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REGISTERED NURSE
CRITICAL CARE
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NAME
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LAST 4 OF SSN
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DATE
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I hereby certify that
ALL information I have provided to IMCS Group on this skills checklist and
all other documentation, is true and accurate. I understand and acknowledge
that any misrepresentation or omission may result in disqualification from
employment and/or immediate termination.
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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.
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Proficiency Scale:
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1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
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Rating Stars (Click)
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General Skills
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1
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2
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3
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4
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Advanced directives
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Patient/family teaching
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Restrictive devices
(restraints)
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Lift/transfer devices
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Specialty beds
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End of life care/palliative
care
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Wound assessment & care
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Automated Medication
Dispensing System, Pyxis, Omnicell, or other
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Bar coding for medication
administration
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Blood Glucose Monitor (BGM)
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Cardioversion/defibrillation
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Electronic ICU
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National Patient Safety
Goals
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Accurate patient
identification
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Effective communication
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Interpretation &
communication of lab values
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Medication administration
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Medication reconciliation
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Labeling (medications &
specimens)
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Anticoagulation therapy
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Monitoring conscious
sedation
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Pain assessment &
management
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Infection control
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Universal precautions
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Isolation
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Minimize risk for falls
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Prevention of pressure
ulcers
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Use of rapid response teams
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Awareness of HCAHPS
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Rating Stars
(Click)
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Cardiovascular
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Assessment of heart sounds
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Interpretation of
arrhythmias
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Performing 12 lead EKG’s
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Interpretation of 12 lead
EKG
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Interpretation of
hemodynamic monitoring
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Rating Stars
(Click)
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Assist with Insertion
& Management of:
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1
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4
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CVC (Central Venous
Catheter)
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Arterial line
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Swanz Ganz catheter
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Flow trac or Vigileo
monitoring caths
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Intra-Aortic Balloon Pump
(IABP)
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Ventricular Assist Device
(LVAD, RVAD)
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Rating Stars
(Click)
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Maintenance &
Management of:
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1
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2
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3
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4
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Permanent pacemakers
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Implantable Cardioverter
Defibrillator (ICD)
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External pacemakers
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Epicardial pacemaker wires
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Discontinuing
venous/arterial sheaths
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Femostop/vasoseal
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Rating Stars
(Click)
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Care of Patients with:
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1
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2
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3
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4
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Abdominal trauma
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Acute gastrointestinal
hemorrhage
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Acute myocardial infarction
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Acute pancreatitis
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Aortic aneurysm
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Balloon tamponade devices
(i.e. Blakemore tube)
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Bowel obstruction
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Cardiac contusion/trauma
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Cardiac tamponade
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Cardiogenic shock
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Cardiomyopathy
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Congestive heart failure
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Dysrhythmias/conduction
disturbances
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Endoluminal graft
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Esophageal varices
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Heart transplant
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Hypertensive crisis
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Liver/pancreas transplant
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MAZE procedure
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Pericarditis/endocarditis
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Peritonitis
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Post open heart
(CABG/valve)
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Pre/post: cardiac
catheterization
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Thoracic/abdominal surgery
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Rating Stars
(Click)
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Medication Administration:
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1
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3
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4
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ACLS medications and
protocols
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Anesthetics
(propofol/presedex)
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Anticonvulsants: Dilantin,
phenobarbital
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Antidysrythmics
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Antiemetics: Reglan,
Zofran
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Antihypertensives
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Antipsychotics: Haldol
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Flolan for pulmonary
hypertension
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H2 receptor antagonists
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Mannitol
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Nebulizer treatments:
Ventolin, Atrovent
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Paralytic Agents: Norcuron,
Pavalon, Nimbex, Tracrium, vecuronium
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Platelet inhibitors
(ReoPro/Integrilin/Aggrastat)
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Rapid sequence intubation
drugs/protocols
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Steroids: Decadron,
Solu-Medrol
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Thrombolytics
(retavase/activase)
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Vasoactive/vasopressor
agents
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Rating Stars
(Click)
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Pulmonary
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Assessment of breath sounds
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Rating Stars
(Click)
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Airway Management, Care
& Maintenance of:
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1
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3
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4
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Oral/NT/ET airway
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Tracheostomy
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Arterial blood gas
analysis/interpretation
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Obtaining ABG blood
sample/arterial line
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Pulse oximetry
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Rating Stars
(Click)
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Ventilator Management:
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1
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2
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3
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4
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BiPAP (Bi-level Positive
Airway Pressure)
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Oscillation/high-frequency
ventilation
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Nitric
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Interpretation of weaning
parameters
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Maintenance &
management of pleural chest tubes
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Rating Stars
(Click)
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Care of Patient with:
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1
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2
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3
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4
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Acute respiratory failure
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Adult Respiratory Distress
Syndrome (ARDS)
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Sudden Inflammation
Respiratory Syndrome (SIRS)
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Inhalation injuries
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Pneumonia
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Pulmonary edema
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Near drowning
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Chronic Obstructive
Pulmonary Disease (COPD)
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Pre/post thoracic surgery
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Pulmonary embolism
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Pulmonary/chest trauma
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Pulmonary hypertension
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Status asthmaticus
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Rating Stars
(Click)
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Neurology
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Cranial nerve assessment
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Glasgow coma scale
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NIH stroke scale
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NIH stroke certification
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Seizure precautions
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Skeletal traction
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Cervical spine
precautions/logroll positioning
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Halo vest/halo traction
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Monitoring of neuromuscular
blocking agents/paralytics
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Assist with lumbar puncture
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Rating Stars
(Click)
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Intracranial/Cerebral
Perfusion Pressure Monitoring (ICP/CPP) via:
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4
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Ventriculostomy
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Subarachnoid screw/bolt
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Rating Stars
(Click)
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Care of Patients with:
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1
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3
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4
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Lumbar drains
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Cerebral aneurysm
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Subarachnoid hemorrhage
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Status epilepticus
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TBI (Traumatic Brain
Injury)
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Spinal cord injury
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CerebroVascular Accident
(CVA)
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Pre/post cranial surgery
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Meningitis
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Myasthenia gravis
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Clipping and/or coilings of
aneurysms
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Pituitary Tumor
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Rating Stars
(Click)
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Trauma & Burns
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Mass casualty
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Electrocution
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Amputation
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Gangrene
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Multiple fractures
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Thermoregulation:
hypothermia/hyperthermia
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Rating Stars
(Click)
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Burns: Calculation of
Total Body Surface Area (BSA):
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3
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4
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Berdow Formula/ “Rule of
Nines”
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Lund and Browder chart
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Fluid resuscitation
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Care & management of
burns
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Rating Stars
(Click)
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Gastrointestinal
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1
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2
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3
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4
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Small bore feeding tube
insertion (Dobhoff or Keofeed)
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Nasogastric tube insertion
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Post pyloric feeding tube
insertion
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Gastric lavage
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Use of activated charcoal
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Maintenance of
gastric/jejunostomy tube
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Stoma care
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Maintenance &
management of enteral tube feedings
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Assisting/monitoring
bedside procedures: endo/chest tubes/bronchs/trach insertion/PEG tubes
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Rating Stars
(Click)
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Renal
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3
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4
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Foley catheter insertion
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Suprapubic tube
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Nephrostomy tube
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Peritoneal dialysis
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Continuous Arteriovenous
Hemofiltration (CAVHD, CVVHD, SCUF, CRRT)
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Hemodialysis of the
critically ill patient
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Rating Stars
(Click)
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Care of Patient with
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4
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Acute renal failure
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Chronic renal failure
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AV fistulas, shunts &
dialysis catheters
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Nephrectomy
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Renal transplant
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Renal/urinary tract trauma
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Rating Stars
(Click)
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Endocrine
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1
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3
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4
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Diabetic Ketoacidosis (DKA)
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Hyperosmolar Hyperglycemic
Nonketotic Coma (HHNK)
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Diabetes Insipidus (DI)
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Syndrome of Inappropriate
Antidiuretic Hormone (SIADH)
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Administration &
monitoring of insulin infusion
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Use of Endo tool
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Rating Stars
(Click)
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Intravenous Management
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1
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3
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4
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Starting peripheral IV’s
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Care of patient with
Peripherally-Inserted Central Catheter (PICC)
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Administration/monitoring
of Total Parenteral Nutrition (TPN)
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Administration of
blood/blood products
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Administration of
narcotics/sedatives: (fentanyl, Valium, Ativan, Versed, morphine)
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Bispectral monitoring
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Rating Stars
(Click)
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Tele-ICU (ICU-E)
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1
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2
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3
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4
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Mentoring
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Communication
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Video assessment
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Utilize tele-ICU system
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Multi-tasking
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Troubleshoot equipment
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Giving directions over AV
system
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Interpretation of data
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Critical thinking
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Diplomacy
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Rating Stars
(Click)
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Other
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1
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2
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3
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4
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Drug or chemical overdose
(TCA, ethanol, ASA)
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Poisoning (CO, cyanide)
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Substance abuse (ETOH,
stimulants, narcotics)
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Human Immunodeficiency
Virus (HIV)
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Multisystem Organ
Dysfunction Syndrome (MODS)
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Anaphylaxis
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Disseminated Intravascular
Coagulation (DIC)
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Septic shock
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Cancer
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Administration of
chemotherapy
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Monitoring of chemotherapy
(does not initiate)
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Hyperbaric oxygenation
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Organ/tissue donation
procedures
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Suicide precautions
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Rating Stars
(Click)
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EMR
|
1
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2
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3
|
4
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Epic
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Cerner
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Eclipsys
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McKesson
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Meditech
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Other Computerized System
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Computerized Physician
Order Entry
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Bar Coding for Medication
Administration
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|
MY EXPERIENCE IS
PRIMARILY IN:
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|
|
Unit
|
No. of Years
|
Unit
|
No. of Years
|
|
|
BURN
|
|
POST PARTUM
|
|
|
|
CRITICAL UNIT
|
|
LABOR & DELIVERY
|
|
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PACU
|
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NEWBORN NURSERY
|
|
|
|
NEUROLOGY
|
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LEVEL II NICU
|
|
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|
TELEMETRY
|
|
LEVEL III NICU
|
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|
MEDICAL
|
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PICU
|
|
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SURGICAL
|
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PEDIATRICS
|
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ONCOLOGY
|
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OB/GYN
|
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|
ORTHOPEDICS
|
|
PSYCHIATRY
|
|
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OPERATING ROOM
|
|
RRT
|
|
|
|
EMERGENCY ROOM
|
|
CRT
|
|
|
|
TRAUMA CENTER
LEVEL 1
|
|
|
|
|
|
COMMUNITY ER
|
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|
|
|
RURAL ER
|
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|
|
|
|
Rating Stars
(Click)
|
Age Specific Competencies
|
1
|
2
|
3
|
4
|
|
|
|
Newborn/Neonatal (birth –
30 days)
|
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|
|
|
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|
Infant (30 days-1 year)
|
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|
Toddler (1-3 years)
|
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|
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|
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|
|
Preschool (3-5 years)
|
|
|
|
|
|
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|
School Age Children (5-12
years)
|
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|
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|
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|
Adolescent (12-17 years)
|
|
|
|
|
|
|
|
Young Adults (18-44 years)
|
|
|
|
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|
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|
Middle Adults (45-64 years)
|
|
|
|
|
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|
Older Adults (>65 years)
|
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|
|
|
| |
Please list any Additional
Skills:
|
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| |
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| |
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| |
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| |
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|
| |
Additional training
|
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| |
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| |
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| |
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| |
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| |
Additional equipment
|
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| |
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| |
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