Perfusionist

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Email us: info@ikajuq.ca

Call us: 1-888-272-9977

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Opthalmic/Otic Medication

1

2

3

Rectal/vaginal medication

1

2

3

IM/SQ medication

1

2

3

IV push medications

1

2

3

IVPB medications

1

2

3

Continuous infusions

1

2

3

PPN

1

2

3

TPN

1

2

3

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)

1

2

3

Infant (31 days to 12 months)

1

2

3

Toddler/Preschool (13 months to 5 years)

1

2

3

School Age Child/adolescent (6 years to 18 years)

1

2

3

Young Adults/Middle Adult (19 years to 64 years)

1

2

3

Older Adults/Elderly (65+ years)

1

2

3

GENERAL SKILLS

Standard Precautions

1

2

3

Isolation Precautions

1

2

3

Pediatric Respiratory/Cardiac Arrest

1

2

3

Adult Respiratory/Cardiac Arrest

1

2

3

Crash Carts

1

2

3

Defibrillators

1

2

3

Care of Patient in Restraints

1

2

3

Pain Management

1

2

3

Automated Med Dispensing Systems

1

2

3

Care Planning & Discharge Planning

1

2

3

Patient/Family Education

1

2

3

Electronic Documentation

1

2

3

System Used - Please List

Patient Head to Toe Assessment

1

2

3

Dressing Changes

1

2

3

Knowledge of Normal Serum Lab Values

1

2

3

Obtaining Cultures (Blood, Sputum, Swab)

1

2

3

Administration of Blood & Blood Products

1

2

3

PCA Pumps

1

2

3

Infusion Pump

1

2

3

Calculate mcg/min and mcg/kg/min

1

2

3

Titrating Medications

1

2

3

KNOWLEDGE AND USE OF

Sedatives

1

2

3

Analgesics

1

2

3

Propofol

1

2

3

Epinephrine

1

2

3

Vasopressin

1

2

3

Amiodarone

1

2

3

TPA

1

2

3

Atropine

Yes

No

Bretylol

1

2

3

Bumex

1

2

3

Digoxin

1

2

3

Dopamine

1

2

3

Dobutrex

1

2

3

Heparin Drip (Precautions & Maintenance)

1

2

3

Inderal

1

2

3

Inocor

1

2

3

Isuprel

1

2

3

Lidocaine

1

2

3

Neosynephrine/Nipride

1

2

3

Nitroglycerin

1

2

3

Pronestyl

1

2

3

Titrate Morphine

1

2

3

Thrombolytic Agents

1

2

3

Magnesium Sulfate

1

2

3

Versed

1

2

3

Prep/Titration of Emergency Drugs

1

2

3

CARDIAC GENERAL SKILLS

Interpretation of 12 lead EKG

1

2

3

Interpretation of Arrhythmias

1

2

3

Defibrillation/Cardioversion

1

2

3

Permanent Pacemaker

1

2

3

Temporary Pacemaker

1

2

3

AICD

1

2

3

Interpretation of Hemodynamic Monitoring

1

2

3

Art-Line (Transducer set-up, D/C)

1

2

3

Swan-Ganz (Transducer set-up, D/C)

1

2

3

Balloon Pump (IABP)

1

2

3

SVO2 Monitoring

1

2

3

Sheath Removal

1

2

3

Interpretation of Cardiac Enzymes

1

2

3

CARDIAC -Care of Patient With:

Aneurysm

1

2

3

Acute MI/Unstable Angina

1

2

3

CHF

1

2

3

Cardiogenic/Hypovolemic Shock

1

2

3

Pre/Post Cardiac Surgery

1

2

3

Pre/Post Cardiac Cath

1

2

3

Percutaneous Transluminal Coronary Angioplasty

1

2

3

Heart Transplant

1

2

3

RESPIRATORY GENERAL SKILLS

Establishing an Airway

1

2

3

Oxygen Delivery Systems

1

2

3

Chest Tubes (Emerson/Pleuravac)

1

2

3

Pulse Oximetry

1

2

3

Interpretation of ABG

1

2

3

Drawing ABG Blood Sample from Art-Line

1

2

3

Use of IPPB

1

2

3

Suctioning

1

2

3

VASCULAR GENERAL SKILLS

Peripheral Pulses

1

2

3

Dopplers

1

2

3

Peripheral IV Insertion, Care and Maintenance

1

2

3

Assisting with Insertion of Central Lines

1

2

3

Care and Maintenance of Central Lines

1

2

3

Assist with IV Cutdown

1

2

3

OTHER

Care of Oncology Patient

1

2

3

Chemotherapy Administration

1

2

3

Care of Patient with Burns

1

2

3

Care of Patient with HIV/AIDS

1

2

3

Hyperbaric Oxygenation

1

2

3

Suicide Precautions

1

2

3

Post Mortem Cares

1

2

3

PERFUSIONIST SKILLS

Patient identification

1

2

3

Procedure confirmation

1

2

3

Blood type, antibodies confirmed

1

2

3

Allergies checked

1

2

3

Blood bank number confirmed

1

2

3

Medical record number confirmed

1

2

3

Chart review

1

2

3

Components checked for package integrity/expiration

1

2

3

Equipment clean

1

2

3

Heat exchanger(s) leak-tested

1

2

3

Occlusion(s) set

1

2

3

Speed controls operational

1

2

3

Flow meter

1

2

3

Rollers, Pump Head & Holder Checks

1

2

3

Servoregulated connections

1

2

3

Cardioplegia-System Checks

1

2

3

Knowledge of Gas line(s) and filer connection

1

2

3

Gas exhaust

1

2

3

Flow meter / gas blender operational

1

2

3

Hoses leak-free

1

2

3

Anesthetic gas scavenge line

1

2

3

Alarms operational

1

2

3

Arterial filter / bubble trap debubbled

1

2

3

Vent(s) tested

1

2

3

Venous line occluder(s) calibrated and tested

1

2

3

Devices securely attached

1

2

3

Cardiotomy positive-pressure relief valve

1

2

3

Negative- pressure relief valve

1

2

3

Vacuum regulator

1

2

3

Circuit / patient temperature probes

1

2

3

Pressure transducers

1

2

3

Inline sensors

1

2

3

Oxygen analyzer

1

2

3

Oxygen analyzer

1

2

3

Water source(s)

1

2

3

Temperature range(s)

1

2

3

Water lines

1

2

3

Tubing clamps

1

2

3

Drugs available and properly labeled

1

2

3

Solutions

1

2

3

Blood products

1

2

3

Sampling syringes / laboratory tubes

1

2

3

Anesthetic vaporizer

1

2

3

Vaporizer

1

2

3

Hand cranks

1

2

3

Duplicate circuit components / hardware

1

2

3

Emergency lighting / flashlight

1

2

3

Emergent restart of Bypass

1

2

3

For Inquiries:

Tel: 1-888-272-9977

Email: info@ikajuq.ca

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