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Please rate your experience / frequency within the last year

0 = No Experience / Observed Only

1 = Limited Experience / Rarely Done (<6 times/year)

2 = May Need Some Review / Occasionally Done (1 - 2 times/month)

3 = Experienced / Frequently Done (daily or weekly)

AGE OF PATIENTS CARED FOR

Newborn/Neonate (birth to 30 days)
Infant (31 days to 12 months)
Toddler/Preschool (13 months to 5 years)
School Age Child/adolescent (6 years to 18 years)
Young Adults/Middle Adult (19 years to 64 years)
Older Adults/Elderly (65+ years)

GENERAL SKILLS

Care of Patient in Restraints
TYPE OF FACILITY EXPERIENCE
Electronic Documentation
IV Pumps
Peripheral IV Insertion, Care and Maintenance
Access/Management of Implanted Ports
Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
Cardiac Monitoring/Interpretation
Titration of drips
Administration of Blood/Blood Products
Do you have charge/supervisor experience?
Knowledge of current Joint Commission National Patient Safety Goals
Knowledge/familiarity with HCAHPS scores

MEDICATION ADMINISTRATION

Moderate/Conscious Sedation
Sedation Reversal Agents
Contrast Medium
Antiemetics
Narcotic Pain Medications

PRE-PROCEDURE

Allen Test
Doppler
EKG lead/pad placement
Blood Pressure Invasive and NonInvasive

HEMODYNAMIC MONITORING

Art Line
Swan Ganz
Waveform Assessment

CARE AND MAINTENANCE OF

Arterial Line
Swan Ganz
IABP
Sheath/Removal of Sheath

GENERAL SKILLS

Calculate mcg/min and mcg/kg/min
Diprovan (Propofol)
Esmolol (Brevibloc)
Lopressor (Metoprolol)
Diltiazem HCL (Cardizem)
Digoxin (Lanoxin)
Nitroglycerin (SL,IV,IC)
Adenocard (Adenosine)
Amiodarone (Cordarone)
Corvert (Ibutilide)
Dobutrex (Dobutamine)
Dopamine Hydrochloride
Aggrastat (Tirofiban)
ReoPro (Abciximab)
TPA (Alteplase)/Strepotkinase
Heparin

CARDIOVASCULAR

Hematoma Recognition/Management
Radial, brachial, femoral, pedal pulse checks
Assessment of heart sounds
General labwork/cardiac enzyme interpretation
ABG Interpretation
Coagulation Interpretation

PULMONARY

Set up Oxygen Delivery Devices(Cannula, NRBM, Ambu)
Assist with Intubation
Suction equipment (oral,NP, In line)
Assessment of breath sounds

NEUROLOGICAL

Identify Sudden Change in LOC
Assess Sensory, Motor, Speech Function,Gag reflex
Glasgow Coma Scale

PULMONARY

Panning Table
Moving Image Intensifier, Knowledge of views( RAO, LAO, cranial, caudal)
Circulate Diagnostic Procedures
Circulate Interventional Procedures
Monitoring/Recording cases
Cardiac Catheterization - Adult (R/L)
Cardiac Catheterization - Pediatric (R/L)
Ventricular Assistive Devices
Coronary Atherectomy
Transluminal Extraction Catheter
Thrombolysis/Thrombectomy
AngioJet
Cardiac Biopsy
Pericardial Tap
Valvuloplasty
Intra Aortic Balloon Pump (IABP) insertion and set up
Continuous Arteriovenous Hemofiltration (CAVH)
Cardioversion
Brachytherapy
FFR (radiwire)
Embolic Protection Devices

PACEMAKERS

Permanent Pacemaker/AICD
Temporary Epicardial/Transthoracic Pacing
Temporary External /transvenous pacing

CARE OF PATIENT DURING EMERGENCY PROCEDURES

Emergency Defibrillation/ Cardioversion
Anaphylaxis
Vasovagal Response
Pneumothorax
Cardiogenic Shock
Embolism
Myocardial Infarction

EQUIPMENT/SUPPLIES

(Hemochron)ACT Machine
Power Injectors
Manual Pressure Hold
Femostop/ C-Clamp
VasoSeal, Angioseal, PerClose

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