Items in red are REQUIRED fields.
Personal Information:
First Name:
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Last Name:
Address:
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Years of Experience:
Directions for completing Skills Checklist:
The following is a list of equipment and/or procedures performed in rendering care to patients. Please indicate the level of experience/proficiency with each and, where applicable, the types of equipment and/or systems with which you are familiar. Use the following KEY as a guideline:
A) Theory Only/No Experience -
Didactic instruction only, no hands-on experience.
B) Limited Experience -
Knows procedure/has used equipment, but has done so infrequently or not within the last six months.
C) Moderate Experience -
Able to demonstrate equipment/procedure, performs the task/skill independently with only resource assistance needed.
D) Proficient/Competent -
Able to demonstrate/perform the task/skill proficiently without any assistance and can instruct/teach.
A. CARDIOVASCULAR
A B C D
1. Assessment
(a) Auscultation (rate, rhythm)
(b) Doppler
(c) Heart sounds/murmurs
2. Equipment & Procedures
(a) Assist with insertion and set up
(I) Arterial line
(II) Central venous line
(III) PA catheter/Swan-Ganz
(IV) Pacemaker
(b) Cardioversion
(c) Interpretation of waveforms and values
(I) A-line
(II) CVP
(d) Monitoring
(I)Basic 12 lead interpretation
(II) Basic arryhthmia interpretation
3. Care of patient with
(a) Acute MI
(b) Aneurysm
(c) Angina
(d) Cardiac arrest
(e) Congestive heart failure (CHF)
(f) Myocarditis
4. Medications
(a) ACLS drugs
(I) Atropine
(II) Bretylium (Bretylol)
(III) Epinephrine (Adrenaline)
(IV) Lidocaine (Xylocaine)
(V) Procainamide (Pronestyl)
(VI) Sodium bicarbonate
(b) Other
(I) Adenosine (Adenocard)
(II) Amiodarone (Cordarone)
(III) Digoxin (Lanoxin)
(IV) Diltiazem (Cardizem)
(V) Dobutamine (Dobutex)
(VI) Dopamine (Intropin)
(VII) Esmolol (Brevibloc)
(VIII) Lasix (Furosemide)
(IX) Nitroglycerin (Tridil)
(X) Nitroprusside (Nipride)
(XI) Thrombolytic therapy
B. PULMONARY
A B C D
1. Assessment
(a) Breath sounds
(a) Rate and work of breathing
2. Interpretation of lab results
(a) Arterial blood gases
3. Equipment & procedures
(a) Airway management devices/suctioning
(I) Endotracheal tube/suctioning
(II) Nasal airway/suctioning
(III) Oropharyngeal/suctioning
(IV) Sputum specimin collection
(V) Tracheostomy/suctioning
(b) Assist with extubation
(c) Assist with intubation
(d) Assist with thoracentesis
(e) Care of the patient on a ventilator
(f) Care of the patient with a chest tube
(I)Assist with set up & insertion
(II) Measuring
(III) Removal
(g) Measure peak flow
(h) Obtaining arterial blood gases
(I) Arterial line
(II) Femoral artery
(III) Radial artery
(i) O2 therapy and medication delivery systems
(I) Bag & mask
(II) ET tube
(III) External CPAP
(IV) Face masks
(V) Inhalers
(VI) Nasal cannula
(VII) Nebulizer
(VIII) Portable O2 tank
(IX) T-piece
(X) Trach collar
(j) Pulse oximetry
(k) Trouble shooting high pressure alarms
(l) Trouble shooting low pressure alarms
4. Care of the patient with
(a) Aspiration
(b) COPD
(c) Hemopneumothorax
(d) Laryngospasm
(e) Pneumonia
(f) Pneumothorax
(g) Pulmonary edema
(h) Pulmonary embolism
(i) Tension pneumothorax
(j) Tuberculosis
5. Medications
(a) Aminophylline (Theophylline)
(b) Bronkosol (Isoetharine hydrochloride)
(c) Epinepherine (Adrenaline)
(d) Isuprel (Isoproterenol hydrochloride)
(e) Steroids
(f) Terbulaline
C. NEUROLOGICAL
A B C D
1. Assessment
(a) Advanced neuro assessment
(I) Glasgow coma scale
(II) Reflex motor deficits
(III) Visual or communications deficits
(b) Level of consciousness
2. Equipment & procedures
(a) Assist with lumbar puncture
(b) Increased ICP management
(I) Medications
(II) Positioning
(III) Regulation of ICP
(IV) Temperature control
(V) Ventilation
(c) Intracranial pressure monitoring
3. Care of the patient with
(a) Basal skull fracture
(b) Closed head injury
(c) CVA
(d) DTs
(e) Encephalitis
(f) Externalized VP shunts
(g) Meningitis
(h) Neuromuscular disease
(i) Overdose
(j) Seizures
(k) Spinal cord injury
4. Medications
(a) Decadron (Dexamethasone)
(b) Dilantin (Phenytoin)
(c) Mannitol (Osmitrol)
(d) Phenobarbital
(e) Solu-medrol (Methylprednisolone sodium succinate)
D. ORTHOPEDICS
A B C D
1. Assessment
(a) Circulation checks
(b) Galt
(c) Range of motion
(d) Skin
2. Equipment & Procedures
(a) Assist with placement of cast
(b) Support devices
(I) Cane/crutch
(II) Cervical collar
(III) Sling
(IV) Transfer boards
3. Care of the patient with
(a) Ankle brace
(b) Ankle splint
(c) Range of motion
(d) Cast
(e) Knee immobilizer
(f) Wrist splint
E. GASTROINTESTINAL
A B C D
1. Assessment
(a) Abdominal bowel sounds
(b) Fluid balance
(c) Nutritional status
2. Interpretation of blood chemistry
3. Equipment & Procedures
(a) Placement of gastroplastic tube
(b) Salem sump to suction
(c) Saline lavage
4. Care of the patient with
(a) Abdominal trauma
(b) Bowel obstruction
(c) GI bleeding
(d) Hepatitis
(e) Liver failure
5. Medications
(a) Antiemetics
(b) Antispasmotic
(c) Charcoal
(d) Urinary tract infection
F. RENAL/GENITOURINARY
A B C D
1. Assessment - fluid balance
2. Interpretation of lab results
(a) BUN & creatine
(b) Electrolytes
3. Equipment & Procedures
(a) Insertion and care of straight and Foley catheter
(I) Female
(II) Male
(b) Urine specimen collection
4. Care of the patient with
(a) Acute renal failure
(b) Peritoneal lavage
(c) Renal trauma
(d) Urinary tract infection
G. ENDOCRINE/METABOLIC
A B C D
1. Assessment
(a) S/S diabetic coma
(b) S/S insulin reation
2. Equipment & Procedures
(a) Blood glucose monitoring
(I) Electronic measuring device
(II) Performing finger stick
3. Care of the patient with
(a) Diabetic ketoacidosis
4. Medications
(a) Insulin
(b) Oral hypoglycemics
H. WOUND MANAGEMENT/SURGICAL
A B C D
1. Equipment & Procedures
(a) Application of steristrips
(b) Assist with staples
(c) Assiste with sutures
(d) Culdocentesis tray
(e) Set up suture tray
(f) Staple removal
(g) Suture removal
I. EENT
A B C D
1. Assessment
(a) Set up fluorescent/Woods lamp exam
