Emergency Room Skills Checklist Form

Items in red are REQUIRED fields.

Personal Information:
First Name:        Middle Initial:
Last Name:
Address:
City:
State:        ZIP:
Phone:
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.
 
 
 



A. CARDIOVASCULAR A      B      C      D
   1. Assessment  
      (a) Auscultation (rate, rhythm)         
      (b) Doppler         
      (c) Heart sounds/murmurs         
   2. Equipment & Procedures  
      (a) Assist with insertion and set up  
         (I) Arterial line         
         (II) Central venous line         
         (III) PA catheter/Swan-Ganz         
         (IV) Pacemaker         
      (b) Cardioversion         
      (c) Interpretation of waveforms and values  
         (I) A-line         
         (II) CVP         
      (d) Monitoring  
         (I)Basic 12 lead interpretation         
         (II) Basic arryhthmia interpretation         
   3. Care of patient with  
      (a) Acute MI         
      (b) Aneurysm         
      (c) Angina         
      (d) Cardiac arrest         
      (e) Congestive heart failure (CHF)         
      (f) Myocarditis         
   4. Medications  
      (a) ACLS drugs  
         (I) Atropine         
         (II) Bretylium (Bretylol)         
         (III) Epinephrine (Adrenaline)         
         (IV) Lidocaine (Xylocaine)         
         (V) Procainamide (Pronestyl)         
         (VI) Sodium bicarbonate         
      (b) Other  
         (I) Adenosine (Adenocard)         
         (II) Amiodarone (Cordarone)         
         (III) Digoxin (Lanoxin)         
         (IV) Diltiazem (Cardizem)         
         (V) Dobutamine (Dobutex)         
         (VI) Dopamine (Intropin)         
         (VII) Esmolol (Brevibloc)         
         (VIII) Lasix (Furosemide)         
         (IX) Nitroglycerin (Tridil)         
         (X) Nitroprusside (Nipride)         
         (XI) Thrombolytic therapy         


B. PULMONARY A      B      C      D
   1. Assessment  
      (a) Breath sounds         
      (a) Rate and work of breathing         
   2. Interpretation of lab results  
      (a) Arterial blood gases         
   3. Equipment & procedures  
      (a) Airway management devices/suctioning  
         (I) Endotracheal tube/suctioning         
         (II) Nasal airway/suctioning         
         (III) Oropharyngeal/suctioning         
         (IV) Sputum specimin collection         
         (V) Tracheostomy/suctioning         
      (b) Assist with extubation         
      (c) Assist with intubation         
      (d) Assist with thoracentesis         
      (e) Care of the patient on a ventilator         
      (f) Care of the patient with a chest tube  
         (I)Assist with set up & insertion         
         (II) Measuring         
         (III) Removal         
      (g) Measure peak flow         
      (h) Obtaining arterial blood gases  
         (I) Arterial line         
         (II) Femoral artery         
         (III) Radial artery         
      (i) O2 therapy and medication delivery systems  
         (I) Bag & mask         
         (II) ET tube         
         (III) External CPAP         
         (IV) Face masks         
         (V) Inhalers         
         (VI) Nasal cannula         
         (VII) Nebulizer         
         (VIII) Portable O2 tank         
         (IX) T-piece         
         (X) Trach collar         
      (j) Pulse oximetry         
      (k) Trouble shooting high pressure alarms         
      (l) Trouble shooting low pressure alarms         
   4. Care of the patient with  
      (a) Aspiration         
      (b) COPD         
      (c) Hemopneumothorax         
      (d) Laryngospasm         
      (e) Pneumonia         
      (f) Pneumothorax         
      (g) Pulmonary edema         
      (h) Pulmonary embolism         
      (i) Tension pneumothorax         
      (j) Tuberculosis         
   5. Medications  
      (a) Aminophylline (Theophylline)         
      (b) Bronkosol (Isoetharine hydrochloride)         
      (c) Epinepherine (Adrenaline)         
      (d) Isuprel (Isoproterenol hydrochloride)         
      (e) Steroids         
      (f) Terbulaline         


C. NEUROLOGICAL A      B      C      D
   1. Assessment  
      (a) Advanced neuro assessment  
         (I) Glasgow coma scale         
         (II) Reflex motor deficits         
         (III) Visual or communications deficits         
      (b) Level of consciousness         
   2. Equipment & procedures  
      (a) Assist with lumbar puncture         
      (b) Increased ICP management  
         (I) Medications         
         (II) Positioning         
         (III) Regulation of ICP         
         (IV) Temperature control         
         (V) Ventilation         
      (c) Intracranial pressure monitoring         
   3. Care of the patient with  
      (a) Basal skull fracture         
      (b) Closed head injury         
      (c) CVA         
      (d) DTs         
      (e) Encephalitis         
      (f) Externalized VP shunts         
      (g) Meningitis         
      (h) Neuromuscular disease         
      (i) Overdose         
      (j) Seizures         
      (k) Spinal cord injury         
   4. Medications  
      (a) Decadron (Dexamethasone)         
      (b) Dilantin (Phenytoin)         
      (c) Mannitol (Osmitrol)         
      (d) Phenobarbital         
      (e) Solu-medrol (Methylprednisolone sodium succinate)         


D. ORTHOPEDICS A      B      C      D
   1. Assessment  
      (a) Circulation checks         
      (b) Galt         
      (c) Range of motion         
      (d) Skin         
   2. Equipment & Procedures  
      (a) Assist with placement of cast         
      (b) Support devices  
         (I) Cane/crutch         
         (II) Cervical collar         
         (III) Sling         
         (IV) Transfer boards         
   3. Care of the patient with  
      (a) Ankle brace         
      (b) Ankle splint         
      (c) Range of motion         
      (d) Cast         
      (e) Knee immobilizer         
      (f) Wrist splint         


E. GASTROINTESTINAL A      B      C      D
   1. Assessment  
      (a) Abdominal bowel sounds         
      (b) Fluid balance         
      (c) Nutritional status         
   2. Interpretation of blood chemistry         
   3. Equipment & Procedures  
      (a) Placement of gastroplastic tube         
      (b) Salem sump to suction         
      (c) Saline lavage         
   4. Care of the patient with  
      (a) Abdominal trauma         
      (b) Bowel obstruction         
      (c) GI bleeding         
      (d) Hepatitis         
      (e) Liver failure         
   5. Medications  
      (a) Antiemetics         
      (b) Antispasmotic         
      (c) Charcoal         
      (d) Urinary tract infection         


F. RENAL/GENITOURINARY A      B      C      D
   1. Assessment - fluid balance         
   2. Interpretation of lab results  
      (a) BUN & creatine         
      (b) Electrolytes         
   3. Equipment & Procedures  
      (a) Insertion and care of straight and Foley catheter  
         (I) Female         
         (II) Male         
      (b) Urine specimen collection         
   4. Care of the patient with  
      (a) Acute renal failure         
      (b) Peritoneal lavage         
      (c) Renal trauma         
      (d) Urinary tract infection         


G. ENDOCRINE/METABOLIC A      B      C      D
   1. Assessment  
      (a) S/S diabetic coma         
      (b) S/S insulin reation         
   2. Equipment & Procedures  
      (a) Blood glucose monitoring  
         (I) Electronic measuring device         
         (II) Performing finger stick         
   3. Care of the patient with  
      (a) Diabetic ketoacidosis         
   4. Medications  
      (a) Insulin         
      (b) Oral hypoglycemics         


H. WOUND MANAGEMENT/SURGICAL A      B      C      D
   1. Equipment & Procedures  
      (a) Application of steristrips         
      (b) Assist with staples         
      (c) Assiste with sutures         
      (d) Culdocentesis tray         
      (e) Set up suture tray         
      (f) Staple removal         
      (g) Suture removal         


I. EENT A      B      C      D
   1. Assessment  
      (a) Set up fluorescent/Woods lamp exam         
      (b) Visual acuity         
   2. Equipment & Procedures  
      (a) Application of eye patch         
      (b) Ear irrigation         
      (c) Eye irrigation         
      (d) Morgan lens irrigation         
      (e) Nasal packing         
      (f) Removal of contact lens         


J. TRAUMA/SHOCK A      B      C      D
   1. Assessment  
      (a) Champion trauma score         
      (b) Poison index         
      (c) Triage         
   2. Equipment & Procedures  
      (a) Air transport of trauma patient         
      (b) Application of mast suit         
      (c) Ground transport         
   3. Care of the patient with  
      (a) Bites, animal         
      (b) Bites, human         
      (c) Bites, venemous snake         
      (d) Bites, venemous spider         
      (e) Burns  
         (I) Rule of nines         
         (II) First degree         
         (III) Second degree         
         (IV) Third degree         
      (f) Dehydration         
      (g) Electrocution         
      (h) Gunshot/stab wounds         
      (i) Hazardous material exposure         
      (j) Heat exhaustion/stroke         
      (k) Hypothermia         
      (l) Major trauma         
      (m) Minor trauma         
      (n) Radiation exposure         
      (o) Shock  
         (I) Anaphylactic         
         (II) Cardiogenic         
         (III) Hypovolemic         
         (IV) Neurogenic         
         (V) Septic         
      (p) Traumatic amputation         


K. INFECTIOUS DISEASES A      B      C      D
   1. Interpretation of lab values - CBC, SMA 7         
   2. Equipment & Procedures  
      (a) Fever management         
      (b) Isolation         
   3. Care of the patient with AIDS         


L. PHLEBOTOMY/IV THERAPY/INVASIVE PROCEDURES A      B      C      D
   1. Equipment & Procedures  
      (a) Administration of blood/blood products  
         (I) Autotransfusion         
         (II) Cryoprecipitate         
         (III) Packed red blood cells         
         (IV) Plasma/albumin         
         (V) Whole blood         
      (b) Assist with cutdown         
      (c) Drawing venous blood         
      (d) Starting IVs  
         (I) Angiocath         
         (II) Butterfly         
         (III) Heparin lock         
   2. Care of the patient with  
      (a) Angiography         
      (b) Central line/catheter/dressing  
         (I) Broviac/Hickman         
         (II) Groshong         
         (III) PICC         
         (IV) Portacath         
      (c) Pericardiocentesis         


M. PAIN MANAGEMENT A      B      C      D
   1. Assessment of pain level/tolerance         
   2. Care of the patient with  
      (a) Epidural anesthesia/analgesia         
      (b) IV conscious sedation         


N. PEDIATRICS A      B      C      D
   1. Equipment & Procedures  
      (a) Child abuse/recognition/reporting         
      (b) Obtaining consent to treatment         
      (c) Pediatric arrest         
   2. Care of the patient with  
      (a) Epiglottitis         
      (b) Near drowning         
      (c) Overdose/poison ingestion         
      (d) Status asthmaticus         
      (e) Status epilepticus         


O. WOMEN'S HEALTH A      B      C      D
   1. Assessment - assist with pelvic exam         
   2. Equipment & Procedures  
      (a) Pelvic tray         
      (b) Rape kit         
      (c) Reporting acts of violence         
   3. Care of the patient with  
      (a) Abruptio placenta         
      (b) DIC         
      (c) Hemorrhage         
      (d) Placenta previa         
      (e) Precipitous delivery         
      (f) Preeclampsia/eclampsia         
      (g) Spontaneous abortion         


P. MISCELLANEOUS  
   1. AMA procedures Yes     No
   2. Suicide precautions Yes     No

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

AGE SPECIFIC PRACTICE:
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+)

EXPERIENCE WITH AGE GROUPS:
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 my Emergency Room 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: