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~'NCORPORATED

CRITICAL CARE (ICUlCCU) SKILLS COMPETENCY CHECKLISTRegistered Nlurse (RN)

Name: Date: _

Total Years of Critical Care Nursing Experience: CJMy primary experience has been in: 0 ICU o CCU o MICU o SICU o NEURO o TRAUMA

Please rate your Skill Level:0- NO Experience. Theory Only1 - Limited competency/proficiency.

Supervision Required.

2 - Acceptable competency/proficiency3 - Competent/proficient. Performed frequently and

independentlY during the past 2 years.

I. CARE OF PATIENTS (eontd):Bone Marrow TransolantHepatic FailureHeoatitisLiver TransplantDiabetes InsipidusDiabetes MellitusDiabetes KetoacidosisHHNKInsulin ShockBowel ObstructionEsophaaeal BleedGI BleedInflammatorv Bowel DiseasePancreatitisPeritonitisTURPUrinary Tract InfectionAdrenal DisordersHyperthyroidismHypothyroidismPituitary DisordersMultisystem Oroan FailureDICHypothermiaHeat Exhaustion/StrokeAmputationOrthopedic IniuriesOsteomyelitisAnaphylactic ShockCardioaenic ShockHvoovolemic ShockNeurooenic ShockSeptic ShockFirst Deoree BurnsSecond Deoree BurnsThird Decree BurnslIIeal Conduit NephrostomvDelirium TremensDruo OverdoseLeukemia

I 0 I 1 I 2 I 3 I I SKILLI SKILLI CARE OF PATIENTS'Abdominal Aortic AneurysmAcute MIAngioplastyCardiac ArrestCardiac TamponadeCardiac TransplantCardiomyopathyCongestive Heart FailureCor PulmonaleCABGDeep Vein Thrombosis - DVTEndocarditis - BacterialEndocarditis - InfectiveIntracoronary Stent PlacementMyocardial contusionPericarditisAcute PneumoniaARDSCOPDLung TransplantPulmonary Edema/HypertensionPulmonary EmbolismStatus AsthmaticusTension PneumothoraxTuberculosisCerebral AneurvsmComaCVAlTIAEncephalitisIntracranial BleedMeningitisMultiple SclerosisNeuromuscular DiseaseSeizuresSkull FractureSpinal Cord InjuriesVP ShuntAcute Renal FailureRenal Rejection SyndromeRenal Transplant

RN SKILLS COMPETENCY CHECKLIST - CRITICAL CAREReviewed/Revised 1212010

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I. CARE OF PATIENTS (contd):HIV/AIDSMRSAlVREElectrocutionHazardous Material ExposureMalignant TumorsNear DrowninqBrain Death/Organ ProcurementBlunt TraumaChest TraumaGun Shot/Stab Wound-AbdomenGun Shot/Stab Wound-ChestGun Shot/Stab Wound-HeadMultiple TraumaCardiothoracic SurqeryGI SurgeryNeurosurqeryVascular SurgeryTransfusion Reaction

III. TITRATING / DOSING OG VASOACTIVE DRUGS

II. MEDICATION ADMINISTRATION (contd):Sodium BicarbonateStreprokinaseTerbutalineVasopamilVerapamilParalvzinQ AqentsContinuous IV InfusionCAD PumpEve/ear instillations1M injectionsInsulin PumpIV PushMetered Dose InhalersNebulizerRectal infusionSuppositorysa injectionsZ track injections

~INCORPORATED

SKILL

II MEDICATION ADMINISTRATION'

I 0 I 1 121 3 ] SKILL o 2 3

AdenosineAlbuterol (Ventolin)AminophvllineAmiodarone (Cardarone)Amrinone (Inocor)AQuamephvtonAtropineBretvliumCharcoalChemotherapeutic agentsCorticosteroidsDiazepam (Valium)DigoxinDilantonDecadromDextranDiliazemEpinephrineEsmololHeparinInsulinIpecacIsoetharine (Bronkosol)KavexelateLactuloseLasixMannitolMetaproterenoJ (Alupen!)MetroproloJ (Lopressor)NitroprussideNitroglycerineParalytic AgentsPhenobarbitalPhenytoin (Dilantin)Procainamide (Pronestyl)Propranolol (Inderall

RN SKILLS COMPETENCY CHECKLIST - CRITICAL CAREReviewed/Revised 1212010

LidocaineDopamineDobutamineINOCORNTGNiprideBreviblockTPA (Activase)IV. PROCEDURES / SKILLS:Admission of patients to unitApnea MonitoringA-V Fistula CareBrace/Solint ApplicationBronchoscopv (assist with)Foley/Straight Cath insertion & Care

a. Maleb. Female

Bladder irrigationCare of supraoubic catheterCardioversionCast careCast application (assist with)Charge Nurse responsibilitiesChemotherapyChest physiotherapyChest tube & drainaqe system

a. Set upb. Assist with insertionc. Care & maintenanced. Troubleshootinge. Removal

EKGa.12leadb. Arrhvthmiasc. Lead placementd. Interpretation

Page 2 of4

~'NCORPORATED2 3o

IV. PROCEDURES / SKILLS (contd):b. Central line care

- Broviac- Groshona- Hickman- PICC- Portacath- Quinton

c. Hyperalimentationd. Intralipidse. Perioheral IV insertion

- Anaiocath- Butterflv

f. Saline Lock/Heparin LockIntubation (assist with)Isolation ProceduresLumbar Puncture (assist with)Nerve StimulatorsNeuroloqical AssessmentsNursina Assessment Care PlanninaOral Airwav InsertionOxyqen Therapy Administration

a. Baq & maskb. ET tubec. External CPAPd. Face maske. Nasal cannulaf. Trach Collara. BiPAPh. ambu baa

Pacemakera. Externalb. Permanentc. Temoorarvd. Transthoracic

Peritoneal Dialvsisa. Automatic cvclerb. Manual

Peritoneal LavaaePre & Post Op Care of:

Heart Catheterization PatientAnaioplastyArterioqramsMvcloaramsAneurvsms

RestraintsSpecimen Collection

a. Blood- femoral arterial stick ] ~~ Al.G-- radial arterial stick T- arterial line- central line- venous stick

b. Culturesc. Sputumd. Urine

I SKILL2 3oI SKILLIV. PROCEDURES / SKILLS (contd):Emerqency Tracheostomy-assistExtubationContinuous Tube FeedinqGavage, intermittent Tube FeedinaFemoral Arterv Sheath MqmURemovalGastric Lavaqe, Iced SalineGastric Suction

a. Intermittentb. Continuous

Glascow Coma ScaleHalo Traction/Cervical TonqsHemodialysis - care durinq/postHemodynamic Monitorinq, Invasive

a. Swan-Ganz cath insertion assistb. Swan-Ganz cath carec. MAPd.CVPe. PAWPlWedae/PAf. Cardiac Outputg. Cardiac Indexh. SV02i. Arterial line insertion assistj. Arterial line carek. SVR / PVR CalculationI. Pulmonary Arterv Pressuresm. Central Venous Pressures

Hemodynamic Monitorina,Non-invasivea. Auscultationb. Dopplerc. Automatic BP cuffd. Palpation

Interpretation of Lab Results./ a. Blood qases

b. Blood chemistryc. Cardiac enzymes!isoenzymesd. CSCe. Coaqulation studiesf. Culturesa. Electrolvtesh. Urine dipstick

Intestinal Tract Tube Insertion/Carea. Gastrostomy tubesb. Jejunostomy tubesc. NasoQastric tubesd. Orogastric tubes

Intraaortic Balloon PumpIntracranial Pressure MonitorinaIntravenous Infusions

a. Blood &Blood Products- albumin- auto infusion- cryoprecipitate- fresh frozen plasma (FFP)- packed RBCs- whole blood

/

RN SKILLS COMPETENCY CHECKLIST - CRITICAL CAREReviewed/Revised 1212010

Page 3 of 4

IV. PROCEDURES I SKILLS (contd):Suctioning

a. ET tube - closedb. ET tube - openc. Nasal-pharyngeald. Tracheostomve.OralfYankaure

Temperaturea. Axillaryb. Oralc. Tympanic

Suicide PrecautionsThoracentesis/Paracentesis-assistVentricular Assist Device (RVAD,LVAD)Vent weaninglinterpret parametersWound/Ostomy Care

a. Colostomv care/baa chanaeb. Ileostomy care/baQ chanQec. Irrigationsd. Pressure ulcers

- staQing- care

e. Stasis ulcersf. Staple insertion· assistQ. Sterile dressing chanaesh. Steristrip applicationI. Surgical wounds with drainsj. Suturing - assist with

V. PAIN MANAGEMENT:Pain assessment using pain scalesEpidural analaesiaIV conscious sedationPatient controlled analgesia (PCA)

~INCORPORATED

SKILL 10111213J SKILLV. PAIN MANAGEMENT (contdY:Narcotic AaentsNon-narcotic aaentsNon-phamnacoloaical measuresVI. EQUIPMENT:Automatic BP cuffsCardiac MonitorCentrifuaeDefibrillatorFemoral Hemostasis DevicesGlucometerHYPo/Hyperthermia blanketInfusion Pumps (specific brands)

--

Apnea MonitorOxygen AnalvzerOxvaen BlenderPulse OxSpecialty Beds

a. Air Fluidizedb. Low air lossc. Rotatinad. Strykere. other soeCify

Ventilatora. CPAPb. High freauencv ietc. Pressured. T-Piecee. Volumef. Peeog.IMV

o 2 3

Do you speak any other language(s) besides English? YE!S / No If YES, please list other language(s): _

Are you familiar with computer charting? Yes / No If YES, what system(s) have you used: _

Comments:. _

I hereby certify that all information I haye provided to Rt\lS Incorporated on this skills checklist is true and accurate. Iunderstand and acknowledge that any misrepresentation or omission may result in disqualification from employmentand/or immediate termination.

Nurse Signature _

RNS, Inc. Reviewer Signature _

RN SKILLS COMPETENCY CHECKLIST - CRITICAL CAREReviewed/Revised 1212010

Date _

Date _

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