PACU Skills Checklist

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Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

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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 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 *

Advanced directives	123
Awareness of HCAHPS	123
Patient / family teaching	123
Lift / transfer devices	123
Specialty beds	123
Restrictive devices (restraints)	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 & education	123
Blood Glucose Monitoring (BGM)	123
Insulin administration	123
National Patient Safety Goals	123
Accurate patient identification	123
Effective communication	123
Interpretation & communication of lab values	123
Medication administration	123
Labeling (medications & specimens)	123
Medication reconciliation	123
Anticoagulation therapy	123
Pain assessment & management	123
Monitoring conscious sedation	123
Infection control	123
Universal precautions	123
Isolation	123
Minimize risk for falls	123
Prevention of pressure ulcers	123
Universal protocol (site / side verification)	123
Normothermia	123
Beta blocker (preop)	123
Anesthesia: General Knowledge Experience	123
Moderate sedation / protocols & procedures	123
Local anesthetics	123
Regional blocks (intrathecal / epidural / spinal)	123
General anesthesia (IV anesthetic agents / inhalation anesthesia agents)	123
Administer & monitor paralytic agents	123
Administer & monitor reversal agents	123
Assessment of dermatomes	123
Neuromuscular blocking agents (depolarizing, non- depolarizing, reversal agents)	123
Benzodiazepines / reversal	123
Opioids / reversal	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 / rate / effort

123

AIRWAY MANAGEMENT, CARE & MAINTENANCE:

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 *

Head positioning to ensure airway patency	123
Oral / NT airway	123
Laryngeal Mask Airway (LMA)	123
Endotracheal tube	123
Tracheostomy	123
Use of ambu bag	123
O2 therapy (NC / mask)	123
Use of CO2 monitoring devices	123
SVO2 monitoring	123
Oral / NT suctioning	123
Assisting with intubation	123
Assisting with extubation	123
Measuring tidal volume	123
Arterial blood gas interpretation / analysis	123
Obtaining ABG blood sample (art line, arterial puncture)	123
Pulse oximetry	123
Mechanical ventilation	123
Pleural chest tubes	123

POSTOPERATIVE CARE (RESPIRATORY):

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 *

Tracheostomy	123
Laryngeal procedures / laryngectomy	123
Lung transplant	123
Video- assisted thoracoscopic surgery (VATS)	123
Radical neck dissection	123
Penetrating/open chest trauma	123
Sinus surgery	123
Adeno- tonsillectomy (T&A)	123
Thoracotomy / lobectomy / pneumonectomy	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 *

Cardiovascular assessment	123
Interpretation of arrhythmias	123
Performing 12 lead EKG's	123
Care of patient with VAD (ventricular assist device)	123

SET UP & 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 *

Hemodynamic monitoring (CVC / aline / PA catheter)	123
External / temporary pacemaker	123
Cardiac arrest / CPR	123
Cardioversion / defibrillation	123

POSTOPERATIVE CARE (CARDIOVASCULAR):

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 pacemaker / AICD insertion	123
Vascular bypass / grafting	123
Embolectomy / thrombectomy	123
Abdominal aortic aneurysm (AAA) repair	123
Thoracic aortic aneurysm repair	123
Endoluminal stenting	123
Vena cava filter	123
Postoperative myocardial infarction	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 *

Baseline neurological assessment	123
Glasgow coma scale	123
Cranial nerve assessment	123
Seizure precautions	123
Cervical spine precautions	123

POSTOPERATIVE CARE (NEURO SURGERY):

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 *

Craniotomy	123
Burr holes	123
Aneurysm clipping / coiling	123
Evacuation of hematoma (subdural, epidural)	123
Carotid endarterectomy	123
Intracranial tumor excision	123
Spinal tumor excision	123
Laminectomy	123
Spinal fusion	123
Ventricular peritoneal shunt	123
Tether Cords	123

SET UP & CARE OF INTRACRANIAL/CEREBRAL PERFUSION PRESSURE MONITORING (ICP/CPP) 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

GASTROINTESTINAL EXPERIENCE - 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 *

Gastric tubes (NG/G)	123
Jejunostomy tube	123
Assessment & management of wound drains (self- suction / irrigation / drainage)	123
Endoscopic procedures	123

POSTOPERATIVE CARE (GI):

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 *

Laparoscopic	123
Exploratory laparotomy	123
Nissen fundoplication	123
Esophageal procedures	123
Abdominal trauma	123
Gastroplasty / bypass (bariatric surgery)	123
Gastrectomy (partial / complete)	123
Whipple procedure	123
Pyloroplasty	123
Vagotomy	123
Appendectomy	123
Bowel / colon resection	123
Colostomy / ileostomy	123
Hernia repair	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 *

Transphenoidal hypophysectomy	123
Adrenalectomy	123
Thyroidectomy	123
Parathyroidectomy	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) Groshong / Hickman	123
Administration of blood / blood products	123
Autotransfusion of blood / blood products	123
Administration of volume expanders (albumin, dextran, etc)	123

MISCELLANEOUS 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 *

Aldrette scoring	123
Experience with level 1 trauma patients	123
Management of patient with malignant hyperthermia	123
Anaphylaxis	123
Care of patients with latex allergies	123
Phlebotomy: peripheral	123
Drawing blood from invasive lines	123

PHARMACOLOGY - USE & ADMINISTRATION 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 *

H2 receptor antagonists: (Zantac, Pepcid, Carafate)	123
Antiemetics (Zofran, Phenergan, Reglan)	123
Steroids: (decadron, Solu-Medrol)	123
Emergency meds (ACLS protocols)	123
Anticonvulsants: (Dilantin, phenobarbital)	123
Inotropes / vasoactive drips	123
Calcium channel blockers: (Cardizem)	123
Antihypertensives: (nipride)	123
Antiarrhythimics: (amiodarone, lidocaine, procan)	123
Diuretics: (Lasix, edecrin sodium, Bumex)	123
Fibrinolytics	123
Glycoprotein IIb / IIIa receptor inhibitors: (Integrilin, Aggrastat)	123
Nebulizer treatments: (Ventolin, Atrovent, racemic, ephinephrine)	123

OTHER 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 *

Post orthopedic / musculoskeletal procedures	123
Post ENT procedures	123
Post breast procedures (mastectomy / lumpectomy)	123
Post GYN procedures	123
Post prostate procedures	123
Post wound care (I&D / debridement)	123

AGE-SPECIFIC COMPETENCIES 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. *