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REGISTERED NURSE
INTERVENTIONAL RADIOLOGY CHECKLIST
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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
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1
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2
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3
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4
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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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Rating Stars
(Click)
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PROCEDURES
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1
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2
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3
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4
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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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Rating Stars
(Click)
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CARDIOVASCULAR
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1
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2
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3
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4
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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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Rating Stars
(Click)
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PULMONARY
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1
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2
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3
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4
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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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Rating Stars
(Click)
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MEDICATIONS
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1
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2
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3
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4
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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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Rating Stars
(Click)
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PAIN/WOUND 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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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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Rating Stars
(Click)
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EMR
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1
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2
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3
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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
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No. of Years
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Unit
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No. of Years
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BURN
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POST PARTUM
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CRITICAL UNIT
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LABOR & DELIVERY
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PACU
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NEWBORN NURSERY
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NEUROLOGY
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LEVEL II NICU
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TELEMETRY
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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
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PSYCHIATRY
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OPERATING ROOM
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RRT
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EMERGENCY ROOM
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CRT
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TRAUMA CENTER
LEVEL 1
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COMMUNITY ER
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RURAL ER
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Rating Stars
(Click)
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AGE APPROPRIATE CARE
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1
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2
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4
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Newborn/Neonatal (birth –
30 days)
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Infant (30 days-1 year)
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Toddler (1-3 years)
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Preschool (3-5 years)
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School Age Children (5-12
years)
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Adolescent (12-17 years)
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Young Adults (18-44 years)
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Middle Adults (45-64
years)
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Older Adults (>65
years)
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Rating Stars
(Click)
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EXPERIENCE WITH AGE GROUPS
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1
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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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CERTIFICATIONS
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Expiry Date :
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ACLS
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BCLS
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Other
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Specify
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