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My responses in this checklist represent a true reflection of my experience and comfort level.

Please self-rate your comfort level in performing tasks in connection with the below checklist. Rate your level of comfort for each line item by following the below ranking system. Simply fill in the appropriate option immediately following the rating number.

     
   
 
     
   
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Level of Comfort/Experience

N/A=Non-applicable

1=Inexperienced in this area

2=Limited comfort/experience in this area

3=Comfortable/experienced in this area

4=Very comfortable/highly experienced in this area

Area

Not Applicable

Inexperienced

Limited

Experienced

Highly Experienced

Cardiovascular

Abnormal heart sounds/murmurs

N/A  

1

2

3

4

Auscultation (rate, rhythm)

N/A  

1

2

3

4

Pulses/circulation checks

N/A  

1

2

3

4

Use of doppler

N/A  

1

2

3

4

Interpretation of cardiac enzymes and isoenzymes

N/A  

1

2

3

4

Interpretation of coagulation studies

N/A  

1

2

3

4

Arterial line insertion

N/A  

1

2

3

4

Central line insertion

N/A  

1

2

3

4

Open Chest emergency

N/A  

1

2

3

4

PA catheter/Swan-Ganz insertion

N/A  

1

2

3

4

Pericardiocentesis

N/A  

1

2

3

4

Automatic internal cardioverter defibrillator

N/A  

1

2

3

4

Cardioversion/Defibrillation

N/A  

1

2

3

4

Cardiac index

N/A  

1

2

3

4

Cardiac output

N/A  

1

2

3

4

CVP monitoring (central venous pressure)

N/A  

1

2

3

4

MAP monitoring (mean arterial pressure)

N/A  

1

2

3

4

PA/Swan-Ganz

N/A  

1

2

3

4

PVR (pulmonary vascular resistance)

N/A  

1

2

3

4

Radial a-line

N/A  

1

2

3

4

SVO2 (mixed venous oxyhemoglobin)

N/A  

1

2

3

4

SVR (systemic vascular resistance)

N/A  

1

2

3

4

Arrhythmia interpretation

N/A  

1

2

3

4

Lead placement

N/A  

1

2

3

4

Rhythm strip assessment

N/A  

1

2

3

4

Set up, run, and interpretation of 12 lead EKG

N/A  

1

2

3

4

Temporary external pacing

N/A  

1

2

3

4

Temporary transvenous

N/A  

1

2

3

4

Temporary epicardial wires

N/A  

1

2

3

4

Permanent

N/A  

1

2

3

4

Abdominal aortic aneurysm repair

N/A  

1

2

3

4

Acute MI

N/A  

1

2

3

4

Cardiac arrest

N/A  

1

2

3

4

Cardiac tamponade

N/A  

1

2

3

4

CHF

N/A  

1

2

3

4

Heart transplant

N/A  

1

2

3

4

Immediate post open-heart surgery

N/A  

1

2

3

4

Infective endocarditis

N/A  

1

2

3

4

Myocardial contusion

N/A  

1

2

3

4

Pericarditis

N/A  

1

2

3

4

PTCA (percutaneous transluminal coronary angioplas

N/A  

1

2

3

4

Post percutaneous balloon valvuloplasty

N/A  

1

2

3

4

Pre/post angioplasty

N/A  

1

2

3

4

Pre/post cardiac cath

N/A  

1

2

3

4

Ventricular assist devices (IABP, RVAD, LVAD)

N/A  

1

2

3

4

Balloon Pumps

N/A  

1

2

3

4

Atropine

N/A  

1

2

3

4

Digoxin (Lanoxin)

N/A  

1

2

3

4

Dobutamine(Dobutrex)

N/A  

1

2

3

4

Dopamine (Intropin)

N/A  

1

2

3

4

Epinephrine (Adrenalin)

N/A  

1

2

3

4

Inocor (Amrinone)

N/A  

1

2

3

4

Isuprel

N/A  

1

2

3

4

Lidocaine (Xylocaine)

N/A  

1

2

3

4

Nipride (Nitroprusside)

N/A  

1

2

3

4

Nitroglycerine (Tridil)

N/A  

1

2

3

4

Sodium Bicarbonate

N/A  

1

2

3

4

TPA (Alteplase)

N/A  

1

2

3

4

 

Pulmonary

Adventitious breath sounds

N/A  

1

2

3

4

Rate and work of breathing

N/A  

1

2

3

4

Interpretation of ABGs (arterial blood gases)

N/A  

1

2

3

4

Assist with intubation

N/A  

1

2

3

4

Assist with extubation

N/A  

1

2

3

4

Insertion of oral airway

N/A  

1

2

3

4

Chest physiotherapy

N/A  

1

2

3

4

Incentive spirometer

N/A  

1

2

3

4

Use of Pleurevac or other chest drainage systems

N/A  

1

2

3

4

Monitor pulse oximetry

N/A  

1

2

3

4

Endotracheal tube suctioning

N/A  

1

2

3

4

Oropharyngeal suctioning

N/A  

1

2

3

4

Nasotracheal suctioning

N/A  

1

2

3

4

Assist with bronchoscopy

N/A  

1

2

3

4

Assist with chest tube insertion

N/A  

1

2

3

4

Assist with emergency tracheostomy

N/A  

1

2

3

4

Assist with thoracentesis

N/A  

1

2

3

4

Ambu bag techniques

N/A  

1

2

3

4

External CPAP

N/A  

1

2

3

4

High frequency jet ventilation

N/A  

1

2

3

4

IMV

N/A  

1

2

3

4

PEEP

N/A  

1

2

3

4

Pressure support

N/A  

1

2

3

4

Troubleshooting with vents

N/A  

1

2

3

4

Weaning from ventilator

N/A  

1

2

3

4

Acute pneumonia

N/A  

1

2

3

4

ARDS

N/A  

1

2

3

4

Chest trauma

N/A  

1

2

3

4

COPD

N/A  

1

2

3

4

Cor pulmonale

N/A  

1

2

3

4

ECMO

N/A  

1

2

3

4

Inhalation injuries

N/A  

1

2

3

4

Lobectomy

N/A  

1

2

3

4

Lung transplant

N/A  

1

2

3

4

Near drowning

N/A  

1

2

3

4

Pneumonectomy

N/A  

1

2

3

4

Pulmonary edema

N/A  

1

2

3

4

Pulmonary embolism

N/A  

1

2

3

4

Thoracotomy

N/A  

1

2

3

4

Tracheostomy

N/A  

1

2

3

4

TB (tuberculosis)

N/A  

1

2

3

4

Alupent (Metaproterenol)

N/A  

1

2

3

4

Corticosteroids

N/A  

1

2

3

4

Ventolin (Albuterol)

N/A  

1

2

3

4

 

Neuro

Assess LOC

N/A  

1

2

3

4

Use Glasgow coma scale

N/A  

1

2

3

4

Cranial nerve assessment

N/A  

1

2

3

4

Seizure precautions

N/A  

1

2

3

4

Spinal precautions

N/A  

1

2

3

4

Cervical traction

N/A  

1

2

3

4

Halo traction

N/A  

1

2

3

4

Assist with lumbar puncture

N/A  

1

2

3

4

Hypo/hyperthermia regulation

N/A  

1

2

3

4

ICP(intracranial pressure ) monitoring

N/A  

1

2

3

4

Nerve stimulators

N/A  

1

2

3

4

Aneurysm precautions

N/A  

1

2

3

4

Basal skull fracture

N/A  

1

2

3

4

Closed head injury

N/A  

1

2

3

4

Coma

N/A  

1

2

3

4

CVA

N/A  

1

2

3

4

DTs

N/A  

1

2

3

4

Encephalitis

N/A  

1

2

3

4

Externalized VP shunts

N/A  

1

2

3

4

Increased ICP

N/A  

1

2

3

4

Intracranial Hemorrhage

N/A  

1

2

3

4

Laminectomy

N/A  

1

2

3

4

Meningitis

N/A  

1

2

3

4

Metastatic tumor/intracranial tumor resection

N/A  

1

2

3

4

MS (multiple sclerosis)

N/A  

1

2

3

4

Post craniotomy

N/A  

1

2

3

4

Seizure disorder

N/A  

1

2

3

4

Spinal cord injury

N/A  

1

2

3

4

Ventriculostomy

N/A  

1

2

3

4

Decadron (Dexamethasone)

N/A  

1

2

3

4

Dilantin (Phenytoin)

N/A  

1

2

3

4

Epidural administration

N/A  

1

2

3

4

Magnesium Sulfate

N/A  

1

2

3

4

Phenobarbital

N/A  

1

2

3

4

Valium (Diazepam)

N/A  

1

2

3

4

 

Gastrointestinal

Assessment of abdomen (bowel sounds)

N/A  

1

2

3

4

Administration of tube feeding

N/A  

1

2

3

4

Balloon tamponade (i.e., Sengstaken-Blakemore)

N/A  

1

2

3

4

Feeding pump

N/A  

1

2

3

4

Flexible feeding tube (i.e., Corpak, Dubhoff)

N/A  

1

2

3

4

Gravity feeding

N/A  

1

2

3

4

Iced saline lavage

N/A  

1

2

3

4

Salem sump to suction

N/A  

1

2

3

4

Gastrostomy tube

N/A  

1

2

3

4

Jejunostomy tube (J-tube)

N/A  

1

2

3

4

T-Tube

N/A  

1

2

3

4

Blunt trauma

N/A  

1

2

3

4

Bowel obstruction

N/A  

1

2

3

4

Colostomy

N/A  

1

2

3

4

Esophageal bleeding

N/A  

1

2

3

4

GI bleeding

N/A  

1

2

3

4

GI surgery

N/A  

1

2

3

4

Hepatitis

N/A  

1

2

3

4

Ileostomy

N/A  

1

2

3

4

Inflammatory bowel disease

N/A  

1

2

3

4

Liver failure

N/A  

1

2

3

4

Liver transplant

N/A  

1

2

3

4

Pancreatitis

N/A  

1

2

3

4

Paralytic ileus

N/A  

1

2

3

4

Penetrating trauma

N/A  

1

2

3

4

Aqua Mephyton (Vitamin K)

N/A  

1

2

3

4

Inderal (Propranolol)

N/A  

1

2

3

4

Kayexelate

N/A  

1

2

3

4

Lactulose (Cephulac)

N/A  

1

2

3

4

Pitressin (Vasopressin)

N/A  

1

2

3

4

TPN and lipid administration

N/A  

1

2

3

4

PPN (peripheral parenteral nutrition)

N/A  

1

2

3

4

 

Renal

Bladder irrigation

N/A  

1

2

3

4

Insertion and care of Foley catheter

N/A  

1

2

3

4

Care of the patient with:

N/A  

1

2

3

4

Acute renal failure

N/A  

1

2

3

4

End stage renal disease

N/A  

1

2

3

4

Hemodialysis

N/A  

1

2

3

4

Nephrectomy

N/A  

1

2

3

4

Nephrectomy tube placement

N/A  

1

2

3

4

Peritoneal dialysis

N/A  

1

2

3

4

Renal rejection syndrome

N/A  

1

2

3

4

Renal transplant

N/A  

1

2

3

4

Supra-pubic catheter

N/A  

1

2

3

4

TURP

N/A  

1

2

3

4

Urinary diversion (ileal conduit nephrostomy)

N/A  

1

2

3

4

UTI

N/A  

1

2

3

4

 

Wound care

Wound care irrigations

N/A  

1

2

3

4

Sterile dressing changes

N/A  

1

2

3

4

Burns

N/A  

1

2

3

4

Pressure sores

N/A  

1

2

3

4

Staged decubitus ulcers

N/A  

1

2

3

4

Surgical wounds with drains (i.e.JP)

N/A  

1

2

3

4

Traumatic wounds

N/A  

1

2

3

4

 

IV Therapy

Start peripheral IVs

N/A  

1

2

3

4

Drawing blood from central line

N/A  

1

2

3

4

Drawing venous blood

N/A  

1

2

3

4

Cryoprecipitate

N/A  

1

2

3

4

Packed red blood cells

N/A  

1

2

3

4

Plasma/albumin

N/A  

1

2

3

4

Whole blood

N/A  

1

2

3

4

IV calculations/titrate drip rates

N/A  

1

2

3

4

Use of infusion pumps

N/A  

1

2

3

4

Broviac

N/A  

1

2

3

4

Groshong

N/A  

1

2

3

4

Hickman

N/A  

1

2

3

4

Portacath

N/A  

1

2

3

4

Quinton

N/A  

1

2

3

4

 

Other nursing responsibilities

Charge nurse responsibilities

N/A  

1

2

3

4

Isolation procedures/precautions

N/A  

1

2

3

4

Use of restraints

N/A  

1

2

3

4

Blood glucose monitoring

N/A  

1

2

3

4

Insulin administration

N/A  

1

2

3

4

Assess for signs and symptoms of insulin shock/diabetic coma

N/A  

1

2

3

4

Oncology/chemotherapy administration

N/A  

1

2

3

4

Collection and handling of lab specimens (blood, nasopharyngeal, stool, urine, wound)

N/A  

1

2

3

4

Anaphylactic shock

N/A  

1

2

3

4

Disseminated intravascular coagulation (DIC)

N/A  

1

2

3

4

Hypovolemic shock

N/A  

1

2

3

4

MAST suit/rotating tourniquets

N/A  

1

2

3

4

Multi-system organ failure

N/A  

1

2

3

4

Organ/tissue donation

N/A  

1

2

3

4

Septic shock

N/A  

1

2

3

4