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GENERAL SKILLS

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 *
Advanced directives123
Patient / family teaching123
Restrictive devices (restraints)123
Lift / transfer devices123
Specialty beds123
End of life care / palliative care123
Wound assessment & care123
Automated Medication Dispensing System, Pyxis, Omnicell, or other123
Bar coding for medication administration123
Diabetic care and education123
Blood Glucose Monitor (BGM)123
Cardioversion / defibrillation123
Electronic ICU123
National Patient Safety Goals123
Accurate patient identification123
Effective communication123
Interpretation & communication of lab values123
Medication administration123
Medication reconciliation123
Labeling (medications & specimens)123
Anticoagulation therapy123
Monitoring conscious sedation123
Pain assessment & management123
Infection control123
Universal precautions123
Isolation123
Minimize risk for falls123
Prevention of pressure ulcers123
Use of rapid response teams123
Awareness of HCAHPS123
CARDIOVASCULAR EXPERIENCE

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 heart sounds123
Interpretation of arrhythmias123
Performing 12 lead EKG’s123
Interpretation of 12 lead EKG123
Interpretation of hemodynamic monitoring123
ASSIST WITH INSERTION & 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 *
CVC (Central Venous Catheter)123
Arterial line123
Swanz Ganz catheter123
Flow trac or Vigileo monitoring caths123
Intra-Aortic Balloon Pump (IABP)123
Ventricular Assist Device (LVAD, RVAD)123
MAINTENANCE & 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 *
Permanent pacemakers123
Implantable Cardioverter Defibrillator (ICD)123
External pacemakers123
Epicardial pacemaker wires123
Discontinuing venous / arterial sheaths123
Femostop / vasoseal123
CARE OF PATIENTS 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 *
Acute myocardial infarction123
Pre / post: cardiac catheterization123
Congestive heart failure123
Cardiomyopathy123
Dysrhythmias / conduction disturbances123
Aortic aneurysm123
Thoracic / abdominal surgery123
Endoluminal graft123
Cardiogenic shock123
Hypertensive crisis123
Pericarditis / endocarditis123
MAZE procedure123
Post open heart (CABG / valve)123
Cardiac contusion / trauma123
Heart transplant123
Cardiac tamponade123
MEDICATION ADMINISTRATION:

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 *
ACLS medications and protocols123
Antidysrythmics123
Antihypertensives123
Vasoactive / vasopressor agents123
Anesthetics (propofol / precedex)123
Thrombolytics (retavase / activase)123
Platelet inhibitors (ReoPro / Integrilin / Aggrastat)123
Flolan for pulmonary hypertension123
PULMONARY EXPERIENCE:

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 breath sounds123
AIRWAY MANAGEMENT, CARE & MAINTENANCE 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 *
Oral / NT / ET airway123
Tracheostomy123
Arterial blood gas analysis / interpretation123
Obtaining ABG blood sample / arterial line123
Pulse oximetry123
VENTILATOR 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 *
BiPAP (Bi-level Positive Airway Pressure)123
Oscillation / high-frequency ventilation123
Nitric123
Interpretation of weaning parameters123
Maintenance & management of pleural chest tubes123
CARE OF 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 *
Acute respiratory failure123
Adult Respiratory Distress Syndrome (ARDS)123
Sudden Inflammation Respiratory Syndrome (SIRS)123
Inhalation injuries123
Pneumonia123
Pulmonary edema123
Near drowning123
Chronic Obstructive Pulmonary Disease (COPD)123
Pre / post thoracic surgery123
Pulmonary embolism123
Pulmonary / chest trauma123
Pulmonary hypertension123
Status asthmaticus123
MEDICATION ADMINISTRATION:

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 *
Rapid sequence intubation drugs / protocols123
Nebulizer treatments: Ventolin, Atrovent123
NEUROLOGY EXPERIENCE:

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 *
Cranial nerve assessment123
Glasgow coma scale123
NIH stroke scale123
NIH stroke certification123
Seizure precautions123
Skeletal traction123
Cervical spine precautions / logroll positioning123
Halo vest/halo traction123
Monitoring of neuromuscular blocking agents / paralytics123
Assist with lumbar puncture123
INTRACRANIAL/CEREBRAL PERFUSION PRESSURE MONITORING VIA:

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 *
Ventriculostomy123
Subarachnoid screw / bolt123
CARE OF PATIENTS 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 drains123
Cerebral aneurysm123
Subarachnoid hemorrhage123
Status epilepticus123
TBI (Traumatic Brain Injury)123
Spinal cord injury123
CerebroVascular Accident (CVA)123
Pre / post cranial surgery123
Meningitis123
Myasthenia gravis123
Clipping and/ or coilings of aneurysms123
Pituitary Tumor123
MEDICATION ADMINISTRATION:

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 *
Steroids: Decadron, Solu-Medrol123
Anticonvulsants: Dilantin, phenobarbital123
Paralytic Agents: Norcuron, Pavalon, Nimbex, Tracrium, vecuronium123
Mannitol123
Antipsychotics: Haldol123
TRAUMA & BURNS EXPERIENCE:

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 *
Mass casualty123
Electrocution123
Amputation123
Gangrene123
Multiple fractures123
Thermo- regulation: hypothermia / hyperthermia123
BURNS: CALCULATION OF TOTAL BODY SURFACE AREA (BSA):

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 *
Berdow Formula / “Rule of Nines”123
Lund and Browder chart123
Fluid resuscitation123
Care & management of burns123
GASTROINTESTINAL EXPERIENCE:

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 *
Small bore feeding tube insertion (Dobhoff or Keofeed)123
Nasogastric tube insertion123
Post pyloric feeding tube insertion123
Gastric lavage123
Use of activated charcoal123
Maintenance of gastric / jejunostomy tube123
Stoma care123
Maintenance & management of enteral tube feedings123
Assisting / monitoring bedside procedures: endo / chest tubes / bronchs / trach insertion / PEG tubes123
CARE OF PATIENTS 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 *
Abdominal trauma123
Acute gastrointestinal hemorrhage123
Esophageal varices123
Balloon tamponade devices (i.e. Blakemore tube)123
Peritonitis123
Acute pancreatitis123
Bowel obstruction123
Liver / pancreas transplant123
MEDICATION ADMINISTRATION:

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 *
Antiemetics: Reglan, Zofran123
H2 receptor antagonists123
RENAL EXPERIENCE:

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 *
Foley catheter insertion123
Suprapubic tube123
Nephrostomy tube123
Peritoneal dialysis123
Continuous Arteriovenous Hemofiltration (CAVHD, CVVHD, SCUF, CRRT)123
Hemodialysis of the critically ill patient123
CARE OF 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 *
Acute renal failure123
Chronic renal failure123
AV fistulas, shunts & dialysis catheters123
Nephrectomy123
Renal transplant123
Renal / urinary tract trauma123
ENDOCRINE EXPERIENCE:

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 *
Diabetic Ketoacidosis (DKA)123
Hyperosmolar Hyperglycemic Nonketotic Coma (HHNK)123
Diabetes Insipidus (DI)123
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)123
Administration & monitoring of insulin infusion123
Use of Endo tool123
INTRAVENOUS MANAGEMENT EXPERIENCE:

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 *
Starting peripheral IV’s123
Care of patient with Peripherally-Inserted Central Catheter (PICC)123
Administration / monitoring of Total Parenteral Nutrition (TPN)123
Administration of blood / blood products123
Administration of narcotics / sedatives: (fentanyl, Valium, Ativan, Versed, morphine)123
Bispectral monitoring123
TELE-ICU (ICU-E) EXPERIENCE:

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 *
Mentoring123
Communication123
Video assessment123
Utilize tele-ICU system123
Multi-tasking123
Troubleshoot equipment123
Giving directions over AV system123
Interpretation of data123
Critical thinking123
Diplomacy123
OTHER EXPERIENCE:

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 *
Drug or chemical overdose (TCA, ethanol, ASA)123
Poisoning (CO, cyanide)123
Substance abuse (ETOH, stimulants, narcotics)123
Human Immuno- deficiency Virus (HIV)123
Multisystem Organ Dysfunction Syndrome (MODS)123
Anaphylaxis123
Disseminated Intravascular Coagulation (DIC)123
Septic shock123
Cancer123
Administration of chemotherapy123
Monitoring of chemotherapy (does not initiate)123
Hyperbaric oxygenation123
Organ / tissue donation procedures123
Suicide precautions123
AGE-SPECIFIC CHECKLIST

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 *
Newborn / neonate (birth-30 days)123
Infant (31 days-1 year)123
Toddler (ages 2-3 years)123
Preschool (ages 4-5 years)123
School age (ages 6-12 years)123
Adolescent (ages 13-21 years)123
Young adult (ages 22-39 years)123
Adult (ages 40-64 years)123
Older adult (ages 65-79 years)123
Elderly (ages 80+ years)123
ATTESTATION *