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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.
 
 
 
 
 
Signature                  :
     
 
Date                  :
     
          Phone                  :
   
   My Recruiting Professional at Health Source Group is:
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      BCLS:

      ACLS: 

      PALS:

      Chemo: 

 
          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= comfortable/highly experienced in this area

Area

Not Applicable

Inexperienced

Limited

Experienced

Highly Experienced

CARDIOVASCULAR

Auscultation (rate, rhythm, volume)

N/A  

1

2

3

4

Blood pressure/invasive (arterial line)

N/A  

1

2

3

4

Heart sounds/murmurs

N/A  

1

2

3

4

Perfusion

N/A  

1

2

3

4

Central venous pressure

N/A  

1

2

3

4

EKG interpretation

N/A  

1

2

3

4

Non-invasive cardiac monitoring

N/A  

1

2

3

4

Pulmonary artery/capillary wedge

N/A  

1

2

3

4

Right/left atrial

N/A  

1

2

3

4

Bacterial endocarditis

N/A  

1

2

3

4

Cardiac arrest

N/A  

1

2

3

4

Cardiomyopathy

N/A  

1

2

3

4

Congenital heart defects/disease

N/A  

1

2

3

4

Hypovolemic shock

N/A  

1

2

3

4

Myocarditis

N/A  

1

2

3

4

Post cardiac surgery

N/A  

1

2

3

4

Digoxin

N/A  

1

2

3

4

Dobutamine(Dobutrex)

N/A  

1

2

3

4

Dopamine (Intropin)

N/A  

1

2

3

4

Epinephrine(Adrenaline)

N/A  

1

2

3

4

Heparin

N/A  

1

2

3

4

Isoproterenal

N/A  

1

2

3

4

Lidocaine (Xylocaine)

N/A  

1

2

3

4

Mannitol

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

 

PULMONARY

Breath sounds

N/A  

1

2

3

4

Rate and work of breathing

N/A  

1

2

3

4

Blood gases

N/A  

1

2

3

4

X-ray reports

N/A  

1

2

3

4

Equipment & Procedures:

N/A  

1

2

3

4

Assist with extubation

N/A  

1

2

3

4

Assist with intubation

N/A  

1

2

3

4

Bulb syringe

N/A  

1

2

3

4

Endotracheal tube suctioning

N/A  

1

2

3

4

Nasal airway/suctioning

N/A  

1

2

3

4

Oral airway/suctioning

N/A  

1

2

3

4

Tracheostomy/suctioning

N/A  

1

2

3

4

Apnea monitor use

N/A  

1

2

3

4

Chest physiotherapy

N/A  

1

2

3

4

Assist with chest tube insertion/removal

N/A  

1

2

3

4

Chest tube set-up

N/A  

1

2

3

4

Obtaining blood gases

N/A  

1

2

3

4

Arterial

N/A  

1

2

3

4

Heel stick

N/A  

1

2

3

4

Peripheral

N/A  

1

2

3

4

Pulse oximeter use

N/A  

1

2

3

4

(Anesthesia) bag &mask

N/A  

1

2

3

4

(Self-inflating) bag &mask

N/A  

1

2

3

4

Isolette

N/A  

1

2

3

4

Nasal cannula

N/A  

1

2

3

4

Nebulizer

N/A  

1

2

3

4

Oxyhood

N/A  

1

2

3

4

Tent

N/A  

1

2

3

4

Trach collar

N/A  

1

2

3

4

Thoracentesis

N/A  

1

2

3

4

CPAP/PEEP

N/A  

1

2

3

4

High frequency jet ventilator

N/A  

1

2

3

4

IMV

N/A  

1

2

3

4

Pressure ventilator

N/A  

1

2

3

4

Volume ventilator

N/A  

1

2

3

4

Weaning

N/A  

1

2

3

4

Bronchiolitis (RSV)

N/A  

1

2

3

4

Chronic respiratory disease

N/A  

1

2

3

4

Croup

N/A  

1

2

3

4

Epiglottitis

N/A  

1

2

3

4

Foreign body aspiration

N/A  

1

2

3

4

Fresh tracheostomy

N/A  

1

2

3

4

Hemothorax

N/A  

1

2

3

4

Pneumonia

N/A  

1

2

3

4

Pneumothorax

N/A  

1

2

3

4

Respiratory distress

N/A  

1

2

3

4

Respiratory failure

N/A  

1

2

3

4

Status asthmaticus

N/A  

1

2

3

4

Aminophylline (Theophylline)

N/A  

1

2

3

4

Prostaglandin

N/A  

1

2

3

4

 

NEUROLOGICAL

Assessment of neurological status

N/A  

1

2

3

4

Intracranial pressure monitoring

N/A  

1

2

3

4

Brain death/organ procurement

N/A  

1

2

3

4

Coma

N/A  

1

2

3

4

Encephalitis

N/A  

1

2

3

4

External VP shunt

N/A  

1

2

3

4

Head trauma

N/A  

1

2

3

4

Meningitis

N/A  

1

2

3

4

Neuromuscular disease

N/A  

1

2

3

4

Post neurosurgery

N/A  

1

2

3

4

Spinal cord injury

N/A  

1

2

3

4

Status epilepticus

N/A  

1

2

3

4

Use of anticonvulsant medication

N/A  

1

2

3

4

 

ORTHOPEDICS

Cervical traction

N/A  

1

2

3

4

Pinned fractures

N/A  

1

2

3

4

Post-vertebral surgery

N/A  

1

2

3

4

 

GASTROINTESTINAL

Abdominal assessment

N/A  

1

2

3

4

Nutritional assessment

N/A  

1

2

3

4

Equipment & procedures

N/A  

1

2

3

4

Abdominal decompression device

N/A  

1

2

3

4

Assist with breast feeding

N/A  

1

2

3

4

Bottle

N/A  

1

2

3

4

Breast milk handling and storage

N/A  

1

2

3

4

Gavage

N/A  

1

2

3

4

Gastrostomy/button

N/A  

1

2

3

4

Jejunal

N/A  

1

2

3

4

Nasogastric (NG tube)

N/A  

1

2

3

4

Test for occult blood

N/A  

1

2

3

4

Abdominal surgery

N/A  

1

2

3

4

Fresh ostomy

N/A  

1

2

3

4

Gastroenteritis/dehydration

N/A  

1

2

3

4

GE reflux

N/A  

1

2

3

4

GI bleeding

N/A  

1

2

3

4

Hepatic failure

N/A  

1

2

3

4

Hepatitis

N/A  

1

2

3

4

Stress ulcer

N/A  

1

2

3

4

 

RENAL/GENITOURINARY

Assessment of fluid balance

N/A  

1

2

3

4

Test urine and interpret lab results (glucose, occult blood, pH, specific gravity)

N/A  

1

2

3

4

Assist with supra-pubic tap

N/A  

1

2

3

4

Catheter

N/A  

1

2

3

4

Diaper/bag

N/A  

1

2

3

4

Foley catheter insertion and care

N/A  

1

2

3

4

Straight catheterization

N/A  

1

2

3

4

Care of supra-pubic catheter

N/A  

1

2

3

4

Acute renal failure

N/A  

1

2

3

4

Hemodialysis

N/A  

1

2

3

4

Nephritis

N/A  

1

2

3

4

Nephrotic syndrome

N/A  

1

2

3

4

Peritoneal dialysis

N/A  

1

2

3

4

Post-renal transplant

N/A  

1

2

3

4

Syndrome inappropriate ADH (SIADH)

N/A  

1

2

3

4

 

ENDOCRINE/METABOLIC

Assessment of electrolyte balance

N/A  

1

2

3

4

Blood glucose monitoring

N/A  

1

2

3

4

Care of the child with diabetic ketoacidosis

N/A  

1

2

3

4

Assess for signs and symptoms of insulin shock/diabetic coma

N/A  

1

2

3

4

Insulin administration

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 decubitis 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

 

ONCOLOGY

Assessment of nutritional status

N/A  

1

2

3

4

Blood chemistry

N/A  

1

2

3

4

Blood counts

N/A  

1

2

3

4

Reverse isolation

N/A  

1

2

3

4

Disseminated intravascular coagulation (DIC)

N/A  

1

2

3

4

Inpatient chemotherapy

N/A  

1

2

3

4

Leukemia

N/A  

1

2

3

4

Malignant tumors

N/A  

1

2

3

4

Radiation implant

N/A  

1

2

3

4

Sickle cell anemia

N/A  

1

2

3

4

 

INFECTIOUS DISEASES

Interpretation of lab results:

N/A  

1

2

3

4

CBC/differential

N/A  

1

2

3

4

Culture reports

N/A  

1

2

3

4

Assist with lumber puncture

N/A  

1

2

3

4

Collect culture specimens

N/A  

1

2

3

4

Cytomegalovirus virus (CMV)

N/A  

1

2

3

4

HIV/AIDS

N/A  

1

2

3

4

Tuberculosis

N/A  

1

2

3

4

 

IV THERAPY

Start peripheral IV’s

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

 

MEDICATION ADMINISTRATION AND USE

Calculation of drugs delivered by continuous infusion

N/A  

1

2

3

4

Dosage calculations

N/A  

1

2

3

4

Eye/ear installations

N/A  

1

2

3

4

IM injections

N/A  

1

2

3

4

IV medications

N/A  

1

2

3

4

Metered dose inhaler

N/A  

1

2

3

4

SQ injections

N/A  

1

2

3

4

Knowledge of emergency drug action and reactions

N/A  

1

2

3

4

 

OTHER NURSING RESPONSIBILITIES

Charge nurse experience

N/A  

1

2

3

4

Use of restraints

N/A  

1

2

3

4

Knowledge of normal growth and development

N/A  

1

2

3

4

Recognize/report signs of child abuse and/or neglect

N/A  

1

2

3

4

Anorexia/bulimia

N/A  

1

2

3

4

Blunt trauma

N/A  

1

2

3

4

Craniofacial reconstruction

N/A  

1

2

3

4

ENT surgery

N/A  

1

2

3

4

Gun shot/open chest

N/A  

1

2

3

4

Ingestion/overdose

N/A  

1

2

3

4

Multiple trauma

N/A  

1

2

3

4

Near drowning

N/A  

1

2

3

4