Skills Checklist Form

Items in red are REQUIRED fields.

Personal Information:
First Name:        Middle Initial:
Last Name:
State:        ZIP:
E-mail Address:
Years of Experience:

Directions for completing Skills Checklist:

The following is a list of equipment and/or procedures performed in rendering care to patients. Please indicate the level of experience/proficiency with each and, where applicable, the types of equipment and/or systems with which you are familiar. Use the following KEY as a guideline:
A) Theory Only/No Experience - Didactic instruction only, no hands-on experience.
B) Limited Experience - Knows procedure/has used equipment, but has done so infrequently or not within the last six months.
C) Moderate Experience - Able to demonstrate equipment/procedure, performs the task/skill independently with only resource assistance needed.
D) Proficient/Competent - Able to demonstrate/perform the task/skill proficiently without any assistance and can instruct/teach.

1. Assessment:  A     B     C     D
      a. Auscultation (rate/rhythm)         
      b. Blood Pressure (non-invasive)         
      c. Doppler         
      d. Heart sounds/murmurs         
      e. Pulses/circulation checks         
2. Equipment/Procedures:  A     B     C     D
      a. Telemetry  
          (I) Basic arrhythmia interpretation         
          (II) Lead placement         
      b. Pacemakers  
          (I) Permanent         
          (II) Temporary         
3. Care of the patient with:  A     B     C     D
      a. Abdominal aortic bypass         
      b. Aneurysm         
      c. Angina         
      d. Cardiac arrest         
      e. Cardiomyopathy         
      f. Cartoid endartarectomy         
      g. Congestive heart failure (CHF)         
      h. Femoral-popliteal bypass/ Aorta-Femoral bypass         
      i. Myocarditis         
      j. Post acute MI (24 - 48 hrs)         
      k. Post angioplasty         
      l. Post cardiac cath         
      m. Post cardiac surgery - bypass grafts/ valvular/ replacement         
      n. Thrombophlebitis         
4. Medications:  A     B     C     D
      a. Heparin drip         
      b. Oral anticoagulants         
      c. Oral & IVP antihypertensives         
      d. Oral & topical nitrates         

1. Assessment:  A     B     C     D
      a. Chest/Lungs: inspection, palpitation, percussion, auscultation         
      b. Breathing patterns/rate/SOB inspiration         
      c. Cough/secretions/hemoptysis         
      d. Pains - chest         
      e. Skin - color         
2. Interpretation of lab results:  A     B     C     D
      a. Blood chemistry         
      b. Blood gases         
3. Equipment & procedures:  A     B     C     D
      a. Airway management devices/suctioning  
          (I) Endotracheal tube/suctioning         
          (II) Nasal airway/suctioning         
          (III) Oropharylgeal/suctioning         
          (IV) Sputum specimen collection         
          (V) Tracheostomy/suctioning         
      b. Assist with intubation         
      c. Assist with thoracentesis         
      d. Care of the patient with a chest tube  
          (I) Assist with setup and insertion         
          (II) Measuring & emptying         
          (III) Removal         
      e. Chest physiotherapy         
      f. Incentive spirometry         
      g. O2 therapy & medication delivery systems  
          (I) Bag & mask         
          (II) External CPAP         
          (III) Face masks         
          (IV) Inhalers         
          (V) Nasal cannula         
          (VI) Portable O2 tank         
          (VII) Trach collar         
      h. Oximetry         
4. Care of the patient with:  A     B     C     D
      a. Bronchoscopy         
      b. COPD         
      c. Fresh tracheostomy         
      d. Lobectomy         
      e. Pneumonectomy         
      f. Pneumonia         
      g. Pulmonary embolism         

1. Assessment:  A     B     C     D
      a. Mental status/LOC/Glasgow Coma Score         
      b. Motor movement/ROM/Strength coordination         
2. Equipment & Procedures:  A     B     C     D
      a. Assist with lumbar puncture         
      b. Use of hyper/hypothermia blanket         
3. Care of the patient with:  A     B     C     D
      a. Closed head injury         
      b. Coma         
      c. CVA         
      d. DTs         
      e. Encephalitis         
      f. Meningitis         
      g. Neuromuscular disease         
      h. Post craniotomy         
      i. Seizures         
      j. Spinal cord injury         
4. Medications:  A     B     C     D
      a. Nonopiod analgesic         
      b. Opiods         
      c. Antidepressants         
      d. Anticonvulsants         

1. Assessment:  A     B     C     D
      a. Joints - Inspection/Palpation         
      b. Posture         
      c. Mobility/gait/positioning/transfers         
      d. Skin - Inspection/Palpation         
      e. Circulation Checks         
2. Equipment/Procedures:  A     B     C     D
      a. Splints: Ace wraps/Immobilizers - Knee, cervical, shoulder, wrist         
      b. K-pad         
      c. Crutches axillary, forearm, cane         
      d. Prosthetics         
      e. Traction: skin/skeletal, Bryant's, Buck's, halo, tongs         
3. Care of the patient with:  A     B     C     D
      a. Amputation         
      b. Arthoscopic surgery         
      c. Cast         
      d. Osteoporosis         
      e. Pinned fractures         
      f. Rheumatic/Arthritic disease         
      g. Total knee/total hip replacement         

1. Assessment:  A     B     C     D
      a. Abdominal/bowel sounds/inspection         
      b. Nutrition - diet/fluid Balance height/weight         
2. Equipment/Procedures:  A     B     C     D
      a. Measuring abdominal girth         
      b. Throat swab         
      c. Guaiac test         
      d. Lavage         
      e. Tube feeding/gavage (placement): NG, GT, JT         
      f. Feeding pumps         
      g. T-tubes, drains         
      h. Vacuum/suction         
3. Care of the patient with:  A     B     C     D
      a. Bowel obstruction         
      b. Colostomy/ileostomy         
      c. GI bleeding - gastritis, peptical ulcer         
      d. GI surgery         
      e. Hepatitis         
      f. Inflammatory bowel disease         
      g. Liver failure         
      h. Paralytic ileus, colitis, appendicitis         

1. Assessment:  A     B     C     D
      a. Vital signs - BP, HR, RR, Temp         
      b. Intake/output         
      c. Weight (recent change)         
      d. Nutrition/fluid balance         
      e. Edema/skin lesions/distention         
      f. Urination - dysuria, discharge, frequency, incontinence, urgency         
2. Equipment/Procedures:  A     B     C     D
      a. Urinalysis  
          (I) Color, appearance, odor         
          (II) Dipstick - blood, ketones, PH, etc.         
          (III) Specific gravity         
      b. Laboratory findings  
          (I) CBC         
          (II) Comprehensive metabolic panel         
          (III) 24 degree urine          ">
          (IV) Culture(s)         
      c. Foley catheterization/straight cath         
      d. Suprapubic catheter         
      e. 3-way catheter         
      f. Bladder irrigations - intermittent, continuous         
      g. Dialysis accesses  
          (I) A-V Fistula         
          (II) Double lumen catheters         
          (III) Peritoneal catheters         
3. Care of the patient with:  A     B     C     D
      a. Hemodialysis         
      b. Nephrectomy         
      c. Peritoneal dialysis         
      d. Renal failure         
      e. Renal transplant         
      f. TURP         
      g. Urinary diversion/ileal conduit/nephrostomy         
      h. Urinary tract infection         

1. Assessment:  A     B     C     D
      a. S/S diabetic coma         
      b. S/S insulin reaction         
2. Equipment/Procedures:  A     B     C     D
      a. Glucometers  
          (I) Type:  / System:         
                Type:  / System:         
      b. Insulin pumps  
          (I) Type:  / System:         
                Type:  / System:         
      c. Performing finger stick         
      d. Visual blood glucose sticks         
3. Care of the patient with:  A     B     C     D
      a. Diabetes mellitus         
      b. Disorders of Adrenal gland (addison's disease)         
      c. Disorders of Pituitary gland (Diabetes insipidus)         
      d. Hyperthyroidism         
      e. Hypothyroidism         
      f. Thyroidectomy         
4. Medications:  A     B     C     D
      a. Insulins         
      b. Antithyperglycemics         
      c. Steroids - Adrenocorticosteroids         
      d. Hormone preparations         

1. Assessment:  A     B     C     D
      a. Skin for impending breakdown         
      b. Stasis ulcers         
      c. Surgical wound healing         
2. Equipment/Procedures:  A     B     C     D
      a. Air fluidized, low airloss beds         
      b. Sterile dressing changes         
      c. Wound care/irrigations         
3. Care of the patient with:  A     B     C     D
      a. Burns         
      b. Pressure sores         
      c. Staged decubitis ulcers         
      d. Surgical wounds with drains         
      e. Traumatic wounds         

1. Assessment:  A     B     C     D
      a. Personal/family/history/mental status         
      b. Motor responses/ROM/strength/endurance         
      c. Nodules/tumors/deformities         
      d. GI/GU - NV, urine, stools, nutrition         
      e. Skin - lesions/tumors, color         
      f. Pain control         
2. Equipment/Procedures:  A     B     C     D
      a. Labs - blood draws/interpretations         
      b. Biopsies         
      c. Bone marrow aspiration         
      d. Reverse isolation         
3. Care of the patient with:  A     B     C     D
      a. Bone marrow transplant         
      b. Fresh onocologic surgery         
      c. Inpatient chemotherapy         
      d. Inpatient hospice         
      e. Leukemia         
      f. Radiation implant         
4. Medications:  Yes   No
      a. Chemotherapy certification   

1. Assessment:  A     B     C     D
      a. Manifestations of infections on systems         
2. Equipment/Procedures:  A     B     C     D
      a. Isolation/universal precautions         
      b. Blood cultures (obtaining specimen)         
      c. Sputum cultures (obtaining specimen)         
      d. Stool cultures (obtaining specimen)         
      e. Wound cultures (obtaining specimen)         
      f. CSF cultures (obtaining specimen)         
      g. CBC with differential         
3. Care of the patient with:  A     B     C     D
      a. Abscesses         
      b. Bacteremia/septic shock         
      c. Systemic fungal disease/Rickettsial disease         
      d. Parasitic infection         
      e. Viral infection         
      f. HIV         
      g. Sexually transmitted disease         
4. Medications - Administrations/Teaching:  A     B     C     D
      a. Immunoglobulin/antitoxins         
      b. Immunizations - MMR, Tetanus, Hep B, influenza, pneumococcal         
      c. Antibacterial drugs         
      d. Antiviral drugs/HIV drugs         

1. Equipment/Procedures:  A     B     C     D
      a. Administration of blood/blood products  
          (I) Albumin         
          (II) Cyroprecipitate         
          (III) Packed red blood cells         
          (IV) Plasma         
          (V) Whole blood         
      b. Drawing blood from central line         
      c. Drawing venous blood         
      d. Starting IVs  
          (I) Angiocath         
          (II) Butterfly         
          (III) Heparin lock         
2. Care of the Patient With:  A     B     C     D
      a. Central line/catheter/dressing  
          (I) Broviac         
          (II) Groshong         
          (III) Hickman         
          (IV) Portacath         
          (V) Quinton         
      b. Peripheral line/dressing         

1. Assessment:  A     B     C     D
      a. Pain level/tolerance         
2. Care of the Patient With:  A     B     C     D
      a. Epidural anesthesia/analgesia         
      b. IV conscious sedation         
      c. Narcotic analgesia         
      d. Patient controlled analgesia (PCA pump)         

Please check the boxes for each age group for which you have expertise in providing age-appropriate nursing care.

A) Newborn.Neonate (Birth - 30 days) D) Preschooler (3-5 years) G) Young Adults (18-39 years)
B) Infant (30 days-1 year) E) School Age Children (5-12 years) H) Middle Adults (39-64 years)
C) Toddler (1-3 years) F) Adolescents (12-18 years) I) Older Adults (64+)

Able to adapt care to incorporate normal growth and development:
A         B         C         D         E         F         G         H         I
Able to adapt method and terminology of patient instruments to their age comprehension and maturity level:
A         B         C         D         E         F         G         H         I
Can ensure a safe environment reflecting specific needs of various age groups:
A         B         C         D         E         F         G         H         I

MY EXPERIENCE IS PRIMARILY IN (Please indicate number of years):
 Medical    year(s)  Cardiothoracic    year(s)  Neuro    year(s)
 Neurological    year(s)  Cardiovascular    year(s)  Burn    year(s)
 Trauma    year(s)  Coronary Care    year(s)  PACC    year(s)
 Other       year(s)

The information I have given is true and accurate to the best of my knowledge. I hereby authorize Professional Nursing Service to release this Medical/Surgical Skills Checklist to Client facilities of PNS in relation to consideration of employment as a Traveler with those facilities.

Yes, I agree and consent to the statement above         Date: