE:       2 MINIMAL EXPERIENCE-requires supervision/assistance
3 MODERATELY EXPERIENCED-requires initial review,
This Skills Checklist is for use by nurses with more than then performs independently
one year experience in their discipline and specialty. 4 VERY EXPERIENCED- proficient
Please be accurate with your assessment.

DESCRIPTION 1 2 3 4
DESCRIPTION 1 2 3 4 m. Debriding Ointments
VENOUS STASIS ULCER TREATMENT n. Mist Therapy
1. Compression Therapy o. Electrical Stimulation
2. Ulcer Assessment Characteristics COLOSTOMY
3. Skin Signs of Venous Stasis 1. Loop w/Rod Stoma
PERIPHERAL ARTERIAL ULCER (PAD) 2. End Stoma
1. Ankle Brachial Index 3. Mucous Fistula
2. Ulcer Assessment Characteristics 4. Double Barrel Stoma
3. Skin Signs of Diminished Circulation 5. Irrigation Procedure
OTHER WOUNDS 6. Stoma Within Incision
1. Fistulae – Pouching, Skin Care 7. Related Conditions/Surgeries
2. Drains – Management of a. Abdominoperineal Resection
3. G/J Tubes – Anchoring, Skin Care b. Rectal Cancer/Colon Cancer
WOUND CARE TREATMENT c. Diverticulitis
1. Debridement d. Colitis/Crohn’s Disease
a. Autolytic e. Pelvic Exenteration Anterior
b. Enzymatic f. Pelvic Exenteration Posterior
c. Mechanical ILEOSTOMY
d. Sharp 1. Loop w/Rod Stoma
e. Surgical CONTINENT ILEOSTOMY
2. Dressings/Treatments 1. Kock Pouch
a. Hydrogels 2. Pelvic Pouch
b. Hydrocolloids UROSTOMY
c. Silver Products 1. Catheterization for Culture and
d. Foams Sensitivity
e. Alginates 2. Related Conditions/Surgeries
f. VAC (Vacuum Assisted Closure) a. Pelvic Exenteration
g. Growth Factors b. Bladder Cancer
h. Skin Substitutes c. Neurogenic Bladder
i. Hyperbaric Oxygen Therapy d. Interstitial Cystitis
j. Culturing of Wounds CONTINENT UROSTOMY
k. Electrical Stimulation 1. Kock Pouch
l. Enzymatic Debriding Agents 2. Indiana Pouch
3. Neobladder

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 WOUND/OSTOMY/CONTINENCE KNOWLEDGE & SKILLS CHECKLIST
DESCRIPTION 1 2 3 4
2. Moisture Barriers
Name:       3. Absorbent Garments
ID #:       4. Skin Care
DESCRIPTION 1 2 3 4 CONTINENCE THERAPUTIC DEVICES
STOMAL, PERISTOMAL SKIN CONDITIONS 1. Vaginal Cones
1. Flush or Recessed Stoma 2. Penile Clamps
2. Stomal Necrosis 3. Male Urinals
3. Stomal Prolapse 4. Male External Catheters
4. Peristomal Hernia 5. Internal Urethral Inserts (Female)
5. Denuded Skin/Ulcerations 6. Catheters – Indwelling
6. Skin Infections/Fungal Infections 7. Catheters – Intermittent Self Cath and
7. Mucocutaneous Separation Teaching for
8. Hyperplasia 8. Magnetic Therapy
9. Pyoderma Gangrenosum 9. Urinary Incontinence/Bladder
10. Stoma Plane Dynamics Programs
OSTOMY EQUIPMENT 10. Fecal Incontinence/Bowel Programs
1. One-Piece/Two-Piece Appliance PEDIATRIC RELATED CONDITIONS
2. Open End, Closed End, Clip or Velcro 1. Necrotizing Enterocolitis
Closure for Pouches 2. Inflammatory Bowel Disease
3. Convex/Flexible Pouching Systems 3. Irritable Bowel Syndrome
4. Skin Barriers/Sealants 4. Meckel Diverticulum
5. Barrier Pastes/ Strips/ Rings/ Discs/ 5. Familial Adenomatous Polyposis
Washers 6. Distal Ureter or Bladder Defects
6. Wound Pouches 7. Hirschsprung’s Disease
7. Molding Kit for Custom Appliances 8. Megacolon
8. Irrigation Procedure 9. Malabsorption Syndromes
9. Single/Double Lumen Catheters for 10. Obstructive Disorders
Culture a. Spinal Cord Injury
10. Reusable Ostomy Equipment 11. Neurogenic Bladder
11. Measure for Ostomy Belts/Peristomal 12. Diaper Dermatitis
Hernia Support Belt 13. Stoma Care – Loop Stoma
CONTINENCE EVAULATION/ASSESSMENT 14. Dehydration Risks in Pediatric Patients
1. Urodynamics 15. High Output Stoma – Skin Barrier
2. Manometry Issues
3. Electromyography G/J TUBES
4. Leak Point Pressures 1. Anchoring Devices
5. Cystometrogram 2. Skin Protection for Leakage of Gastric
6. Uroflametry Contents
7. Biofeedback – Diagnostic/Treatment 3. Long Term Tubes/Skin Level Devices for
8. PNTML (Pudendal Nerve Terminal Feeding
Motor Latency) 4. Procedures for Flushing/Treatment for
9. Ultrasound Clogging
CONTINENCE SKIN CARE/CONTAINMENT OTHER
1. Skin Sealants 1. IV Infiltration Wounds
2. Incision Care
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 WOUND/OSTOMY/CONTINENCE KNOWLEDGE & SKILLS CHECKLIST

Name:      
ID #:      
OTHER (CONT)
DESCRIPTION 1 2 3 4
3. Burns
4. Bariatric Patients
5. Self-Catheterization/Teaching
6. Indwelling Catheter Care
7. Medications
8. Bowel and Bladder Training Programs
INTERPRETATION OF LAB RESULTS
1. Albumin/Total Protein
2. Obtaining Wound Cultures
3. Urine Cultures
4. Tumor Staging
5. Pathology Reports
MISCELLANEOUS
1. National Patient Safety Goals
2. Computerized Charting
a. Cerner
b. Eclipsys
c. Epic
d. McKesson
e. Meditech
f. Other:

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 WOUND/OSTOMY/CONTINENCE KNOWLEDGE & SKILLS CHECKLIST
MY EXPERIENCE IS PRIMARILY IN:
Name:      
NEUROLOGY       years
Please check the boxes below for each age group for PULMONARY       years
which you have expertise in providing age-appropriate SURGICAL       years
nursing care. MEDICAL       years
CARDIAC CARE       years
A. Newborn/Neonatal (birth – 30 days) TELEMETRY       years
B. Infant (30 days – 1 year)
C. Toddler (1 – 3 years) I HAVE CURRENT CERTIFICATIONS FOR:
D. Preschool (3 – 5 years)
E. School Age Children (5 – 12 years) TYPE EXPIRATION DATE (MM/DD/YY)
F. Adolescent (12 – 18 years) ARRHYTHMIA      
G. Young Adults (18 – 39 years) CRITICAL CARE      
H. Middle Adults (40 – 64 years) ACLS      
I. Older Adults (64 + years) BLS      
TNCC      
EXPERIENCE WITH AGE GROUPS: NRP      
1. Able to assess age appropriate behavior, motor skills PALS      
and physiological norms. NALS      
Other            
A B C D E F G H I Other            
Other            
Other            
2. Able to adapt care according to normal growth and
development. The information I have provided in this knowledge and
skills checklist it true and accurate to the best of my
A B C D E F G H I knowledge.

           
3. Able to communicate and instruct patient according to Signature (Written/Electronic) Date
their age, maturity and comprehension ability. ID #:      

A B C D E F G H I This skills checklist has been reviewed and approved by

Nicole Bloxham, RN.

4. Able to provide a safe environment according to the            

specific needs of various age groups. Signature (Written/Electronic) Date
ID #:      
A B C D E F G H I
Please return to: Northwest Nurse Staffing Company, PA
ATTN: Records Dept.
Fax: (866) 352-4338

Email: records@nns-ic.com

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