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 (1 month to 1 year)
    Toddler (1 year to 3 years)
    Preschooler (3 years to 5 years)
    School Age Child (5 years to 12 years)
    Adolescents (12 years to 18 years)
    Young Adults (18 years to 39 years)
    Middle Adults (39 years to 64 years)
    Older Adults (64 years to 79 years)
    Elderly Adults (over 79+ years)
    GENERAL SKILLS
    Standard Precautions
    Isolation Precautions
    Pediatric Respiratory/Cardiac Arrest
    Adult Respiratory/Cardiac Arrest
    Transplant Patients
    Crash Carts
    Defibrillators
    Care of Patient in Restraints
    Pain Management
    Automated Med Dispensing Systems
    Care Planning & Discharge Planning
    Patient/Family Education
    Electronic Documentation
    Systems Used - Please List
    Patient Head to Toe Assessment
    Dressing Changes
    Knowledge of Normal Serum Lab Values
    Obtaining Cultures (Blood, Sputum, Swab)
    Administration of Blood & Blood Products
    PCA Pumps
    Infusion Pump
    Calculate mcg/min and mcg/kg/min
    Titrating Medications
    KNOWLEDGE AND USE OF
    Sedatives
    Analgesics
    Propofol
    Epinephrine
    Vasopressin
    Amiodarone
    TPA
    Atropine
    Bretylol
    Bumex
    Digoxin
    Dopamine
    Dobutrex
    Heparin Drip (Precautions & Maintenance)
    Inderal
    Inocor
    Isuprel
    Lidocaine
    Neosynephrine/Nipride
    Nitroglycerin
    Pronestyl
    Titrate Morphine
    Thrombolytic Agents
    Magnesium Sulfate
    Versed
    Prep/Titration of Emergency Drugs
    Intra-Peritoneal Chemotherapy Infusions
    CARDIAC GENERAL SKILLS
    Interpretation of 12 lead EKG
    Interpretation of Arrhythmias
    Defibrillation/Cardioversion
    Permanent Pacemaker
    Temporary Pacemaker
    AICD
    Interpretation of Hemodynamic Monitoring
    Art-Line (Transducer set-up, D/C)
    Swan-Ganz (Transducer set-up, D/C)
    Balloon Pump (IABP)
    SVO2 Monitoring
    Sheath Removal
    Interpretation of Cardiac Enzymes
    CARDIAC -Care of Patient With:
    Aneurysm
    Acute MI/Unstable Angina
    CHF
    Cardiogenic/Hypovolemic Shock
    Pre/Post Cardiac Surgery
    Pre/Post Cardiac Cath
    Percutaneous Transluminal Coronary Angioplasty
    Heart Transplant
    RESPIRATORY GENERAL SKILLS
    Establishing an Airway
    Oxygen Delivery Systems
    Chest Tubes (Emerson/Pleuravac)
    Pulse Oximetry
    Interpretation of ABG
    Drawing ABG Blood Sample from Art-Line
    Use of IPPB
    Use of Pressure Support
    Suctioning
    VASCULAR GENERAL SKILLS
    Peripheral Pulses
    Dopplers
    Peripheral IV Insertion, Care and Maintenance
    Assisting with Insertion of Central Lines
    Care and Maintenance of Central Lines
    Assist with IV Cutdown
    OTHER
    Care of Oncology Patient
    Chemotherapy Administration
    Care of Patient with Burns
    Care of Patient with HIV/AIDS
    Hyperbaric Oxygenation
    Suicide Precautions
    Post Mortem Cares
    PERFUSIONIST SKILLS
    Patient identification
    Procedure confirmation
    Blood type, antibodies confirmed
    Allergies checked
    Blood bank number confirmed
    Medical record number confirmed
    Chart review
    Components checked for package integrity/expiration
    Equipment clean
    Heat exchanger(s) leak-tested
    Occlusion(s) set
    Speed controls operational
    Flow meter
    Rollers, Pump Head & Holder Checks
    Servoregulated connections
    Cardioplegia-System Checks
    Knowledge of Gas line(s) and filer connection
    Gas exhaust
    Flow meter / gas blender operational
    Hoses leak-free
    Anesthetic gas scavenge line
    Alarms operational
    Arterial filter / bubble trap debubbled
    Vent(s) tested
    Venous line occluder(s) calibrated and tested
    Devices securely attached
    Cardiotomy positive-pressure relief valve
    Negative- pressure relief valve
    Vacuum regulator
    Circuit / patient temperature probes
    Pressure transducers
    Inline sensors
    Oxygen analyzer
    Water source(s)
    Temperature range(s)
    Water lines
    Tubing clamps
    Drugs available and properly labeled
    Solutions
    Blood products
    Sampling syringes / laboratory tubes
    Anesthetic vaporizer
    Vaporizer
    Hand cranks
    Duplicate circuit components / hardware
    Emergency lighting / flashlight
    Emergent restart of Bypass