HSI SKILLS ASSESSMENT - Medical/Surgical NAME: DATE: 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 PATIENT AND FAMILY TEACHING 1) Diabetes 2) Colonstomy/ Ileostomy 3) Nutrition 4) Skin Care CARDIOVASCULAR 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 PULMONARY 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 ENDOCINE 1) Caring for Diabetic Patient 2) Checking Capilliary Blood Glucose 3) Hormone Therapy ONCOLOGY 1) Standard Precations 2) Caring for AIDS Patient 4) Mixing and Administering Chemo Agents GASTROINTESTINAL 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 GENITOURINARY/ RENAL 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 NUROLOGY 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 MUSCULOSKELETAL 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 MISCELLANEOUS 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 CARING FOR PATIENTS RECEIVING THE FOLLOWING 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) ADMINISTERING MEDICATION 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)
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