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Personal Information

First Name
 Last Name
Social Security #

(ex. 987654321)		 Date

(ex. 02/18/1981)
E-Mail Address
 Phone Number

(ex. 123-456-7890)

Experience Level

Please rate your level of experience for the sections 1-12 by using this scale:

  • A - Not Applicable
  • B - No Experience
  • C - Some Experience
  • D - Competent and Skilled

Section 1: Cardiovascular
  A. Assessment:
    1. Abnormal Heart Sounds/Murmurs A B C D
    2. Auscultation A B C D
    3. Blood Pressure/Non-Invasive A B C D
    4. Doppler A B C D
    5. Pulse/Circulation Checks A B C D
  B. Care of patient with the following:
    1. Abdominal Aortic Bypass A B C D
    2. Acute MI A B C D
    3. Cardiac Arrest A B C D
    4. Cardiac Tamponade A B C D
    5. Congestive Heart Failure A B C D
    6. Immediate Post Open-Heart Surgery A B C D
    7. Pericarditis A B C D
    8. Post Commissurotomy, Valve Repair/Replacement A B C D
    9. Post Intracoronary Stent Placement A B C D
    10. Post Percutaneous Balloon Valvuloplasty A B C D
    11. Post Rotoblade A B C D
    12. Pre/Post Angioplasty A B C D
    13. Pre/Post Cardiac Catheter A B C D
  C. Medications:
    1. Atropine A B C D
    2. Bicarbonate A B C D
    3. Bretylium A B C D
    4. Digoxin A B C D
    5. Dobutamine A B C D
    6. Dopamine A B C D
    7. Epinephrine A B C D
    8. Inocor A B C D
    9. Lidocaine A B C D
    10. Metoprolol A B C D
    11. Nipride A B C D
    12. Nitoglycerine A B C D
    13. Procainamide A B C D
    14. Reteplase Recombinant A B C D
    15. Streptokinase A B C D
    16. TPA A B C D
    17. Verapamil A B C D
  E. Procedures and Equipment:
    1. Assisted With the Following
      a. Arterial Line Insertion A B C D
      b. Central Line Insertion A B C D
      c. Open Chest Emergency A B C D
      d. PA Catheter/Swan-Ganz Insertion A B C D
      e. Pericardiocentesis A B C D
      f. Transesophageal Echocardiogram A B C D
    2. Automatic Internal Cardioverter Defibrillator A B C D
    3. Cardioversion A B C D
    4. CAVH-D A B C D
    5. Hemodynamic Monitoring
      a. Cardiac Index A B C D
      b. Cardiac Output A B C D
      c. CVP Monitoring A B C D
      d. Femoral Artery Sheath Removal A B C D
      e. MAP A B C D
      f. PA/Swan-Ganz A B C D
      g. PCW Pressure A B C D
      h. PVR A B C D
      i. Radial A-Line A B C D
      j. SVO2 A B C D
      k. SVR A B C D
    6. Intra Aortic Balloon Pump A B C D
    7. Monitoring
      a. 12 Lead EKG Interpretation A B C D
      b. Arrhythmia Interpretation A B C D
      c. Lead Placement A B C D
      d. Rhythm Strip Assessment A B C D
      e. Set-Up and Run 12 Lead EKG A B C D
    8. Pacemaker
      a. External A B C D
      b. Permanent A B C D
      c. Temporary A B C D
      d. Transthoracic A B C D
    9. Ventricular Assist Device A B C D

Section 2: Endocrine/Metabolic
  A. Care of patient with the following:
    1. Diabetes Mellitus A B C D
    2. Diabetes Ketoacidosis A B C D
    3. Disorders of the Adrenal Gland A B C D
    4. Disorders of Pituitary Gland A B C D
    5. Drug Overdose A B C D
    6. Hyperthyroidism A B C D
    7. Hypothyroidism A B C D
    8. Insulin Shock A B C D
    9. Thyroidectomy A B C D
B. Medications:
    1. Insulin Pump A B C D
  C. Procedures and Equipment:
    1. Blood Glucose Monitoring Device
    2. Blood Glucose Monitoring A B C D
    3. Performing Finger Stick A B C D
 

Section 3: Gastrointestinal
  A. Care of patient with the following:
    1. Bowel Obstruction A B C D
    2. Colostomy/Ileostomy A B C D
    3. ERCP A B C D
    4. Esophageal Bleeding A B C D
    5. GI Bleeding A B C D
    6. GI Surgery A B C D
    7. Hepatitis A B C D
    8. Inflammatory Bowel Disease A B C D
    9. Liver Failure A B C D
    10. Liver Transplant A B C D
    11. Pancreatitis A B C D
    12. Paralytic Ileus A B C D
  B. Procedures and Equipment:
    1. Administration of Tube Feeding A B C D
    2. Balloon Tamponade A B C D
    3. Feeding Pump A B C D
    4. Flexible Feeding Tube A B C D
    5. Gravity Feeding A B C D
    6. Iced Saline Lavage A B C D
    7. Management of the Following:
      a. Gastrostomy Tube

A B C D

      b. Jejunostomy Tube A B C D
      c. T-Tube A B C D
      d. TPN and Lipids Administration A B C D
      e. PPN A B C D
    8. Placement of Nasogastric Tube A B C D
    9. Salem Sump to Suction A B C D
 

Section 4: Neurological
  A. Assessment:
    1. Cranial Nervers A B C D
    2. Glasgow Coma Scale A B C D
    3. Level of Consciousness A B C D
    4. Pathologic Reflexes A B C D
    5. Reflex/Motor Deficits A B C D
    6. Visual or Communication Deficits A B C D
  B. Care of patient with the following:
    1. Aneurysm Precautions A B C D
    2. Basal Skull Fracture A B C D
    3. Closed Head Injury A B C D
    4. Coma A B C D
    5. CVA A B C D
    6. DT's A B C D
    7. Encephalitis A B C D
    8. Externalized VP Shunts A B C D
    9. Increased ICP A B C D
    10. Laminectomy A B C D
    11. Meningitis A B C D
    12. Metastatic Tumor/Intracranial Tumor Resection A B C D
    13. Multiple Sclerosis A B C D
    14. Post Craniotomy A B C D
    15. Spinal Cord Injury A B C D
  C. Procedures and Equipment:
    1. Assist With Lumbar Puncture A B C D
    2. Halo Traction/Cervical Tongs A B C D
    3. Intracranial Pressure Monitoring A B C D
    4. Nerve Stimulators A B C D
    5. Rotating Bed A B C D
    6. Seizure Precautions A B C D
    7. Spinal Precautions A B C D
    8. Stryker Frame A B C D
    9. Use of Hyper/Hypothermia Blanket A B C D
 

Section 5: Pain Management
  A. Assessment of Pain Level/Tolerance A B C D
  B. Care of patient with the following:
    1. Epidural Anesthesia/Analgesia A B C D
    2. IV Conscious Sedation A B C D
    3. Patient Controlled Analgesia A B C D
 

Section 6: Phlebotomy/IV Therapy
  A. Care of patient with the following:
    1. Central Line/Catheter/Dressing
      a. Broviac

A B C D

      b. Groshong A B C D
      c. Hickman A B C D
      d. Portacath A B C D
      e. Quinton A B C D
    2. Peripheral Line/Dressing A B C D
  B. Procedures and Equipment:
    1. Administration of Blood/Blood Products:
      a. Cryoprecipitate

A B C D

      b. Packed Red Blood Cells

A B C D

      c. Plasma/Albumin A B C D
      d. Whole Blood A B C D
    2. Drawing Blood from Central Line A B C D
    3. Drawing Venous Blood A B C D
    4. Starting IV's:
      a. Angiocath

A B C D

      b. Butterfly A B C D
      c. Heparin Lock A B C D
 

Section 7: Pulmonary
  A. Care of patient with the following:
    1. Acute Pneumonia A B C D
    2. ARDS A B C D
    3. Chest Trauma A B C D
    4. COPD A B C D
    5. Cor Pulmonale A B C D
    6. Fresh Tracheostomy A B C D
    7. Lobectomy A B C D
    8. Lung Transplant A B C D
    9. Near Drowning A B C D
    10. Pneumonectomy A B C D
    11. Pulmonary Edema/Hypertension A B C D
    12. Pulmonary Embolism A B C D
    13. Status Asthmaticus A B C D
    14. Thoracotomy A B C D
    15. Tuberculosis A B C D
  B. Interpretation of Lab Results:
    1. Arterial Blood Gases A B C D
  C. Procedures and Equipment:
    1. Air Leak Troubleshooting
      a. Mediastinal Chest Tube Removal A B C D
      b. Pleural Chest Tube Removal A B C D
    2. Airway Management Devices/Suctioning
      a. Endotracheal Tube/Suctioning A B C D
      b. Extubation A B C D
      c. Nasal Airway/Suctioning A B C D
      d. Oximetry A B C D
      e. Sputum Specimen Collection A B C D
      f. Tracheostomy/Suctioning A B C D
    3. Assisted  With the Following:
      a. Bronchoscopy A B C D
      b. Chest Tube Insertion A B C D
      c. Thoracentesis A B C D
    4. Establishing An Airway
      a. Assist With Intubation A B C D
      b. Oral Airway Insertion A B C D
    5. Identification/Intervention For Respiratory Complications
      a. Aspiration A B C D
      b. Laryngospasm A B C D
      c. Tension Pneumothorax A B C D
      d. Use of Pleurevac or Thorclex Drainage A B C D
      e. Use of Water Seal Drainage A B C D
    6. Oxygen Therapy and Medication Delivery Systems
      a. Ambu Bag and Mask A B C D
      b. ET Tube A B C D
      c. Face Masks A B C D
      d. Nasal Cannula A B C D
      e. Portable Oxygen Tank A B C D
      f. Trach Collar A B C D
    7. Ventilator Management
      a. External CPAP A B C D
      b. High Frequency Jet Ventilation A B C D
      c. IMV A B C D
      d. PEEP A B C D
      e. Pressure Support A B C D
      f. Weaning Modes and T-Piece Weaning A B C D
 

Section 8: Renal/Genitourinary
  A. Assessment:
    1. Arterio Venous Fistula/Shunt A B C D
    2. Fluid Status A B C D
  B. Care of patient with the following:
    1. Acute Renal Failure A B C D
    2. CAVH Dialysis A B C D
    3. Hemodialysis A B C D
    4. Nephrectomy A B C D
    5. Peritoneal Dialysis A B C D
    6. Renal Rejection Syndrome A B C D
    7. Renal Transplant A B C D
    8. TURP A B C D
    9. Urinary Diversion/Ileal Conduit Nephrostomy A B C D
    10. Urinary Tract Infection A B C D
  C. Procedures and Equipment:
    1. Bladder Irrigation A B C D
    2. Insertion and Care of Straight and Foley Catheter
      a. 3-Way Foley A B C D
      b. Female A B C D
      c. Male A B C D
    3. Supra-Pubic A B C D
 

Section 9: Wound Management
  A. Assessment:
    1. Skin For Impending Breakdown A B C D
    2. Stasis Ulcers A B C D
    3. Surgical Wound Healing A B C D
  B. Care of patient with the following:
    1. Burns A B C D
    2. Pressure Sores A B C D
    3. Staged Decubitus Ulcers A B C D
    4. Surgical Wounds With Drain A B C D
    5. Traumatic Wounds A B C D
  C. Procedures and Equipment:
    1. Air Fluidized, Low Air Loss Beds A B C D
    2. Sterile Dressing Changes A B C D
    3. Wound Care/Irrigations A B C D
 

Section 10: Miscellaneous
  A. Care of patient with the following:
    1. Anaphylactic Shock A B C D
    2. Disseminated Intravascular Coagulation A B C D
    3. Hypovolemic Shock A B C D
    4. Multi-System Organ Failure A B C D
    5. Organ/Tissue Donation A B C D
    6. Septic Shock A B C D

Level of care per age group

Please rate your level of providing age-appropriate nursing care experience for the following sections by using this system:

  • A - Newborn (Birth - 30 Days)
  • B - Infant (30 Days - 1 Year)
  • C - Toddler (1 - 3)
  • D - Preschooler (3 - 5)
  • E - School Age (5 - 12)
  • F - Adolescent (12 - 18)
  • G - Young Adults (18 - 39)
  • H - Middle Adults (39 - 64)
  • I - Older Adults (64+)
  A B C D E F G H I
Able to adapt care to incorporate normal growth and development.
Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.
Can ensure a safe environment reflecting specific needs of various age groups.

Primary Experience

Please indicate, in number of years, your primary experience in the following fields:

Burn PACU
Cardiothoracic Surgical
Cardiovascular MAT/Child
Coronary Care PEDS:  
Medical OBG/GYN:
Neuro Pysch:
ER Other:

Certification(s)

Please check the boxes below and indicate the expiration date for each certificate that you have. If you do not know the exact date, please use the last date of the specific month (e.g., 08/31/2003).

BCLS Exp. Date (MM/DD/YY)
Other: Exp. Date (MM/DD/YY)
Computerized Charting System Exp. Date (MM/DD/YY)
Medication Administration System Exp. Date (MM/DD/YY)

Digital Signature

The following  two fields will act as your digital signature and are required.

The information I have given is true and accurate to the best of my knowledge. I hereby authorize ABC Health Care, Inc to release this Skills Checklist to Client facilities in relation to consideration of my employment with those facilities.
Your 8 digit birth date: (ex. 02181981)

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