Intensive / Critical Care Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

WORK SETTING 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 *

Inpatient Acute Care Facility	123
Trauma Center	123
Academic/Teaching Facility	123
Outpatient Care Facility	123
Long term care/Skilled Nursing	123
Clinic/Ambulatory	123
Home Health Setting	123

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 directives	123
Patient / family teaching	123
Restrictive devices (restraints)	123
Lift / transfer devices	123
Specialty beds	123
End of life care / palliative care	123
Wound assessment & care	123
Automated Medication Dispensing System, Pyxis, Omnicell, or other	123
Bar coding for medication administration	123
Diabetic care and education	123
Blood Glucose Monitor (BGM)	123
Cardioversion / defibrillation	123
Electronic ICU	123
National Patient Safety Goals	123
Accurate patient identification	123
Effective communication	123
Interpretation & communication of lab values	123
Medication administration	123
Medication reconciliation	123
Labeling (medications & specimens)	123
Anticoagulation therapy	123
Monitoring conscious sedation	123
Pain assessment & management	123
Infection control	123
Universal precautions	123
Isolation	123
Minimize risk for falls	123
Prevention of pressure ulcers	123
Use of rapid response teams	123
Awareness of HCAHPS	123

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 sounds	123
Interpretation of arrhythmias	123
Performing 12 lead EKG’s	123
Interpretation of 12 lead EKG	123
Interpretation of hemodynamic monitoring	123

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 line	123
Swanz Ganz catheter	123
Flow trac or Vigileo monitoring caths	123
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 pacemakers	123
Implantable Cardioverter Defibrillator (ICD)	123
External pacemakers	123
Epicardial pacemaker wires	123
Discontinuing venous / arterial sheaths	123
Femostop / vasoseal	123

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 infarction	123
Pre / post: cardiac catheterization	123
Congestive heart failure	123
Cardiomyopathy	123
Dysrhythmias / conduction disturbances	123
Aortic aneurysm	123
Thoracic / abdominal surgery	123
Endoluminal graft	123
Cardiogenic shock	123
Hypertensive crisis	123
Pericarditis / endocarditis	123
MAZE procedure	123
Post open heart (CABG / valve)	123
Cardiac contusion / trauma	123
Heart transplant	123
Cardiac tamponade	123

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 protocols	123
Antidysrythmics	123
Antihypertensives	123
Vasoactive / vasopressor agents	123
Anesthetics (propofol / precedex)	123
Thrombolytics (retavase / activase)	123
Platelet inhibitors (ReoPro / Integrilin / Aggrastat)	123
Flolan for pulmonary hypertension	123

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 sounds

123

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 airway	123
Tracheostomy	123
Arterial blood gas analysis / interpretation	123
Obtaining ABG blood sample / arterial line	123
Pulse oximetry	123

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 ventilation	123
Nitric	123
Interpretation of weaning parameters	123
Maintenance & management of pleural chest tubes	123

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 failure	123
Adult Respiratory Distress Syndrome (ARDS)	123
Sudden Inflammation Respiratory Syndrome (SIRS)	123
Inhalation injuries	123
Pneumonia	123
Pulmonary edema	123
Near drowning	123
Chronic Obstructive Pulmonary Disease (COPD)	123
Pre / post thoracic surgery	123
Pulmonary embolism	123
Pulmonary / chest trauma	123
Pulmonary hypertension	123
Status asthmaticus	123

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 / protocols	123
Nebulizer treatments: Ventolin, Atrovent	123

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 assessment	123
Glasgow coma scale	123
NIH stroke scale	123
NIH stroke certification	123
Seizure precautions	123
Skeletal traction	123
Cervical spine precautions / logroll positioning	123
Halo vest/halo traction	123
Monitoring of neuromuscular blocking agents / paralytics	123
Assist with lumbar puncture	123

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 *

Ventriculostomy	123
Subarachnoid screw / bolt	123

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 drains	123
Cerebral aneurysm	123
Subarachnoid hemorrhage	123
Status epilepticus	123
TBI (Traumatic Brain Injury)	123
Spinal cord injury	123
CerebroVascular Accident (CVA)	123
Pre / post cranial surgery	123
Meningitis	123
Myasthenia gravis	123
Clipping and/ or coilings of aneurysms	123
Pituitary Tumor	123

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-Medrol	123
Anticonvulsants: Dilantin, phenobarbital	123
Paralytic Agents: Norcuron, Pavalon, Nimbex, Tracrium, vecuronium	123
Mannitol	123
Antipsychotics: Haldol	123

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 casualty	123
Electrocution	123
Amputation	123
Gangrene	123
Multiple fractures	123
Thermo- regulation: hypothermia / hyperthermia	123

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 chart	123
Fluid resuscitation	123
Care & management of burns	123

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 insertion	123
Post pyloric feeding tube insertion	123
Gastric lavage	123
Use of activated charcoal	123
Maintenance of gastric / jejunostomy tube	123
Stoma care	123
Maintenance & management of enteral tube feedings	123
Assisting / monitoring bedside procedures: endo / chest tubes / bronchs / trach insertion / PEG tubes	123

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 trauma	123
Acute gastrointestinal hemorrhage	123
Esophageal varices	123
Balloon tamponade devices (i.e. Blakemore tube)	123
Peritonitis	123
Acute pancreatitis	123
Bowel obstruction	123
Liver / pancreas transplant	123

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, Zofran	123
H2 receptor antagonists	123

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 insertion	123
Suprapubic tube	123
Nephrostomy tube	123
Peritoneal dialysis	123
Continuous Arteriovenous Hemofiltration (CAVHD, CVVHD, SCUF, CRRT)	123
Hemodialysis of the critically ill patient	123

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 failure	123
Chronic renal failure	123
AV fistulas, shunts & dialysis catheters	123
Nephrectomy	123
Renal transplant	123
Renal / urinary tract trauma	123

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 infusion	123
Use of Endo tool	123

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’s	123
Care of patient with Peripherally-Inserted Central Catheter (PICC)	123
Administration / monitoring of Total Parenteral Nutrition (TPN)	123
Administration of blood / blood products	123
Administration of narcotics / sedatives: (fentanyl, Valium, Ativan, Versed, morphine)	123
Bispectral monitoring	123

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 *

Mentoring	123
Communication	123
Video assessment	123
Utilize tele-ICU system	123
Multi-tasking	123
Troubleshoot equipment	123
Giving directions over AV system	123
Interpretation of data	123
Critical thinking	123
Diplomacy	123

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
Anaphylaxis	123
Disseminated Intravascular Coagulation (DIC)	123
Septic shock	123
Cancer	123
Administration of chemotherapy	123
Monitoring of chemotherapy (does not initiate)	123
Hyperbaric oxygenation	123
Organ / tissue donation procedures	123
Suicide precautions	123

AGE-SPECIFIC 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 *

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

ATTESTATION: *

I certify that the information provide above accurately reflects my experience in each of the clinical areas identified within the past three years.

If you agree with the Attestation above, please electronically sign your name. *