The following checklist will be used to match your skills and interests with available assignments.
Please enter your information, and we will store this information with your application/profile.
Please indicate your level of proficiency by marking the appropriate number.
First Name:
Middle Initial:
Last Name:
SSN:
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-
E-mail Address:
Home Phone:
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-
Work Phone:
-
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Cell Phone:
-
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City:
State:
0. Theory, no practice 1. Limited 2. Confident 3. Very Confident
General:
Experience:
Admit patient to pre-procedure holding
0
1
2
3
Complete assessments, obtain family history & risk factors
0
1
2
3
Start peripheral IV
0
1
2
3
Complete pre-procedure checklist
0
1
2
3
Transport pre-procedure patient to the Lab
0
1
2
3
Transport post-procedure patient to in-hospital units
0
1
2
3
Procedures:
Bronchoscopy - Prepare
0
1
2
3
Bronchoscopy - Assist
0
1
2
3
Liver Biopsy - Prepare
0
1
2
3
Liver Biopsy - Assist
0
1
2
3
Small Bowel Biopsy - Prepare
0
1
2
3
Small Bowel Biopsy - Assist
0
1
2
3
Colon Biopsy - Prepare
0
1
2
3
Colon Biopsy - Assist
0
1
2
3
Esophagogastroduodenoscopy (EGD) - Prepare
0
1
2
3
Esophagogastroduodenoscopy (EGD) - Assist
0
1
2
3
Colonoscopy - Prepare
0
1
2
3
Colonoscopy - Assist
0
1
2
3
ERCP - Prepare
0
1
2
3
ERCP - Assist
0
1
2
3
Other Procedures (please list):
0
1
2
3
0
1
2
3
0
1
2
3
Provide care for the post-procedure patient
0
1
2
3
Cardiovascular:
Assess heart sounds and peripheral pulses
0
1
2
3
Interpret arrhythmias
0
1
2
3
Perform CPR
0
1
2
3
Perform defibrillation
0
1
2
3
Participate as a team member in resuscitation
0
1
2
3
Pulmonary:
Assess lung sounds
0
1
2
3
Set up oxygen devices
0
1
2
3
Obtain pulse oximetry reading
0
1
2
3
Interpret ABG
0
1
2
3
Use Ambu bag
0
1
2
3
Assist with intubation
0
1
2
3
Assist with chest tube insertion
0
1
2
3
Provide care for the patient with mechanical ventilation
0
1
2
3
Neurological:
Identify sudden change in level of consciousness
0
1
2
3
Assess sensory, motor, speech
0
1
2
3
Assess reflexes (Babinski, gag)
0
1
2
3
Medications:
Titrate vasoactive drugs
0
1
2
3
Calculate mcg/min and mcg/kg/min
0
1
2
3
Use IV infusion pump to calculate drug doses
0
1
2
3
Adminster IV epinephrine
0
1
2
3
Administer IV dopamine
0
1
2
3
Administer IV nitroglycerine
0
1
2
3
Administer IV dobutamine (Dobutrex)
0
1
2
3
Administer IV lidocaine
0
1
2
3
Administer IV diltiazem (Cardizem)
0
1
2
3
Administer IV atropine
0
1
2
3
Administer IV heparin
0
1
2
3
Administer IV benzodiazepines (Valium, Versed, Ativan)
0
1
2
3
Administer IV propofol (Diprivan)
0
1
2
3
Administer IV neuromuscular blocking agents (Pavulon, Norcuron)
0
1
2
3
Administer IV narcotics (morphine, fentanyl)
0
1
2
3
Pain/Wound Management:
Assess pain level/tolerance
0
1
2
3
Care of patient with anesthesia/analgesia
0
1
2
3
Care of patient with IV conscious sedation
0
1
2
3
Care of patient with narcotic analgesia
0
1
2
3
Care of patient with patient controlled analgesia (PCA pump)
0
1
2
3
Assess surgical wound status with/without drain(s)
0
1
2
3
Care of patient with sterile dressing changes
0
1
2
3
Care of patient with FemoStop device
0
1
2
3
Assessment of VasoSeal, AngioSeal, Per Close success
0
1
2
3
Age-Specific Practice Criteria:
Please check the box corresponding to each
age group for which you have expertise in
providing age-appropriate nursing care.
