* = Required Information
Last Name
*
First Name
*
Middle I.
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)
NEUROLOGY
ASSESSMENT
Level of Consciousness
A
B
C
Glasgow Coma Scale
A
B
C
Pathologic Reflexes
A
B
C
Cerebellar functions
A
B
C
Cranial Nerves
A
B
C
EQUIPMENT AND PROCEDURES
Assist with Lumber Puncture
A
B
C
Halo Traction
A
B
C
Nerve Stimulator
A
B
C
Use of hyper/hypothermia Blanket
A
B
C
Seizure Precautions
A
B
C
CARE OF A PATIENT WITH:
CVA/TIA
A
B
C
Seizures
A
B
C
Drug Overdose
A
B
C
Closed head injury
A
B
C
Coma
A
B
C
Meningitis
A
B
C
Aneurysm precautions
A
B
C
Basal skull fracture
A
B
C
Intracranial Hemorrhage
A
B
C
Multiple Sclerosis
A
B
C
DTs (Delirium Tremens)
A
B
C
Externalized VP shunts
A
B
C
Meningitis
A
B
C
Post craniotomy
A
B
C
Encephalitis
A
B
C
Neuromuscular disease
A
B
C
Spinal cord injury
A
B
C
MEDICATIONS
Valium (Diazepam)
A
B
C
Carbidopa-Levodopa (Sinemet)
A
B
C
Dilantin (Phenytoin)
A
B
C
Lorazepam (Ativan)
A
B
C
Decadron (Dexamethasone)
A
B
C
Methylprednisolone (Solumedrol)
A
B
C
Phenobarbital
A
B
C
Clonazepam (Klonopin)
A
B
C
Carbamazepine (Tegretol)
A
B
C
Cardiovascular
ASSESSMENT
Auscultation (rate, rhythm)
A
B
C
Heart Sounds/murmurs
A
B
C
Pulses/Circulation checks
A
B
C
INTERPRETATION OF LAB. RESULTS
Complete blood count
A
B
C
Blood chemistry
A
B
C
Cardiac enzymes / Isoenzymes
A
B
C
Coagulation studies
A
B
C
EQUIPMENT, PROCEDURES AND HEMODYNAMICS
Obtaining 12 lead EKG
A
B
C
Basic 12 lead EKG interpretation
A
B
C
Interpretation of Arrhythmias
A
B
C
Lead placement: 11, MCL1
A
B
C
Pacemaker: Permanent
A
B
C
Pacemaker: Temporary epicardial wires
A
B
C
Pacemaker: Temporary external pacing
A
B
C
Pacemaker: Temporary transvenous
A
B
C
Cardiac arrest/ CPR
A
B
C
Femoral artery sheath removal
A
B
C
A-Line (Transducer set-up,D/C)
A
B
C
Swan-Ganz (Transducer set-up,D/C)
A
B
C
CVP monitoring
A
B
C
Cardiac Output monitoring
A
B
C
PAOP (wedge) readings
A
B
C
Interpretation of PA pressure readings
A
B
C
ASSIST WITH:
Arterial line insertion
A
B
C
Central line insertion
A
B
C
Swan-Ganz catheter insertion
A
B
C
Cardiac Arrest/ CPR
A
B
C
CARE OF THE PATIENT WITH:
Congestive heart failure (CHF)
A
B
C
Cardiomyopathy
A
B
C
Cardiac arrest
A
B
C
Abdominal aortic bypass
A
B
C
Angina
A
B
C
Carotid endarterectomy
A
B
C
Post acute MI (24-48hours)
A
B
C
Femoral-popliteal bypass
A
B
C
Hypertensive crises
A
B
C
Deep venous thrombosis (DVT)
A
B
C
Aneurysm
A
B
C
Peripheral vascular disease(PVD)
A
B
C
Pre/ Post Cardiac Catheterization
A
B
C
Pre/ Post Cardiac Surgery
A
B
C
Open Serial Wound (Debridement)
A
B
C
MEDICATIONS
Amiodarone
A
B
C
Atropine
A
B
C
Bretylium (Bretylol)
A
B
C
Cardizem (Diltiazem hydrochloride)
A
B
C
Digoxin (Lanoxin)
A
B
C
Dobutamine (Dobutrex)
A
B
C
Epinephrine (Adrenaline)
A
B
C
Heparin
A
B
C
Inderal
A
B
C
Lidocaine (Xylocaine)
A
B
C
Nitroglycerine (Tridil)
A
B
C
Nitroprusside (Nipride)
A
B
C
Norepinephrine (Levophed)
A
B
C
Vasopressin (Pitressin)
A
B
C
Verapamil (Calan,Isoptin
A
B
C
Verelan
A
B
C
PULMONARY
ASSESSMENT
Breathing patterns
A
B
C
Breath sounds
A
B
C
INTERPRETATION OF LAB. RESULTS
Arterial blood gas (ABG)
A
B
C
Blood chemistry
A
B
C
EQUIPMENT AND PROCEDURES
Assist with:
Intubation and extubation
A
B
C
Chest tube insertion and set up
A
B
C
Mediastinal tube removal
A
B
C
Thoracentesis
A
B
C
Pulse oximetry
A
B
C
Patients on ventilator:
A
B
C
Care of endotracheal tube/suctioning
A
B
C
Care of Nasal airway/suctioning
A
B
C
Care of Tracheostomy/suctioning
A
B
C
Use of pleuravac or Thoraclex
A
B
C
Use of water seal drainage system
A
B
C
Ventilator weaning modes
A
B
C
Endotracheal tube
A
B
C
Establish an Airway
A
B
C
Ambu Bag
A
B
C
Chest Tubes (Emersion / Pleuravac)
A
B
C
Pulse Oximetry
A
B
C
Interpretation of ABG
A
B
C
Use Of IPPB
A
B
C
Incentive Spirometer
A
B
C
Ambu bag and mask
A
B
C
Oral airway insertion
A
B
C
Oral Suctioning
A
B
C
Initiating CPT
A
B
C
Perfoming arterial puncture for ABG'S
A
B
C
Nasotracheal Suctioning
A
B
C
CARE OF A PATIENT WITH:
COPD
A
B
C
ARDS
A
B
C
Pre / Post Thoracic Surgery
A
B
C
Pulmonary Embolism
A
B
C
Pulmonary Edema
A
B
C
Pneumothorax
A
B
C
Pneumonia
A
B
C
Inhalation Injuries
A
B
C
Emphysema
A
B
C
Asthma
A
B
C
VASCULAR
Peripheral Pulses
A
B
C
Fluid Overload
A
B
C
Ultrasonic Doppler
A
B
C
Starting IV's
A
B
C
Subcutaneous Central Line
A
B
C
Infusion Pumps
A
B
C
Hickman/Broviac/Groshong Catheters
A
B
C
TPN/Hyper alimentation
A
B
C
Maintenance of Heparin Lock
A
B
C
Air Occlusive Dressing
A
B
C
Knowledge of Blood & Blood Products
A
B
C
Peritoneal Dialysis
A
B
C
Hemo dialysis
A
B
C
Heparin Drip (Precautions & Maintenance)
A
B
C
Sickle Cell Anemia
A
B
C
Thrombophlebitis
A
B
C
GASTROINTESTINAL
Assessment of abdominal/ Bowel sounds
A
B
C
NG Tube Insertion
A
B
C
Interpretation of blood chemistry
A
B
C
Saline lavage
A
B
C
Administration of tube feeding
A
B
C
CARE OF:
Flexible feeding tubes (dobhoff,Corpak)
A
B
C
Gastrostomy Tube
A
B
C
Jejunostomy Tube
A
B
C
Enterostomal Care
A
B
C
CARE OF A PATIENT WITH:
Pancreatitis
A
B
C
G.I. Bleeding
A
B
C
Colostomy
A
B
C
Ileostomy
A
B
C
Esophageal Bleeding
A
B
C
Bowel Obstruction
A
B
C
Whipple Procedure
A
B
C
Hepatitis
A
B
C
Inflammatory bowel disease
A
B
C
Liver Transplant
A
B
C
Paralytic Ileuses
A
B
C
ERCP
A
B
C
GENITOURINARY/RENAL
Foley Catheter Insertion
A
B
C
GU Irrigations
A
B
C
Nephrostomy Tube care
A
B
C
Suprapubic catheter care
A
B
C
Fluid and electrolyte balance/ Replacement
A
B
C
Bladder irrigation
A
B
C
Routine specimen collection
A
B
C
24 hour specimen collection
A
B
C
Manual CAPD administration
A
B
C
P. Dialysis via autocycler
A
B
C
CARE OF A PATIENT WITH:
T.U.R.P.
A
B
C
Shunts and Fistulas
A
B
C
Nephrectomy
A
B
C
Renal Transplant
A
B
C
Renal Trauma
A
B
C
Chronic/Acute Renal Failure
A
B
C
Hemodialysis
A
B
C
GYNECOLOGY
Endometriosis
A
B
C
Gyn Exam / Prep
A
B
C
Self Breast Exam
A
B
C
Tubal Ligation
A
B
C
Ectopic Pregnancy
A
B
C
Mastectomy
A
B
C
Hysterectomy
A
B
C
ORTHOPEDIC
Total Joint Replacement
A
B
C
Arthroscopic Surgery
A
B
C
Bucks Extension
A
B
C
K - Wires / Steinman Pins
A
B
C
METABOLIC / IMMUNE
Assessment of S/S of DKA
A
B
C
Assessment of S/S of insulin shock
A
B
C
Interpretation of blood glucose value
A
B
C
Interpretation of thyroid function test
A
B
C
EQUIPMENT AND PROCEDURES
Visual blood glucose strips
A
B
C
Visual blood ketone strips
A
B
C
Blood glucose monitoring with measuring device
A
B
C
Diabetic teaching
A
B
C
I/V insulin administration/titration
A
B
C
CARE OF PATIENTS WITH
Diabetes Insipidus
A
B
C
Diabetes mellitus
A
B
C
Diabetic ketoacidosis
A
B
C
Hyperthyroidism (Grave's disease)
A
B
C
Hypothyroidism
A
B
C
Hypoglycemia
A
B
C
Cushing's syndrome
A
B
C
Disorders of adrenal gland
A
B
C
( Addison's disease)
A
B
C
HIV/ AIDS
A
B
C
Post adrenalectomy
A
B
C
Post thyroidectomy
A
B
C
Post hypophysectomy
A
B
C
WOUND MANAGEMENT
ASSESSMENT
Skin for impending breakdown
A
B
C
Surgical wound healing
A
B
C
Decubitus ulcers
A
B
C
Use of air fluidized, low airloss beds
A
B
C
PAIN MANAGEMENT
Assessment of pain level / tolerance
A
B
C
Anesthetic agents
A
B
C
Narcotic analgesia
A
B
C
Non-narcotic analgesia
A
B
C
IV conscious sedation
A
B
C
Patient controlled analgesia (PCA) pump
A
B
C
Epidural analgesia- catheter delivered
A
B
C
Wound care / irrigation
A
B
C
Sterile dressing changes
A
B
C
Care of patient with burns
A
B
C
Care of patient with decubitus ulcers
A
B
C
Care of surgical wounds with drains
A
B
C
MEDICATION DELIVERY METHODS
Continuous IV infusions
A
B
C
Eye/ Ear instillations
A
B
C
IM injections
A
B
C
IV push
A
B
C
Subcutaneous injections
A
B
C
Medication pump devices
A
B
C
Meter dosed inhalers
A
B
C
Z track injections
A
B
C
PHLEBOTOMY / IV THERAPY
Starting IVs
A
B
C
Administration of blood / blood products
A
B
C
Drawing blood from central line catheter
A
B
C
Care of central line /catheter/dressing
A
B
C
Care of peripheral line / dressing
A
B
C
MISCELLANEOUS
Care of a Patient With:
Burns
A
B
C
Multiple injuries from accident
A
B
C
Organ transplant
A
B
C
Ortho Trauma
A
B
C
Skeletal Traction
A
B
C
AGE EXPERIENCE
Indicate groups in which you have expertise in providing, age-appropriate nursing care.
0 - 30 Days
Yes
No
30 Days - 1 year
Yes
No
1 - 5 years
Yes
No
5 - 13 years
Yes
No
13 - 18 years
Yes
No
18 - 39 years
Yes
No
39 - 64 years
Yes
No
64 years +
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.
Signature
*
Date
Submit