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)
    		•
    TYPE OF FACILITY EXPERIENCE
    TYPE OF FACILITY EXPERIENCE
    TYPES OF ICU EXPERIENCE
    ICU (General ICU)
    MICU (Medical Intensive Care Unit)
    SICU (Surgical Intensive Care Unit)
    CCU (Cardiac Care Unit)
    CVICU (Cardiovascular Intensive Care Unit)
    TICU (Trauma Intensive Care Unit)
    Neurosurgical ICU
    Burn ICU
    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
    Electronic Documentation
    Peripheral IV Insertion, Care and Maintenance
    Access/Management of Implanted Ports
    Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
    Cardiac Monitoring/Interpretation
    PCA/Epidural pumps
    Titration of drips
    Emergent line placements
    Administration of Blood/Blood Products
    Knowledge of "Do Not Use Abbreviations"
    Do you have charge/supervisor experience?
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    Other Automated Med Dispensing Systems:
    Other Electronic Documentation:
    IV Pumps
    Other IV Pumps:
    CRRT Equipment
    Other CRRT Equipment:
    MEDICATION ADMINISTRATION
    Moderate/Conscious Sedation
    Sedation Reversal Agents
    Antibiotics IM/IV
    Antiemetics
    Adenosine
    Aminophylline(Theophylline)
    Atropine
    Anticoagulants
    Anticonvulsants
    Antihypertensives
    Barbituate Induced Coma
    Charcoal
    Cardizem
    Cordarone (Amiodarone)
    Decadron
    Dopamine
    Diuretics
    Epinephrine
    Heparin Drip protocol
    Inotropes (Digoxin,Dobutamine,Primacor)
    Inocor
    Insulin Infusions
    Intrathecal Medication
    Isuprel
    Kayexelate
    Lidocaine
    Mannitol
    Nicardipine
    Nitroglycerin
    Nipride
    Norepinephrine
    Sedatives: Propofol, Precedex, Fentanyl, Ketamine, Versed
    Phenylephrine (Neosynephrine)
    Steroids
    Thrombolytic Therapy
    Vasopressin
    Ventolin (Albuterol)
    CARDIOVASCULAR
    Care of the Patient With:
    Adult ECMO
    Continuous Cardiac Monitoring
    Femoral-Arterial Sheath/Removal
    Intra Aortic Balloon Pump
    Epicardial Pacing
    Transcutaneous Cardiac Pacing
    Impella Heart Pump
    Abdominal Aortic Aneurysm/Bypass
    Acute MI
    Angioplasty
    Bacterial Endocarditis
    Pericarditis
    Carotid Endarterectomy
    Fem-Pop Bypass
    Cardiac Arrest
    CHF
    Fresh Open Heart Surgery
    Open Heart Surgery ( more than 6 hrs. post-op)
    Heart Transplant
    Myocardial Contusion
    Mediastinal Tube
    Vascular Surgeries
    Cardiac Tamponade
    EP Study and Ablation
    POST Pacemaker/AICD Insertion
    Pre/Post Cardiac Cath
    Post Artherectomy (DCA)
    Hyperthermia Blanket
    Hypothermia protocol (post arrest)
    Shock:
    Anaphylactic
    Cardiogenic
    Hypovolemic
    Neurogenic
    Septic
    Pacemaker:
    External
    Permanent
    Temporary
    Transthoracic
    Ventricular Assist Device (RVAD,LVAD, BIVAD)
    Hemodynamic Monitoring:
    Set up, use and Interpreation of Reading of CVP
    Set up, use and Interpretation of Reading of PA/Swan-Ganz
    Transducer Setup and Monitoring
    Cardiac Output
    Cardiac Index
    Wedge Pressures
    SVO2
    Set up and use of Arterial Line
    PULMONARY
    Care of the Patient With:
    Ventilator/Weaning
    CPAP/BIPAP
    Asphyxiation (Near Drowning)
    Oral Airway
    Endotracheal Tube
    Laryngeal Spasm
    Tracheostomy
    Lung Transplant
    Epistaxis
    Aspiration
    ARDS
    COPD
    COVID
    Lobectomy
    Pneumonectomy
    Pneumothorax/Tension Pneumothorax
    Hemothorax
    Pneumonia
    Assist with Emergency Tracheostomy
    Thoracentesis
    Inhalation Injuries
    Pulmonary Edema
    Pulmonary Embolism
    Status Asthmaticus
    Tuberculosis
    Chest Tube (pleurevac/Thoraclex)
    Bedside Bronchoscopies
    Assist with Intubation
    Assist with Extubation
    Assist with Chest Tube Insertion
    ABG Interpretation
    Other Ventilator/Weaning:
    NEUROLOGICAL
    Intracranial Pressure Monitoring
    Ventriculostomy Drain
    Increased ICP
    Closed Head Injuries
    Heat Exhaustion
    Multiple Sclerosis
    Psychiatric Disorders
    Aneurysm Precautions
    Basal Skull Fracture
    Coma
    CVA
    Encephalitis
    Craniotomy
    Delirium Tremors
    Meningitis
    Seizures
    Status Epilepticus
    Spinal Cord Injury
    Halo Traction/Cervical Tongs
    Intracranial Tumor Resection
    Cranial Nerve Assessment
    Reflex/Motor Deficits
    Assist with Lumbar Puncture
    Stryker Frame
    Lumbar Drains
    Overdose
    ORTHOPEDICS
    Multiple Long Bone Fractures
    Pelvic Fracture
    Open Book Pelvic Fracture
    Fracture/Dislocation
    Traumatic Amputation
    Osteoporosis
    Pined Fractures
    Total Joint Replacements
    Brace/Splint Application
    Fractured Ribs/Sternum
    Traction Devices
    GASTROINTESTINAL
    Gastric Lavage
    Gastrostomy Tube
    Jejunostomy Tube
    Nasogastric Tube
    Salem Sump
    PEG Tube
    Acute Cholecystitis
    Bowel Obstruction
    Cirrhosis
    GI Bleed
    Paralytic Ileus
    GI Surgery
    Pancreatitis
    Liver Failure
    Liver Transplant
    Acute Abdominal Pain
    Blunt Abdominal Trauma
    Penetrating Abdominal Trauma
    Ostomies
    Esophageal Bleeding
    Whipple
    RENAL/GENITOURINARY
    AV Fistula
    Suprapubic Catheter
    Hemodialysis
    Peritoneal Dialysis
    Nephrostomy Tube
    Peritoneal Lavage
    Acute Renal Failure
    Renal Transplant
    Renal Rejection Syndrome
    Nephrectomy
    TURP
    Bladder Irrigation
    CRRT (continuous Renal Replacement Therapy)
    ENDOCRINE/METABOLIC
    Adrenal Disorders (Addison's Disease)
    Diabetic Ketoacidosis
    Diabetes Mellitus
    Insulin Shock
    Hypothyroidism
    Hyperthyroidism (Graves Disease)
    Pituitary Disorders
    Thyroidectomy
    INFECTIOUS DISEASE
    Hepatitis
    HIV
    MRSA ( Methicillin Resistant Staphylococcus)
    VRE ( Vancomycin Resistant Enterococci)
    CRE ( Carbapenem Resistant Enterobacteriaceae)
    C Difficile
    Tuberculosis
    Isolation Precautions/Procedures
    ONCOLOGY
    Chemotherapy
    Bone Marrow Transplants
    Leukemia
    Lymphoma
    Radiation Implants
    WOUND MANAGEMENT
    Multiple Abdominal Wounds and Drains
    Gunshot Wound
    Stab Wound
    Lacerations
    Hazardous Material Exposure
    Radiation Exposure
    Stasis Ulcers
    Surgical Wound Healing
    Traumatic Wounds
    Multi System Organ Failure
    DIC
    Organ/Tissue Donation
    Burns:
    First Degree
    Second Degree
    Third Degree
    Rule of Nines
    Fluid Resuscitation Burn Formula
    Electrical Burns
    CARDIAC MONITORS
    Hewlett-Packard
    Spacelab
    Siemens
    Marquette
    Mennen
    Lifecare
    Nihon-Koder
    Other Cardiac Monitors Please List: