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
    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
    PCA/Epidural pumps
    Titration of drips
    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
    NEUROLOGIC - Care of patients with:
    Pre/Post Neuro Surgery
    Basal Skull Fracture
    Closed Head Injuries
    Coma
    Delirium Tremens
    Encephalitis
    Meningitis
    Spinal Cord Injuries
    Seizures
    Overdose
    Stroke/TIA
    Guilliane Barre Syndrome
    Alzheimer's Disease
    Externalized AV Shunt
    Post Craniotomy
    CARDIAC - Care of patients with:
    Pre/Post Cardiac Surgery
    Cardiac Transplant
    Abdominal Aortic Aneurysm/Bypass
    Angina
    Cardiac Arrest
    Cardiomyopathy
    Femoral Poplitieal Bypass
    Myocarditis
    Post Angioplasty/Stent
    Thrombophlebitis
    CHF
    Chest Pain
    Post MI
    Temporary pacemaker
    Permanent pacemaker
    ORTHOPEDIC - Care of patients with:
    Total Joint Replacement Procedures
    Fractures
    Rheumatic/Arthritic Disease
    Spinal Fusion
    Amputation
    Traction Devices
    Walking asistants (i.e. Crutches, Walker, Cane)
    RESPIRATORY - Care of patients with:
    Lung Transplant
    Bronchoscopy
    Lobectomy
    Tracheostomy Tube
    COPD
    Asthma
    Pneumonia
    Pre/Post Thoracic Surgery
    Chest Tubes
    Tuberculosis
    Pneumonectomy
    Pulmonary Embolism
    Thoracotomy
    Pulmonary Edema
    Pneumothorax
    Laryngospasm
    GASTROINTESTINAL - Care of Patient with:
    Post Abdominal Surgery
    Liver Transplant
    Pancreas Transplant
    Ileostomy
    Colostomy
    Inflammatory Bowel Disease
    Bowel Obstruction
    Hepatitis
    GI Bleeding
    Liver Failure
    Paralytic Ileus
    Abdominal Trauma
    RENAL/GU - Care of patients with:
    Kidney Transplant
    Insertion of Catheter (Straight and Foley)
    Bladder Irrigations
    Peritoneal Dialysis
    Hemodialysis
    A-V Fistula/Shunt Care
    Suprapubic Catheter
    Nephrostomy Tube
    Nephrectomy
    Urinary Tract Infection
    Pyelonephritis
    Renal Failure
    Renal Transplant
    TURP
    Ileal Conduit
    Renal Trauma
    Renal Calculi
    ENDOCRINE - Care of patients with:
    Hyperthyroidism
    Hypothyroidism
    Thyroidectomy
    Diabetes Mellitus
    Diabetes Insipidus
    Diabetic Ketoacidosis
    KNOWLEDGE AND USE OF
    Insulin
    Single Type
    Mixed Insulins
    Insulin Infusion
    WOUND/SKIN - Care of Patient with:
    Multiple Abdominal Wounds and Drains
    Gunshot Wound
    Stab Wound
    Lacerations
    Dressing Changes
    Pressure Relief Mattresses
    Decubitus Ulcers
    Traumatic Wounds
    Leg Ulcers
    First Degree Burns
    Second Degree Burns
    Third Degree Burns
    ADDITIONAL MEDICAL/SURGICAL SKILLS-Care of Patient With
    Hemovacs
    Jackson-Pratt Drains
    Penrose Drains
    Surgical Wound Irrigations & Dressings
    INFECTIOUS DISEASE - Care of the patient with:
    HIV
    MRSA
    CRE
    VRE
    C. Difficile
    Hepatitis
    Influenza
    Isolation Precautions
    MEDICATIONS
    Antibiotics
    Antihypertensives
    anticoagulants
    Anticonvulsants
    Narcotics
    Digoxin
    Diuretics
    Steroids
    Diltiazem
    Antiemetics
    Antispasmotics
    Oral Hypoglycemics
    Inhalers
    IV Conscious Sedation
    Reversal Agents (Narcan, Romazicon)