Items in red are REQUIRED fields.
Personal Information:
First Name:
Middle Initial:
Last Name:
Address:
City:
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E-mail Address:
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
(d) Pulses/Circulation checks
2. Interpretation of Lab Results
(a) Cardiac Enzymes/Isoenzymes
(b) Coagulation studies
3. Equipment & Procedures
(a) Monitotring/Telemetry
(1) Arrhythmia interpretation
(2) Basic 12 lead interpretation
(3) Lead placement: 5 electrode telemetry
(4) Lead placement: I, III, V-leads
(5) Lead placement: Lead II and MCL1
(b) Pacemaker
(1) Permanent
(2) Temporary epocardial wires
(3) Temporary external placement
(4) Temporary transvenous
(c) Assist With
(1) Arterial line insertion
(2) Central line insertion
(d) Hemodynamic Monitoring
(1) A-line (radial)
(2) CVP monitoring
(3) Femoral artery sheath removal
(4) Swan-Ganz
(e) Perform
(1) Controlled cardioversion
(2) Emergency defibrillation
(3) Cardiopulmonary resuscitation (CPR)
4. Care of the Patient With:
(a) Abdominal aortic bypass
(b) Aneurysm
(c) Angina
(d) Cardiac arrest
(e) Cardiomyopathy
(f) Carotid endarterectomy
(g) Congestive heart failure (CHF)
(h) Femoral-popliteal bypass
(i) Post acute MI (24-48 hours)
(j) Post angioplasty
(k) Post arthrectomy (DCA)
(l) Post CABG (24 hours)
(m) Post cardiac catheterization
(n) Post stent placement
(o) Cardiogenic shock
5. Medications
(a) Atropine
(b) Diuretics
(c) Digoxin
(d) Andrenergics
(e) Beta blockers
(f) Ca+ channel blockers
(g) Lidocaine
(h) Vasopressors
(i) Nitrates
(j) Antiarhythmics
(k) Preparation of emergency medications
(l) Oral, IV and subcutaneous anticoagulants
(m) Thrombolytic agents
B. PULMONARY
A B C D
1. Assessment
(a) Breath sounds
(b) Breathing patterns
2. Interpretation of Lab Results
(a) Arterial blood gases
(b) Blood chemistry
3. Equipment and Procedures
(a) Assist with intubation
(b) Assist with thoracentesis
(c) Care of airway management devices/suctioning
(1) Endotracheal tube/suctioning
(2) Nasal airway/suctioning
(3) Oropharyngeal/suctioning
(4) Oximetry
(5) Sputum specimen collection
(6) Tracheostomy/suctioning
(d) Care of patient on ventilator
(1) Extubation
(2) Weaning modes
(e) Care of patient with chest tube:
(1) Assist with set-up & insertion
(2) Mediastinal tube removal
(3) Pleural tube removal
(4) Use of Pleurevac or Thoraclex
(5) Use of water seal drainage system
(f) Chest physiotherapy
(g) Establishing an airway
(h) Incentive spirometry
(i) Oxygen therapy & medication delivery systems
(1) Ambu bag and mask
(2) ET tube
(3) External CPAP
(4) Face masks
(5) Inhalers
(6) Nasal cannula
(7) Portable oxygen tanks
(8) Tracheostomy
(9) Transtracheal cannulation
(j) Oral airway insertion
(k) Restraints
4. Care of the patient with:
(a) ARDS
(b) Bronchoscopy
(c) COPD
(d) Fresh trachostomy
(e) Lobectomy
(f) Pneumonectomy
(g) Pneumonia
(h) Pulmonary edema
(i) Pulmonary embolism
(j) Status asthmaticus
(k) Thoracotomy
(l) Tuberculosis
5. Meications
(a) Aminophylline
(b) Corticosteroids
(c) Atrovent
(d) Antibiotics
(e) Albuterol
C. NEUROLOGICAL
A B C D
1. Assessment
(a) Cerebellar function
(b) Cranial nerves
(c) Glasgow coma scale
(d) Level of consciousness
(e) Pathologic reflexes
2. Equipment and procedures
(a) Assist with lumbar puncture
(b) Halo traction
(c) Nerve stimulator
(d) Rotation bed
(e) Seizure precautions
(f) Use of hyper/hypothermia blanket
(g) Bed alarms
3. Care of the patient with:
(a) Aneurysm precautions
(b) Basal skull fracture
(c) Closed head injury
(d) Coma
(e) TIA/CVA
(f) DT's
(g) Encephalitis
(h) Externalized VP shunts
(i) Meningitis
(j) Multiple sclerosis
(k) Neuromuscular disease
(l) Post Craniotomy
(m) Seizures
(n) Spinal cord injury
4. Medications
(a) Dilantin
(b) Phenobarbitol
(c) Versed
(d) Lasix/Mannitol
(e) Valium
(f) Morphine sulfate
(g) Oral analgesics/narcotics
D. GASTROINTESTINAL
A B C D
1. Assessment
(a) Abdominal/bowel sounds
(b) Fluid Balance
(c) Nutritional
2. Interpretation of Blood Chemistry
3. Equipment and procedures
(a) Administration of Tube Feeding
(1) Feeding pump
(2) Gravity feeding
(b) Flexible feeding tube (Corpak, Dobhoff, etc.)
(c) Placement of nasogastric tube
(d) Salem sump to suction
(e) Saline lavage
4. Management of:
(a) Gastronomy tube
(b) Jejunostomy tube
(c) PPN (peripheral parenteral nutrition)
(d) TPN and lipids administration
(e) T-tube
5. Care of the patient with:
(a) Bowel obstruction
(b) Colostomy
(c) ERCP
(d) Esophageal bleeding
(e) GI bleeding
(f) GI surgery
(g) Hepatitis
(h) Ileostomy
(i) Inflammatory bowel disease
(j) Liver failure
(k) Liver transplant
(l) Pancreatitis
(m) Paralytic ileus
(n) Whipple procedure
(o) Pre/post open abdominal surgery
E. RENAL/GENITOURINARY
A B C D
1. Assessment
(a) A-V fistula/shunt
(b) Fluid & elctrolyte imbalance
2. Interpretation of BUN & Cretinine
3. Equipment and Procedures
(a) Foley catheter insertion
(1) Female
(2) Male
(b) Supra-pubic
(c) Bladder irrigation
(1) Continuous
(2) Intermittent
