* = Required Information
PROFICIENCY SCALE
A: Theory, no practice
B: Intermittent experience
C: One-two years experience
D: Two plus years experience
Name
*
Date
SKILL
RESPIRATORY
Airway Management:
Chin Lift
A
B
C
D
Jaw Trust
A
B
C
D
Insertion of Oral Airways
A
B
C
D
Insertion of Nasal Airways
A
B
C
D
Removal of Oral/nasal Airways
A
B
C
D
Oxygen Administration via:
Nasal Cannula
A
B
C
D
Face Tent
A
B
C
D
Mask
A
B
C
D
Vent
A
B
C
D
Non-Rebreather
A
B
C
D
Aerosol
A
B
C
D
Continuous Suction Set-up
A
B
C
D
Intermittent Suction Set-up
A
B
C
D
Use of pulse oximeter
A
B
C
D
Extubation
A
B
C
D
Assist with intubation
A
B
C
D
Assessment of breath sounds
A
B
C
D
Respiratory Obstruction
A
B
C
D
Hypoventilation
A
B
C
D
Laryngospasm/Bronchospasm
A
B
C
D
Aspiration
A
B
C
D
Atelectasis
A
B
C
D
Use of Ambu Bag
A
B
C
D
Tracheostomy
A
B
C
D
Chest Tube
A
B
C
D
Ventilator
A
B
C
D
Assist with Arterial Line Insertion
A
B
C
D
Arterial Line D/C
A
B
C
D
Draw Blood from Arterial Line
A
B
C
D
Draw ABGs via Arterial Stick
A
B
C
D
Interperate ABGs
A
B
C
D
CARDIOVASCULAR:
Abnormal Heart Sounds
A
B
C
D
Basic Arrythmias
A
B
C
D
Use of Cardiac Monitors
A
B
C
D
Controlled Cardioversion
A
B
C
D
Set up CVP Line
A
B
C
D
Care of CVP Line
A
B
C
D
D/C Central Line
A
B
C
D
Use of Doppler
A
B
C
D
Care of Patient with::
Post-Op AAA Repair
A
B
C
D
Hypovolemia
A
B
C
D
Pacemaker
A
B
C
D
Management of Shock
A
B
C
D
Management of Hypertensive Crisis
A
B
C
D
Management of Hypotensive Crisis
A
B
C
D
Assessment of Peripheral Pulses
A
B
C
D
Vasoactive Drug Administration
A
B
C
D
NEUROLOGICAL:
Level of Consciousness
A
B
C
D
Seizure Precautions
A
B
C
D
Intracranial Pressure Monitoring
A
B
C
D
Administration of Steroids
A
B
C
D
Care of Post-Op Craniotomy
A
B
C
D
GASTROINTESTINAL::
Nasogastric Tube Insertion
A
B
C
D
Enterostomal Care
A
B
C
D
Operation of Gomco/Emerson Suction
A
B
C
D
GENITOURINARY:
Insertion of Straight Catheter
A
B
C
D
Insertion of Foley Catheter
A
B
C
D
Management of three-way Foley Catheter w/ Bladder Irrigation
A
B
C
D
Care of Nephrostomy/Suprapubic Tubes
A
B
C
D
Management of Post-Op Renal Transplant
A
B
C
D
ORTHOPEDIC:
Cast Care
A
B
C
D
Management of Skeletal Traction
A
B
C
D
Use of Continuous Passive Motion Machine (CPM)
A
B
C
D
Management of Post-Op Total Joint Replacement
A
B
C
D
PAIN MANAGEMENT:
Administration of Morphine
A
B
C
D
Administration of Meperidine
A
B
C
D
Administration of Fentanyl
A
B
C
D
Fracture tables
A
B
C
D
Laser
A
B
C
D
MISCELLANEOUS:
Care of Patient with:
Malignant Hyperthermia
A
B
C
D
Latex Allergy
A
B
C
D
HIV / AIDS
A
B
C
D
Hypothermia
A
B
C
D
Infectious Disease
A
B
C
D
Anaphylactic Shock
A
B
C
D
Patient Stimulation and Stir-up Regimen
A
B
C
D
Dressing Change
A
B
C
D
Isolation Techniques
A
B
C
D
Use of Reversal Drugs
A
B
C
D
Use of Warming Blankets
A
B
C
D
Use of Computers
A
B
C
D
Use of Anti-Emetic Drugs
A
B
C
D
"The information I have given is true and accurate to the best of my knowledge. I hereby authorize PACE Medical Staffing, Inc. to release this list to client health care facilities of PACE Medical Staffing, Inc."
Name
Years of Experience in PACU
Signature
*
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