CYNET_SYSTEMS_MAIN_LOGO.gif   REGISTERED NURSE INTENSIVE CARE UNIT CHECKLIST
   NAME    
   LAST 4 OF SSN      
   DATE    
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.  
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.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

  
       
Rating Stars (Click) Cardiac 1 2 3 4  
Defibrillation/Cardioversion  
Assisting with Insertion of Central Lines   
Pacemakers‐External    
Permanent or Temporary Pacemaker   
Cardiac Arrest/CPR  
A‐Line (Transducer setup‐D/C)  
Swan Ganz (Transducer setup‐D/C)   
Balloon Pump (IABP)   
SVO2 Monitoring    
Automatic Internal Cardioverter Defib  
Rating Stars (Click) Care of patient with 1 2 3 4  
Aneurysm  
Acute MI/Unstable Angina  
Cardiogenic/Hypovolemic Shock  
Pre/Post Cardiac Surgery  
Heart Transplant  
PTCA  
COPD  
ARDS  
Pulmonary Embolism  
Pulmonary Edema  
Pneumonia  
Inhalation Injuries  
CVA  
Seizure Disorder  
Overdose  
Neuro Injury/Trauma  
Pre/Post Neuro Surgery  
Cranial Hemorrhage  
Aphasia  
Multiple Sclerosis  
Pancreatitis  
GI Bleed  
Esophageal Bleeding  
Bowel Obstruction  
Liver Transplant  
Paralitic Ileus  
TURP  
Shunts and Fistulas  
Nephrectomy  
Renal Transplant  
Renal Trauma  
Rating Stars (Click) Use and Administration of the following 1 2 3 4  
Atropine  
Bretylol  
Bumex  
Digoxin  
Dopamine  
Dobutrex  
Inderal  
Inocor  
Isuprel  
Lidocaine  
Neosynephrine/Nipride  
NTG  
Pronestyl  
Titrate Morphine  
Verapamil  
Thrombolitic Agents  
Prep/Titration of Emergency Drugs  
Aminophylline  
Corticosteroids  
Bronkosol  
Ventolin  
Alupent  
Decadron  
Dilantin  
Magnesium Sulfate  
Phenobarbital  
Steroids  
Valium  
Versed  
Rating Stars (Click) Respiratory 1 2 3 4  
Lung Transplant  
Establishing an Airway  
Pulse Oximetry  
Interpretation of ABG  
Drawing ABG Blood Sample from A‐Line  
Incentive Spirometer  
Rating Stars (Click) Neurology 1 2 3 4  
Assessment of Neuro Signs  
Use of Glascow Coma Scale  
Seizure Precautions  
Assist with Lumbar Puncture  
ICP Monitoring  
Crutchfield Tongs  
Halo Traction  
Stryker Frame  
Assessment of Sensory‐Motor Function  
Cervical Traction  
Cranial Nerve Assessment  
LOC Assessment  
Pre/Post Neuro Surgical Care  
Visual Acuity Measurement  
Rating Stars (Click) Vascular 1 2 3 4  
Peripheral Pulses  
Fluid Overload  
Starting IV's  
Subcutaneous Central Line  
Hickman/Broviac/Groshong Catheters  
Mainenance of Heparin Lock  
TPN/Hyperalimentation  
Air Occlusive Dressing  
Infusion Pump  
Peritoneal Dialysis  
Hemodialysis  
Heparin Drip ‐ Precautions and Maintenance  
Rating Stars (Click) Gastrointestinal 1 2 3 4  
NG Tube Insertion  
Gastronomy Tube  
Jejunoostomy Tube  
Enterostomal Care  
Rating Stars (Click) Genito Urinary/Renal 1 2 3 4  
Foley Catheter Insertion  
GU Irrigations  
Nephrostomy Tube  
Suprapubic Tube  
Electrolyte Imbalance/Replacement  
Rating Stars (Click) Other 1 2 3 4  
Oncology  
Chemotherapy  
Isolation Techniques  
Hyperbaric Oxygenation  
Fingerstick Blood Glucose monitoring  
Rating Stars (Click) Equipment 1 2 3 4  
Bear I  
Bear II  
Bear V  
Bennett 7200  
CPAP  
Emerson  
EMV  
MA‐I  
MA‐II  
Monihan  
Ohio 560  
PEEP  
Pressure Pre‐Set  
Servo 900b  
Servo 900c  
Servo 900e  
Siemens  
Hewlett‐Packard  
Spacelab  
Marquette  
Mennen  
Lifecare  
Nihon‐Koder  
Rating Stars (Click) EMR 1 2 3 4  
Epic  
Cerner  
Eclipsys  
McKesson  
Meditech  
Other Computerized System  
Computerized Physician Order Entry  
Bar Coding for Medication Administration  
MY EXPERIENCE IS PRIMARILY IN:  
Unit No. of Years Unit No. of Years  
BURN POST PARTUM  
CRITICAL UNIT LABOR & DELIVERY  
PACU NEWBORN NURSERY  
NEUROLOGY LEVEL II NICU  
TELEMETRY LEVEL III NICU  
MEDICAL PICU  
SURGICAL  PEDIATRICS  
ONCOLOGY OB/GYN  
ORTHOPEDICS PSYCHIATRY  
OPERATING ROOM RRT  
EMERGENCY ROOM CRT  
TRAUMA CENTER LEVEL 1      
COMMUNITY ER      
RURAL ER      
Rating Stars (Click) AGE APPROPRIATE CARE 1 2 3 4  
Newborn/Neonatal (birth – 30 days)  
Infant (30 days-1 year)  
Toddler (1-3 years)  
Preschool (3-5 years)  
School Age Children (5-12 years)  
Adolescent (12-17 years)  
Young Adults (18-44 years)  
Middle Adults (45-64 years)  
Older Adults (>65 years)