Your Contact Information

Cardiovascular - Assessment:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Normal Heart Tones (i.e.: S1, S2)123
Abnormal Heart Tones (i.e.: murmur, gallop, friction rub)123
Identification of PMI (Point Maximal Intensity)123
Blood Pressure (non-invasive)123
Pulses/Circulation via palpation123
Pulses/Circulation via Doppler123
Insertion site invasive lines123
12-lead EKG interpretation123
EKG Changes for MI123
Arrhythmia interpretation123
Implement ACLS/Cardiac protocols123
S/S DVT123
Check crash cart and restock as necessary123
Cardiovascular - Provision of care for:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
AAA (Abdominal Aortic Aneurysm)123
Aortic Stenosis123
Cardiomyopathy123
Cardiac Arrest123
Cardiac Catheterization123
Carotid Endarterectomy123
Cardiac Tamponade123
CHF123
MI123
Mitral Valve Stenosis123
Myocardial contusion123
Post cardiac surgery complications123
Pericardial Window123
Post AICD Insertion123
Pericardial Effusion123
Pericarditis123
Pre/Post PTCA123
Stent Replacement123
Cardiovascular - Procedures:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Application of fem-stop to sheath site123
Application of holter monitor123
Removal of radial arterial line123
Removal of femoral sheath123
Perform venipuncture123
Obtain lab specimens from A-line123
Obtain lab specimens from Central Line123
Perform 12-lead EKG123
Proper cardiac monitor lead placement123
Cardiovascular - Management of:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Blood and blood product administration123
Blood transfusion reactions123
Cardiovascular - Hemodynamic Monitoring:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Management of Arterial Line123
Management of CVP Line123
Zero and calibration of transducers123
Assess adequate perfusion with invasive lines123
Cardiovascular - Management of Pacemakers:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Epicardial wires123
Epicardial pacing123
Transvenous pacing123
Transcutaneous pacing123
Manipulation of TPM settings123
Troubleshoot TPM settings123
Permanent Pacemaker123
Recognition of failure to sense, capture123
Cardiovascular - Assist with:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Set-Up for cardioversion123
Cardioversion123
Central line insertion123
Arterial line insertion123
Pericardiocentesis123
Transesophageal echocardiogram123
Pulmonary - Assessment:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Auscultate breath sounds123
Identify adventitious lung sounds123
Interpretation of pulse oximetry values123
Identify S/S of respiratory distress123
Identify presence of subcutaneous emphysema123
Assess capillary refill123
Pulmonary - Provision of Care:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Acute Pneumonia123
ARDS123
Bronchoscopy123
Chest Trauma123
COPD123
Cor Pulmonale123
Fresh Tracheostomy123
Lobectomy123
Pneumonectomy123
Pulmonary Edema123
Pulmonary Hypertension123
Pulmonary Embolism123
Status Asthmaticus123
Thoracotomy123
Tuberculosis123
Pulmonary - Chest Tubes:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Perform chest tube set-up123
Assist with chest tube insertion123
Monitor & record chest tube output123
Identify and troubleshoot clotted chest tube123
Identify and troubleshoot patient bleeding from chest tube123
Identify presence of air leak123
Assist with chest tube removal123
Pulmonary - Procedures:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Perform NT (Nasotracheal) suctioning123
Perform suctioning of tracheostomy123
Collection of sputum via NT suction123
O2 Masks/Cannulas123
Ambu bag123
Chest physiotherapy123
Incentive spirometry123
Nebulizer set up123
Use of pleurevac123
Pulse oximetry123
Pulmonary - Assist with:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Emergency Tracheostomy123
Emergency Intubation123
Thoracentesis123
Neurology - Assessment:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Glasgow Coma Scale123
Reflex/Motor Deficits123
Visual/Communication Deficits123
Cranial nerves123
NIH Stroke Scale (NIHSS)123
Neurology - Provision of Care:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Aneurysm precautions123
Closed head injury123
Coma123
CVA123
DT’s123
Encephalopathy123
Intracranial hemorrhage123
Seizure disorders123
Spinal cord injury123
TIA123
Neurology - Assist with:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Lumbar puncture123
Gastrointestinal - Assessment:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Bowel Sounds123
Nutritional status123
Proper N/G Tube placement123
Gastrointestinal - Provision of Care:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Bowel Obstruction123
Colostomy123
ERCP123
Esophageal Bleed123
GI Bleed123
Hepatitis123
Ileostomy123
Inflammatory Bowel Disease123
Liver Failure123
Liver Transplant123
Pancreatitis123
Paralytic Ileus123
Post GI surgery (resection, etc.)123
Gastrointestinal - Procedures:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Administration of tube feeding123
Administration of gravity feeding123
Flexible feeding tube (Dobhoff)123
Continuous suction123
Iced saline lavage123
Insertion and maintenance of N/G Tube123
Insertion and maintenance of Rectal Tube123
PPN (peripheral parenteral nutrition)123
TPN and lipids administration123
Utilization of feeding pump123
Endocrine - Provision of Care:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Diabetes mellitus123
Diabetic ketoacidosis123
Diabetes Insipidus123
Hyperthyroidism123
Hypothyroidism123
Insulin Shock123
Thyroidectomy123
Endocrine - Procedures:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Fingerstick blood glucose123
Implementation of sliding scale insulin123
Endocrine - Equipment:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Blood glucose monitoring devices123
Use of Insulin Pen123
Renal - Assessment:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
A-V Fistula/Shunt123
Fluid Status123
Renal - Provision of Care:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Acute Renal Failure123
CAVH dialysis123
CVVH dialysis123
Chronic Renal Failure123
Hemodialysis123
Nephrectomy123
Nephrostomy tube123
Peritoneal dialysis123
Urinary tract infection123
TURP123
Renal - Procedures:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Insertion and care of Male/Female indwelling urinary catheter (Foley)123
Insertion and care of suprapubic catheter123
Perform bladder irrigations123
Urine specimen collection123
Multisystem - Assessment:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Perform comprehensive multi-system assessment123
Multisystem - Provision of Care:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
AIDS123
Altered mental status123
Anaphylactic shock123
Anemia123
Cancer123
Delirium123
Dementia123
Drug Overdose123
Healthcare-acquired infection: catheter-associated urinary tract infections (CAUTI)123
Healthcare-acquired infection: central-line associated bloodstream infections (CLABSI)123
Hypovolemic shock123
Infectious diseases (MRSA, VRE, Influenza)123
Psychological disorders (anxiety, depression)123
Sepsis/septic shock123
Substance abuse123
Multisystem - Pain Management:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Assessment of pain level123
Assessment of therapeutic response123
Multisystem - Care of the patient with:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Broviac Catheter123
Groshong Catheter123
Hickman Catheter123
PICC Line123
Port-A-Cath123
Quinton Catheter123
Multisystem - Procedures:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Insert and manage peripheral IV123
Perform central line dressing changes123
Perform PICC line dressing changes123
Integumentary - Assess for:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Skin intact123
Stasis ulcers123
Surgical wound healing123
Integumentary - Provision of Care:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Burns123
Pressure sores123
Staged decubitus ulcers123
Surgical wounds w/drains123
Traumatic wounds123
Integumentary - Procedures:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Sterile dressing changes123
Wound care/irrigations123
Integumentary - Equipment:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Air fluidized, low airloss beds123
Labs - Interpretation of:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
ABG's123
BUN/Creatinine123
Coagulation Studies123
Electrolytes123
Cardiac Enzymes123
Blood glucose123
Thyroid Panel123
Cardiac Progressive Care Pharmacology - Provision of Care:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Perform & manage dosage drip calculations123
Assess for therapeutic response123
Manage & titrate multiple drips123
Continuous Subcutaneous Infusion Pumps123
Assess and manage PCA Pumps123
Perform and manage IV conscious sedation123
Administer appropriate reversal agents123
Management of Epidural Administration (anesthesia/analgesia)123
Cardiac Progressive Care Pharmacology - Medications:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Aminophylline (Theophylline)123
Amiodarone (Cordarone)123
Atropine123
AquaMephyton (Vitamin K)123
Apresoline123
Bretylium (Bretylol)123
Corticosteroids123
Decadron (Dexamethasone)123
Digoxin (Lanoxin)123
Dilantin (Phenytoin)123
Diltiazem (Cardizem)123
Dobutamine (Dobutrex)123
Dopamine (Intropin)123
Lasix (Furosemide)123
Epinephrine (Adrenalin)123
Esmolol (Brevibloc)123
Heparin Drip123
Inderal (Propranolol)123
Inocor (Amrinone)123
Kayexelate123
Lactulose (Cephulac)123
Levophed123
Lidocaine123
Metoprolol (Lopressor)123
Nitroglycerin (Tridil)123
Phenobarbital123
Procainamide (Pronestyl)123
Sodium Bicarbonate123
Valium (Diazepam)123
Verapamil (Calan, Isoptin, Verelan)123
Ventolin (Albuterol)123
Versed123
Patient Education:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Cardiac rehabilitation patient teaching123
Turn, cough, and deep breathing technique123
Use of incentive spirometer123
Importance of increasing mobility post-op when applicable123
Splinting technique post-op123
Patient Advocacy:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Provide care for end-of-life decisions123
Adhere to legal procedures regarding notification of organ donation provider123
Demonstrate spiritual and cultural considerations for the PCU patient123
Provide for the integration of comfort care and death with dignity123
Demonstrate effective coping skills in caring for the PCU patient123
Perform time out123
Obtain/witness informed consent123
Age Specific:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
Infant (Birth to 1 year)123
Toddler (1-3 years)123
Pre-school (3-6 years)123
School Age (6-12 years)123
Adolescent ( 12-18 years)123
Young Adult ( 18-30 years)123
Mature Adult (30-60 years)123
Elderly (>60 years)123
I certify that the information provide above accurately reflects my experience in each of the clinical areas identified within the past three years.

Professional's Signature:
clear
 +