Answer the following questions indicating with a check mark 9 the skill level that best applies:
SKILL LEVEL KEY: 0=No Experience; never done or dealt with, 1=Minimal; requires supervision,
performed once, 2=Competent; can perform safely and independently, 3=Expert; able to teach skill
1) Skin integrity/ protection of
2) Range of motion
3) Charting (Focus)
4) Use of patient lifting devices
1) Diabetes
2) Colonstomy/ Ileostomy
3) Nutrition
4) Skin Care
1) Directing CPR Team
2) Cardio Pulmunary Arrests\ Management
3) Care of Pacemaker Patient
4) Pre/Post-op Angioplasty
5) Care of 48+hr Post-op Open Heart Patient
6) Post-op Vascular Patients (as in Aneurysms)
7) Angina (Acute or Chronic)
8) Ability to interpret Cardiac Rhythms
9) Patients with Central Lines
10) Assessing Abnormal Heart Sounds
11) Assessing and Treating Orthostatic Hypotensionn
1) Assessing Chest Sounds
2) Administering Oxygen (Nasal, Mask, Canula)
3) Assisting with Set-up and Maintentaning Chest Tubes
4) Using Oxygen Saturation Monitor
5) Using Chest Drainage Systems
6) Caring for Patients with Pulmonary Emboli
7) Caring for Patients with Tracheostomy
8) Changing Tracheostomy
9) Nasal Tracheal suctioning
PULMONARY (continued)
10) Pre/Post Thoracic Surgery
11) Instructing Patient in use of Incent. Spirometer
12) COPD
13) CHF
14) Asthma
1) Caring for Diabetic Patient
2) Checking Capilliary Blood Glucose
3) Hormone Therapy
1) Standard Precations
2) Caring for AIDS Patient
4) Mixing and Administering Chemo Agents
1) Inserting and Maintaining NG Feeding Tubes
2) Administering Feeding Tubes
3) Checking Tube Feeding and NG Tube Placement
4) Inserting and Maintaining Continuous Suction NG Tubes
5) Caring for Acute GI Bleed
6) Managing Abdominal Wounds
7) Pre/Post-Op GI Surgery
8) Stools Tests
9) Assessing Bowels Sounds
10) Ileostomy/Colostomy Care
11) Obtaining Culture Samples for Bacterial, Viral Studies
12) Nasal Washing for ILI
13) Caring for Patient on Total Parenteral Nutrition
1) Inserting/ Maintaining Urinary Catheters
2) Caring for Patient with Acute Renal Failure
3) Caring for Patient with Chronic Renal Failure
4) Caring for Post Renal/ Genitourinary Surgery
5) Caring for Patient with Post Peritoneal Dialysis
6) Caring for Patient with Post Hemodialysis
7) Collecting Urine Specimens
8) Managing Urostomy
9) Managing Suprapubic Catheter
1) Neuro Vital Assessment
2) Seizure Precations
3) Managing Halo Traction
4) Caring for Patients with Spinal Cord Injury
5) Pre/ Post Neurological Surgery
6) Caring for Patients with:
7) Degenerative Diseases of the Nervous System
8) Drug Overdoses
9) Head Injury
10) Cerebral aneurysm
11) Chronic CVA/ TIA
12) Managing Patient with Epidurl Catheter
1) Caring for Patients with:
2) Braces
3) Casts
4) Collars
5) Slings/Sprints
6) Skeletal and Skin Traction
7) Traction
8) Using TENS Unit
9) Crutch Walking/Walkers
10) Total Knee Replacement
11) Total Hip Replacement
12) Athroscopy/ Athrotomy
13) Amputation
14) Caring for Patient on Continuous Passive Motion
1) Administering Blood and Blood Products
2) Caring for Drains and Tubes (i.e. Hemovac)
3) Establishing IV's
4) Obtaining Peripheral Venous Blood
5) Monitoring and assessing I and O
6) Performing Complex Dressing Changes
7) Using PCA Systems
8) Using SCD or Venidyne Devices
9) Using PICC , Hickman Central Line
1) Acetaminophen (Tylenol)
2) Acetylsaliccylic Acid (Aspirin, ASA)
3) Antibiotics
4) Beta Blockers
5) Calcium Channel Blockers
6) Cimetidine (Tagamet)
7) Codeine
8) Dexamethasone (Decadron)
9) Diazepam (Valium)
10) Digoxin (Lanoxin)
11) Duramorph
12) Furosemide (Lasix)
13) Heparin
14) Insulin
15) Lorazepam (Ativan)
16) Morphine
17) Naloxone (Narcan)
18) Nitroglycerine
19) Phenytoin (Dilantin)
20) Potassium Chloride
21) Theophylline
22) Verapamil (Calan)
23) Warfarin (Coumadin)
1) Inhalation Medications
2) Oral Medications
3) Topical Medications
4) Vaginal Suppositories
5) Rectal Suppositories
6) Intravenously
7) Subcutaneously
8) Intra Muscularly
9) Naso/ Gastric
10) Gastric J Tube
Please check the box or boxes that corresponds with your expertise in age related care: Newborn/ Neonate (birth to 30 days ) Adolescent (12 to 18 years) Infant (30 days to 1 year Young Adult (18 to 39 years) Toddler (1 to 3 years) Middle Adult (39 to 64 years) Preschooler (3 to 5 years) Old Adult (64 years and older) School age children (5 to 12 years) I confirm that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form.


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