Age of Patients Cared ForNewborn/Neonate (birth to 30 days)* 1 2 3 4 Infant (1 month to 1 year)* 1 2 3 4 Toddler (1 year to 3 years)* 1 2 3 4 Preschooler (3 years to 5 years)* 1 2 3 4 School Age Child (5 years to 12 years)* 1 2 3 4 Adolescents (12 years to 18 years)* 1 2 3 4 Young Adults (18 years to 39 years)* 1 2 3 4 Middle Adults (39 years to 64 years)* 1 2 3 4 Older Adults (64 years to 79 years)* 1 2 3 4 Elderly Adults (over 79+ years)* 1 2 3 4 General SkillsStandard Precautions* 1 2 3 4 Isolation Precautions* 1 2 3 4 Pediatric Respiratory/Cardiac Arrest* 1 2 3 4 Adult Respiratory/Cardiac Arrest* 1 2 3 4 Crash Carts* 1 2 3 4 Defibrillators* 1 2 3 4 Patient and Family Education* 1 2 3 4 Electronic Documentation* 1 2 3 4 List Types:Managing Food-Drug Interactions* 1 2 3 4 Managing Food-Drug Timing* 1 2 3 4 Managing Nutrition Therapy Complications* 1 2 3 4 Assessment/Patient CareDevelop Plan of Treatment* 1 2 3 4 Document Refusal of Care* 1 2 3 4 Document Non-Compliance* 1 2 3 4 Determine Usual or Adjusted Body Weight* 1 2 3 4 Determine Energy Requirements* 1 2 3 4 Determine Protein Requirements* 1 2 3 4 Determine Fluid Requirements* 1 2 3 4 Determine Electrolyte Requirements* 1 2 3 4 Determine Fat Requirements* 1 2 3 4 Determine Micronutrient Requirements* 1 2 3 4 Perform Nutrition Education* 1 2 3 4 Perform Nutrition Assessments* 1 2 3 4 Nutrition StatusClinic Malnutrition* 1 2 3 4 Poor Diet* 1 2 3 4 Eating Difficulties* 1 2 3 4 Marginal Malnutrition* 1 2 3 4 Metabolic Demands* 1 2 3 4 Nutrient Deficiencies* 1 2 3 4 Assess Fluid Status* 1 2 3 4 Kwashiorkor* 1 2 3 4 Marasmus* 1 2 3 4 Cachexia* 1 2 3 4 Protein Calorie Malnutrition* 1 2 3 4 Conditions/Diseases Affecting NutritionAbdominal Wounds and Surgeries* 1 2 3 4 Abnormal Bleeding* 1 2 3 4 Acute MI* 1 2 3 4 Acute Renal Failure* 1 2 3 4 Alzheimer's Disease* 1 2 3 4 Anorexia Nervosa* 1 2 3 4 Aspiration* 1 2 3 4 Bulimia* 1 2 3 4 Cancer* 1 2 3 4 Chronic Diarrhea* 1 2 3 4 Coma* 1 2 3 4 Congenital Heart Defects* 1 2 3 4 Congestive Heart Failure* 1 2 3 4 COPD* 1 2 3 4 CVA* 1 2 3 4 Decubitus* 1 2 3 4 Depression* 1 2 3 4 Diabetes* 1 2 3 4 Diabetic Ketoacidosis* 1 2 3 4 Draining Abscesses* 1 2 3 4 Draining Wounds* 1 2 3 4 Drug Overdose* 1 2 3 4 Dysphagia* 1 2 3 4 Elevated Cholesterol/Triglycerides* 1 2 3 4 End Stage Renal Disease* 1 2 3 4 Epiglottitis* 1 2 3 4 Excessive Alcohol Intake* 1 2 3 4 Extensive Burns* 1 2 3 4 Failure to Thrive* 1 2 3 4 Fever* 1 2 3 4 Fistulae* 1 2 3 4 Hemodialysis* 1 2 3 4 Hepatitis* 1 2 3 4 HIV/AIDS* 1 2 3 4 Homelessness/Limited Access to Food* 1 2 3 4 Hyperemesis* 1 2 3 4 Infection* 1 2 3 4 Inflammatory Bowel Disease* 1 2 3 4 Liver Failure* 1 2 3 4 Low Blood Sugar* 1 2 3 4 Major Surgery* 1 2 3 4 Malabsorption Syndromes* 1 2 3 4 Morbid Obesity* 1 2 3 4 Mucositis* 1 2 3 4 Pancreatitis* 1 2 3 4 Peritoneal Dialysis* 1 2 3 4 Post-Op Gastric Stapling/Gastric Bypass* 1 2 3 4 Pregnancy* 1 2 3 4 Protracted Emesis* 1 2 3 4 Radiation* 1 2 3 4 RDS* 1 2 3 4 Refeeding Syndrome* 1 2 3 4 Renal Transplants* 1 2 3 4 Sepsis* 1 2 3 4 Short Gut Syndrome* 1 2 3 4 Sickle Cell Anemia* 1 2 3 4 Status Asthmaticus* 1 2 3 4 Stomatitis* 1 2 3 4 Transplants* 1 2 3 4 Trauma* 1 2 3 4 Tuberculosis* 1 2 3 4 Vented Patient* 1 2 3 4 Wounds* 1 2 3 4 Medication Affecting NutritionSteroids* 1 2 3 4 Immunosuppressants* 1 2 3 4 Antineoplastics* 1 2 3 4 Insulin* 1 2 3 4 Diuretics* 1 2 3 4 Blood Thinners* 1 2 3 4 Laxatives* 1 2 3 4 Lab MonitoringLFT's* 1 2 3 4 Serum Ammonia* 1 2 3 4 Serum Amylase* 1 2 3 4 Cholesterol* 1 2 3 4 BUN* 1 2 3 4 Serum Electrolytes* 1 2 3 4 Blood Glucose* 1 2 3 4 Hematology* 1 2 3 4 Creatinine* 1 2 3 4 Albumin* 1 2 3 4 Pre-Albumin* 1 2 3 4 C-Reactive Proteins* 1 2 3 4 Nitrogen Balance* 1 2 3 4 Acid/Base Balance* 1 2 3 4 Protein-Energy Balance* 1 2 3 4 Vitamins and Minerals* 1 2 3 4 Managing Nutrition TherapyOral Diets* 1 2 3 4 Enteral Nutrition* 1 2 3 4 Parenteral Nutrition* 1 2 3 4 Writing Orders for Nutrition* 1 2 3 4 Intake and Output* 1 2 3 4 Fluid Balanace* 1 2 3 4 Calorie Counts* 1 2 3 4 Small Bowel Feeding Tubes* 1 2 3 4 Gastrostomy Tubes* 1 2 3 4 Jejunostomy Tubes* 1 2 3 4 SettingsHospital* 1 2 3 4 Clinic* 1 2 3 4 Long Term Care* 1 2 3 4 Retirement Center* 1 2 3 4 Hospice* 1 2 3 4 Home Health* 1 2 3 4 Research* 1 2 3 4 Daycare* 1 2 3 4 Correctional Facility* 1 2 3 4 Restaurant* 1 2 3 4 Public Health* 1 2 3 4 Community Programs* 1 2 3 4 CertificationsRD/RDNYesYesNoOther SkillsList Types:Application Agreement* I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form.** I hereby consent to allow CrossMed Healthcare Staffing Solutions to release these skills checklist to the client facilities.*Name* First Last Email* Phone*TODAY'S DATE* MM slash DD slash YYYY
