* = Required Information
Please mark the corresponding experience level for each section
A - Able to perform without any supervision
B - Perform infrequently (would require some supervision)
C - No experience (Require Assistance / Supervision)
CARDIOVASCULAR
ASSESSMENT
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
EQUIPMENTS & PROCEDURES
A
B
C
A
B
C
ASSIST WITH:
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
PACEMAKER
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
HEMODYNAMICS / MONITORING
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
CARE OF PATIENT WITH:
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
USE & ADMINISTRATION OF:
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
PULMONARY

ASSESSMENT
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
ASSIST WITH:
A
B
C
A
B
C
A
B
C
A
B
C
CARE OF PATIENT WITH:
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
MEDICATIONS
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
NEUROLOGICAL

ASSESSMENT
A
B
C
A
B
C
A
B
C
A
B
C
EQUIPMENT & PROCEDURES
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
CARE OF PATIENTS WITH:
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
MEDICATIONS
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
GASTROINTESTINAL

ASSESSMENT
A
B
C
A
B
C
A
B
C
EQUIPMENT & PROCEDURES
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
CARE OF THE PATIENT WITH
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
MEDICATIONS
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
RENAL / GENITOURINARY

ASSESSMENT
A
B
C
A
B
C
INTERPRETATION OF LAB RESULTS
A
B
C
A
B
C
EQUIPMENT & PROCEDURES
A
B
C
A
B
C
A
B
C
A
B
C
CARE OF THE PATIENT WITH
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
ENDOCRINE / METABOLISM

INTERPRETATION OF LAB RESULTS
A
B
C
A
B
C
A
B
C
Blood glucose measuring device type
A
B
C
A
B
C
A
B
C
CARE OF PATIENT WITH:
A
B
C
A
B
C
Disorders of Adrenal gland (e.g Addison's disease)>Diabetic Ketoacidosis
A
B
C
Disorder of pituitory gland(e.g DI)
A
B
C
Drug overdose
A
B
C
Hyperthyroidism (Grave's disease)
A
B
C
Hypothyroidism (Myxedema)
A
B
C
Insulin shock
A
B
C
Thyrotoxicosis (Thyroid Crises)
A
B
C
Thyroidectomy
A
B
C
Disorders of thyroid gland
A
B
C
WOUND MANAGEMENT
ASSESSMENT
Skin for impending breakdown
A
B
C
Stasis ulcers
A
B
C
Surgical wound healing
A
B
C
EQUIPMENT & PROCEDURES
Air fluidized, low airloss beds
A
B
C
Sterile dressing changes
A
B
C
wound care/irrigations
A
B
C
CARE OF PATIENT WITH:
Burns
A
B
C
Pressure sores
A
B
C
Staged decubitus ulcers
A
B
C
Surgical wounds with drain(s)
A
B
C
Traumatic wounds
A
B
C
PHLEBOTOMY/IV THERAPY
EQUIPMENT & PROCEDURES
Administration of blood/blood products
A
B
C
Administration of blood/blood products
A
B
C
Drawing blood from central line
A
B
C
Drawing venous blood
A
B
C
Starting IVs
A
B
C
CARE OF PATIENT WITH:
Central line/catheter/dressing
A
B
C
Peripheral line/dressing
A
B
C
PAIN MANAGEMENT
Assessment of pain level/Tolerance
A
B
C
CARE OF PATIENT WITH:
Epidural anesthesia/analgesia
A
B
C
IV conscious sedation
A
B
C
Patient controlled analgesia
A
B
C
Patient controlled analgesia
A
B
C
MISCELLANEOUS
CARE OF THE PATIENT WITH
Anaphylactic shock
A
B
C
Disseminated intravascular coagulation (DIC)
A
B
C
Hypovolemic shock
A
B
C
Multi-system organ failure
A
B
C
Organ/tissue transplant
A
B
C
Septic shock
A
B
C
AGE EXPERIENCE
Indicate groups in which you have expertise in providing age-appropriate nursing care.


Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
The information that I have given is accurate and true to the best of my knowledge. I hereby authorize Pace Medical Staffing, Inc. to release same to her client health care facilities.