LTC Skills Checklist "*" indicates required fields Name* First Last Email* Phone*Years Experience in Clinical Specialty:*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.Patient Care1. CARDIAC:*ABCDUse of cardiac monitorsAssessment of heart soundsCardiac ArrestCPRCare of patients with CHFAtropine administrationDigoxin administrationDopamine administrationInderal administrationLidocaine administration2. GENITOURINARY:*ABCDFluid BalanceFoley Catheter InsertionIleostomyGU IrrigationsNephrostomy Tube3. ENDOCRINE:*ABCDBlood Glucose ChecksInsulin AdministrationCare of patients with Diabetes4. GASTROINTESTINAL:*ABCDNG tube care and feedingsGastrostomy tube care and feedingsColostomy CareAssessment of Bowel Sounds5. LEADERSHIP/PATIENT CARE:*ABCDTaking ChargeAdmission ProceduresDischarge ProceduresPatient EducationPatient Care Plans6. MEDICATIONS/IV THERAPY:*ABCDMedication CalculationReconstitutionOral AdministrationEye AdministrationIM AdministrationSQ AdministrationRectal AdministrationStarting IV’sIV Medication AdministrationCentral Line Care7. NEUROLOGY:*ABCDAssessment of Neurological StatusSeizure PrecautionsCare of a patient with a CVACare of a patient with Alzheimer’sCare of patients with Spinal Cord InjuryDecadron AdministrationDilantin AdministrationPhenobarbital AdministrationValium Administration8. ORTHO/SKIN:*ABCDAssessment of skinWound Care and TreatmentsUse of special pressure relief devicesCare of pts with a total hip replacementCare of pts with a total knee replacementCrutch Walking9. RESPIRATORY:*ABCDPulse OximetryOxygen Administration via nasal cannuiaOxygen Administration via face maskPrinciples of chest percussionCare of patients with ventilatorCare of patients with COPDCare of patients with ARDSCare of patient with a TracheotomyAge Specific:Please indicate the frequency with which you provide care for each age group:*ABCDInfant (Birth to 1 year)Toddler (1-3 years)Pre-school (3-6 years)School Age (6-12 years)Adolescent ( 12-18 years)Young Adult ( 18-30 years)Mature Adult (30-60 years)Elderly (>60 years)* The information I have given is true and accurate to the best of my knowledge. I hereby authorize Professional Nursing Service to release my Skills Checklist to Client facilities of PNS in relation to consideration of employment as a Traveler with those facilities.Date* MM slash DD slash YYYY
