Instructions:

Please rate your experience / frequency (within the last year) using the following scale (check the appropriate boxes below):

  • 0 = No Experience / Observed Only
  • 1 = Limited Experience / Rarely Done (<6 times/year)
  • 2 = May Need Some Review / Occasionally Done (1 - 2 times/month)
  • 3 = Experienced / Frequently Done (daily or weekly)
  • AGE OF PATIENTS CARED FOR
    Newborn/Neonate (birth to 30 days)
    Infant (31 days to 12 months)
    Toddler/Preschool (13 months to 5 years)
    School Age Child/adolescent (6 years to 18 years)
    Young Adults/Middle Adult (19 years to 64 years)
    Older Adults/Elderly (65+ years)
    GENERAL SKILLS
    Care of Patient in Restraints
    Automated Med Dispensing Systems
    Other Automated Med Dispensing Systems:
    Electronic Documentation
    Other Electronic Documentation:
    IV Pumps
    Other IV Pumps:
    Peripheral IV Insertion, Care and Maintenance
    Access/Management of Implanted Ports
    Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
    Cardiac Monitoring/Interpretation
    Titration of drips
    Administration of Blood/Blood Products
    Do you have charge/supervisor experience?
    Knowledge of "Do Not Use Abbreviations"
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    MEDICATION ADMINISTRATION
    Moderate/Conscious Sedation
    Sedation Reversal Agents
    Antibiotics IM/IV
    Contrast Medium
    Antiemetics
    Narcotic Pain Medications
    PRE-PROCEDURE
    Allen Test
    Doppler
    EKG lead/pad placement
    Blood Pressure Invasive and NonInvasive
    HEMODYNAMIC MONITORING
    Art Line
    Swan Ganz
    Waveform Assessment
    CARE AND MAINTENANCE OF
    Arterial Line
    Swan Ganz
    IABP
    Sheath/Removal of Sheath
    MEDICATIONS
    Calculate mcg/min and mcg/kg/min
    Diprovan (Propofol)
    Esmolol (Brevibloc)
    Lopressor (Metoprolol)
    Diltiazem HCL (Cardizem)
    Digoxin (Lanoxin)
    Nitroglycerin (SL,IV,IC)
    Adenocard (Adenosine)
    Amiodarone (Cordarone)
    Corvert (Ibutilide)
    Dobutrex (Dobutamine)
    Dopamine Hydrochloride
    Aggrastat (Tirofiban)
    Integrilin (Eptifibatide)
    ReoPro (Abciximab)
    TPA (Alteplase)/Strepotkinase
    Heparin
    CARDIOVASCULAR
    Hematoma Recognition/Management
    Radial, brachial, femoral, pedal pulse checks
    Assessment of heart sounds
    General labwork/cardiac enzyme interpretation
    ABG Interpretation
    Coagulation Interpretation
    PULMONARY
    Set up Oxygen Delivery Devices(Cannula, NRBM, Ambu)
    Assist with Intubation
    Suction equipment (oral,NP, In line)
    Assessment of breath sounds
    NEUROLOGICAL
    Identify Sudden Change in LOC
    Assess Sensory, Motor, Speech Function,Gag reflex
    Glasgow Coma Scale
    PROCEDURES DIAGNOSTIC AND INTERVENTIONAL
    Panning Table
    Moving Image Intensifier, Knowledge of views( RAO, LAO, cranial, caudal)
    Scrub Diagnostic Procedures
    Circulate Diagnostic Procedures
    Scrub Interventional Procedures
    Circulate Interventional Procedures
    Monitoring/Recording cases
    Cardiac Catheterization - Adult (R/L)
    Cardiac Catheterization - Pediatric (R/L)
    Shunt Detection and Calculation
    Angioplasty/PCI/Stent
    Ventricular Assistive Devices
    Coronary Atherectomy
    Pericardiocentesis
    Transluminal Extraction Catheter
    PercuSurge Procedure
    Thrombolysis/Thrombectomy
    AngioJet
    Cardiac Biopsy
    Pericardial Tap
    Valvuloplasty
    Intra Aortic Balloon Pump (IABP) insertion and set up
    Continuous Arteriovenous Hemofiltration (CAVH)
    Cardioversion
    Brachytherapy
    FFR (radiwire)
    IVUS/Volcano
    Embolic Protection Devices
    PACEMAKERS
    Permanent Pacemaker/AICD
    Temporary Epicardial/Transthoracic Pacing
    Temporary External /transvenous pacing
    CARE OF PATIENT DURING EMERGENCY PROCEDURES
    Emergency Defibrillation/ Cardioversion
    Anaphylaxis
    Vasovagal Response
    Pneumothorax
    Cardiogenic Shock
    Embolism
    Myocardial Infarction
    EQUIPMENT/SUPPLIES
    (Hemochron)ACT Machine
    Power Injectors
    Manual Pressure Hold
    Femostop/ C-Clamp
    VasoSeal, Angioseal, PerClose