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 AdultsMiddle 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
    PCA/Epidural pumps
    Titration of drips
    Administration of Blood/Blood Products
    Administration of FFP, Cryo, Platelets
    Pediatric/divided RBC Units
    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
    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/LAB INTERPRETATION
    Art Line
    Swan Ganz
    Waveform Assessment
    General labwork interpretation
    ABG Interpretation
    Coagulation Interpretation
    CARE AND MAINTENANCE OF
    Arterial Line
    Swan Ganz
    Sheath/Removal of Sheath
    MEDICATIONS
    Calculate mcg/min and mcg/kg/min
    Diprovan (Propofol)
    Esmolol (Brevibloc)
    Digoxin (Lanoxin)
    Nitroglycerin (SL,IV,IC)
    Dopamine Hydrochloride
    Integrilin (Eptifibatide)
    TPA (Alteplase)/Strepotkinase
    Antihistamines
    Beta Blockers
    Heparin
    Pediatric Medication Doses
    CARDIOVASCULAR
    Hematoma Recognition/Management
    Radial, brachial, femoral, pedal pulse checks
    Assessment of heart sounds
    Use of Doppler
    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)
    Hickman CVL, Broviac, Groshong, Jugular CVL, Subclavian CVL
    Hemodialysis Catheter, Femoral Line
    Implantable Ports/Infusaport/Mediport
    PICC
    Declotting Central Venous Lines
    Angiography
    Cerebral/Spinal Angiogram
    Ultrasound or CT guided Biopsy
    Uterine Fibroid Embolization
    Vertebroplasty
    Myelogram
    Lumbar Puncture
    Aortogram with Runoff
    Peripheral Angioplasty/stenting
    Greenfield Filter
    Intravascular Ultrasound
    TIPS
    EVLT (Endovascular Laser Therapy)
    Neuroradiology
    Discogram
    Vertebro/Kyphoplasty
    AAA Endograft Repair
    CARE OF PATIENT DURING EMERGENCY PROCEDURES
    Emergency Defibrillation/ Cardioversion
    Anaphylaxis
    Vasovagal Response
    Pneumothorax
    Cardiogenic Shock
    Embolism
    Cardiac/Respiratory arrest
    EQUIPMENT/SUPPLIES
    ACT Machine
    Power Injectors
    Manual Pressure Hold
    Femostop/ C-Clamp
    VasoSeal, Angioseal, PerClose