Skills Checklist – Critical Care

Skills Checklist – Critical Care

• Name
  
  First
  
  Last
• Phone
• Email
  
• PRIMARY CRITICAL CARE EXPERIENCE (CHECK ALL THAT APPLY):*
  • 
    ICU
  • 
    CCU
  • 
    MICU
  • 
    SICU
  • 
    NEURO
  • 
    TRAUMA
• CARE OF PATIENTS WITH*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Abdominal Aortic Aneurysm
  Acute MI
  Cardiac Tamponade
  Cardiac Transplant
  Congestive Heart Failure
  Intracoronary Stent Placement
  ARDS
  COPD
  Lung Transplant
  Pulmonary Edema/Hypertension
  Pulmonary Embolism
  Status Asthmaticus
  Tension Pneumothorax
  Tuberculosis
  Cerebral Aneurysm
  CVA/TIA
  Seizures
  Skull Fracture
  Spinal Cord Injuries
  VP Shunt
  Acute Renal Failure
  Renal Transplant
  Hepatic Failure
  Hepatitis
  Liver Transplant
  Diabetes Insipidus
  Diabetes Mellitus
  Diabetic Ketoacidosis
  Insulin Shock
  GI Bleed
  Pancreatitis
  TURP
  Urinary Tract Infection
  DIC
  Hypothermia
  Amputation
  Orthopedic Injuries
  Osteomyelitis
  Cardiogenic Shock
  Hypovolemic Shock
  Neurogenic Shock
  Septic Shock
  First Degree Burns
  Second Degree Burns
  Third Degree Burns
  Drug Overdose
  Delirium Tremens
  Near Drowning
  Renal Trauma
  GI Surgery
  Neurosurgery
  Vascular Surgery
  Transfusion Reaction

• MEDICATION ADMINISTRATION*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Antiarrthymics
  Antihypertensive
  Antipsychotics
  Antiseizure
  Benzodiazepines
  Procedural Sedation
  Anticoagulants
  Emergency Medication
  Narcotics/Opioids
  Vassopressors
  Steroids
  Non-opioid Analgesics
  Reversal Agents
  Insulin
  Ipecac
  Kayexelate
  Lactulose
  Lasix
  Mannitol
  Paralytic Agents
  TPA
  Continuous IV Infusion
  Eye/ear instillations
  Insulin Pump
  Metered Dose Inhalers

• PROCEDURES/SKILLS*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  A-V Fistula Care
  Brace/Splint Application
  Bronchoscopy (assist with)
  Foley/Straight Cath insertion & care
  Chest tube & drainage system
  EKG Intrepretation
  Gastric Suction
  Glascow Coma Scale
  Halo Traction/Cervical Tongs
  Hemodialysis – Care during/post
  Hemodynamic Monitoring, Invasive
  Hemodynamic Monitoring, Non-invasive
  Interpretation of Lab Results
  Intestinal Tract Tube Insertion/Care
  T-tubes (care only)
  Intraaortic Balloon Pump
  Intracranial Pressure Monitoring
  Intravenous Infusions
  Blood & Blood Products
  Central line care
  Peripheral IV insertion & care
  Pacemaker
  Peritoneal Dialysis
  Specimen Collection
  Suctioning
  Temperature
  Wound/Ostomy Care
  Pressure ulcers
  Pain Management

• EQUIPMENT*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Pneumatic Stockings
  Cardiac Monitor
  Defibrillator
  Glucometer
  Specialty Beds
  Ventilator
  Infusion Pumps (specific brands)

• Infusion Pump Brand #1
• Infusion Pump Brand #2
• Infusion Pump Brand #3
• Infusion Pump Brand expertise
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Infusion Pump Brand #1
  Infusion Pump Brand #2
  Infusion Pump Brand #3

• Do you speak any languages other than English?*
  • No

  If yes, enter languages above, separated by commas.

• Age Group Experience*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Newborn (birth – 30 days)
  Infant (30 days – 1 year)
  Toddler (1 – 3 years)
  Preschooler (3 – 5 years)
  School Age (5 – 12 years)
  Adolescents (12 – 18 years)
  Young Adults (18 – 39 years)
  Middle Adults (39-64 years)
  Older Adults (64+ years)

• Confirmation*
  • 
    I attest that the information I have given is both true and, to the best of my knowledge, represents an accurate self assessment of my professional skills and/or education.
• Signature
• Date
  
  Date Format: MM slash DD slash YYYY