Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
| GENERAL | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Admit patient to pre-procedure holding |
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| Complete assessments, obtain family history & risk factors |
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| Start peripheral IV |
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| Complete pre-procedure checklist |
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| Transport pre-procedure patient to the Lab. |
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| Transport post-procedure patient to in-hospital units |
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| PROCEDURES | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Cerebral Angiogram – Prepare |
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| Cerebral Angiogram – Assist |
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| Lower Extremity Angiogram – Prepare |
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| Lower Extremity Angiogram – Assist |
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| Upper Extremity Angiogram – Prepare |
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| Upper Extremity Angiogram – Assist |
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| Ultrasound Guided Biopsy – Prepare |
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| Ultrasound Guided Biopsy – Assist |
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| CT Scan Guided Biopsy – Prepare |
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| CT Scan Guided Biopsy – Assist |
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| Liver Biopsy and Embolization – Prepare |
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| Liver Biopsy and Embolization – Assist |
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| Prepare and Assist with Line Placement – Broviac |
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| Prepare and Assist with Line Placement – Groshong |
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| Prepare and Assist with Line Placement – Hickman |
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| Prepare and Assist with Line Placement – PICC |
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| Prepare and Assist with Line Placement – PortaCath |
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| Uterine Fibroid Embolization – Prepare |
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| Uterine Fibroid Embolization – Assist |
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| Temporary Hemodialysis Shunt Placement– Prepare |
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| Temporary Hemodialysis Shunt Placement– Assist |
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| Permanent Hemodialysis Shunt Placement– Prepare |
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| Permanent Hemodialysis Shunt Placement– Assist |
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| AV Fistula/Shunt Declotting – Prepare |
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| AV Fistula/Shunt Declotting – Assist |
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| Vertebroplasty – Prepare |
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| Vertebroplasty – Assist |
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| Lumbar Puncture – Prepare |
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| Lumbar Puncture – Assist |
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| Myelogram – Prepare |
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| Myelogram – Assist |
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| Other Procedures (please list): |
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| Provide care for the post-procedure patient |
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| CARDIOVASCULAR | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Assess heart sounds and peripheral pulses |
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| Interpret arrhythmias |
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| Perform CPR |
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| Perform defibrillation |
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| Participate as a team member in resuscitation |
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| PULMONARY | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Assess lung sounds |
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| Set up oxygen devices |
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| Obtain pulse oximetry reading |
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| Interpret ABG |
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| Use Ambu bag |
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| Assist with intubation |
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| Assist with chest tube insertion |
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| Provide care for the patient with mechanical ventilation |
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| MEDICATIONS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Titrate vasoactive drugs |
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| Calculate mcg/min and mcg/kg/min |
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| Use IV infusion pump to calculate drug doses |
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| Administer IV dopamine |
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| Administer IV nitroglycerine |
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| Administer IV dobutamine (Dobutrex) |
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| Administer IV lidocaine |
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| Administer IV diltiazem (Cardizem) |
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| Administer IV epinephrine |
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| Administer IV atropine |
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| Administer IV heparin |
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| Administer IV benzodiazepines (Valium, Versed, Ativan) |
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| Administer IV propofol (Diprivan) |
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| Administer IV neuromuscular blocking agents (Pavulon, Norcuron) |
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| Administer IV narcotics (morphine, fentanyl) |
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| PAIN/WOUND MANAGEMENT | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Assess pain level/tolerance |
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| Care of patient with anesthesia/analgesia |
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| Care of patient with IV conscious sedation |
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| Care of patient with narcotic analgesia |
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| Care of patient with patient controlled analgesia (PCA pump) |
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| Assess surgical wound status with/without drain(s) |
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| Care of patient with sterile dressing changes |
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| Care of patient with FemoStop device |
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| Assessment of VasoSeal, AngioSeal, PerClose success |
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| AGE SPECIFIC PRACTICE CRITERIA | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Pediatric (1-18years) |
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| Adolescents (12 - 18 years) |
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| Adult (19 - 65 years) |
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| Older adults (Older than 65years) |
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| EXPERIENCE WITH AGE GROUPS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Calculate body weight to verify correct dosing of medication |
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| Assess immunization status for pediatric, and adolescent |
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| Set age-appropriate short-term and long-term goals in care planning |
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| Provide age-appropriate education, considering possible vision and hearing impairment for Older than 65years |
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