ICU – Professional Nursing Service

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.

Cardiovascular

1. Assessment:*

	A	B	C	D
Normal Heart Tones (i.e.: S1, S2)
Abnormal Heart Tones (i.e.: murmur, gallop, friction rub)
Identification of PMI (Point Maximal Intensity)
Blood Pressure (non-invasive)
Pulses/Circulation via palpation
Pulses/Circulation via Doppler
Insertion site invasive lines
12-lead EKG interpretation
EKG Changes for MI
Rhythm interpretation
S/S DVT

2. Provision of care for:*

	A	B	C	D
Aortic Dissection
Aortic Stenosis
Cardiac Arrest
Cardiac Tamponade
Cardiomyopathy
CHF
Left Ventricular Hypertrophy
Mitral Valve Stenosis
Myocardial contusion
Myocardial Infarction
Pericardial Effusion
Pericardial Window
Pericarditis
Post AICD Insertion
Post cardiac procedural complications
Post Cardiac Cath
Post Percutaneous Coronary Intervention (i.e.: PTCA, Stent)
Pulmonary Hypertension
Retroperitoneal Bleed

3. Procedures:*

	A	B	C	D
Obtain Cardiac Output
PCWP Measurement
Obtain CVP Measurement
Removal of radial arterial line
Removal of femoral sheath
Venipuncture
Obtain lab specimens from A-line
Obtain lab specimens from Central Line
Perform 12-lead EKG
Proper Cardiac Monitor lead placement

4. Administration:*

5. Hemodynamic Monitoring:*

6. Management of IABP:*

7. Pacemaker:*

8. Management of Temporary Pacemaker:*

9. Identification and interpretation of:*

10. Perform calculations for:*

11. Assist with:*

Pulmonary

1. Assessment:*

	A	B	C	D
Auscultate breath sounds
Identify adventitious lung sounds
Auscultate for confirmation of ET Tube placement
Assess and confirm proper vent settings
Assess patient on mechanical ventilation
Assess pulmonary stability post-extubation
Interpretation of Oximetry Values

2. Provision of Care:*

3. Procedures:*

	A	B	C	D
Application of BiPAP
Application of CPAP
Application of Pulse Oximetry
Implement Ventilator Acquired Pneumonia protocols
Perform ET Tube suctioning
Perform NT(Nasotracheal) suctioning
Perform suctioning of Tracheostomy
Collection of Sputum via NT Suction
Collection of Sputum Specimen via ET
Assist with extubation of patient

4. Assist with:*

5. Chest Tubes:*

Gastrointestinal

1. Assessment:*

2. GI Bleed*

	A	B	C	D

3. Procedures:*

Neurology

1. Assessment:*

2. Provision of Care:*

Endocrine

1. Provision of Care:*

2. Procedures:*

3. Equipment:*

Renal

1. Assessment:*

2. Provision of Care:*

Multisystem

1.*

	A	B	C	D
1. Perform comprehensive multi-system assessment

2. Provision of Care:*

3. Pain Management:*

4. Care of the patient with:*

Labs

1. Interpretation of:*

CCU Pharmacology

1. Provision of Care:*

2. Medications:*

	A	B	C	D
Alupent (Metaproterenol)
Amicar
Aminophylline (Theophylline)
Amiodarone (Cordarone)
Atropine
Apresoline
Bretylium (Bretylol)
Corticosteroids
Digoxin (Lanoxin)
Diltiazem (Cardizem)
Dobutamine (Dobutrex)
Dopamine (Intropin)
Esmolol (Brevibloc)
Epinephrine (Adrenalin)
Heparin Drip
Inocor (Amrinone)
Levophed
Lidocaine
Metoprolol (Lopressor)
Neosynephrine
Nipride (Nitroprusside)
Nitroglycerin (Tridil)
Procainamide (Pronestyl)
Propofol (Diprivan)
Sodium Bicarbonate
Succinylcholine
Vasopressin
Verapamil (Calan, Isoptin, Verelan)
Procainamide (Pronestyl)
Vecuronium
Ventolin (Albuterol)

Patient Education

1.*

Patient Advocacy

1.*

	A	B	C	D
Provide care for end-of-life decisions that families face in ICU such as withdrawal of life support
Adhere to legal procedures regarding notification of organ donation provider
Demonstrate Spiritual and Cultural Considerations for the Critical Care patient
Provide for the integration of comfort care and death with dignity
Demonstrate effective coping skills in caring for the critical care patient

Age Specific:

Please indicate the frequency with which you provide care for each age group:*

Date*

	A	B	C	D
Management of Arterial Line
Management of PA/Swan-Ganz
Management of CVP Line
Zero and calibration of transducers
Assess adequate perfusion with invasive lines

	A	B	C	D
Waveform interpretation
Determination of appropriate timing
Perfusion assessment
Recognize IABP complications

	A	B	C	D
Recognition of failure to sense, capture
Manipulation of TPM settings
Troubleshoot TPM settings
Management of epicardial wires

	A	B	C	D
Arterial waveform
PA/Swan-Ganz waveform
PCWP waveform
CVP waveform
SVO2 Data

	A	B	C	D
Set-Up for cardioversion
Cardioversion
Central line insertion
CAVH-D
Arterial line insertion
PA/Swan-Ganz insertion
Pericardiocentesis
Transesophageal Echocardiogram

	A	B	C	D
Blood and blood product
Identification of blood transfusion reactions

	A	B	C	D
PPM
Transvenous
Transcutaneous

	A	B	C	D
PVR
SVR

	A	B	C	D
Acute Pneumonia
ARDS
Chest Trauma
COPD
Cor Pulmonale
Fresh Tracheostomy
Pulmonary Edema
Pulmonary Embolism
Pulmonary Hypertension
Status Asthmaticus
Tuberculosis

ICU Skills Checklist

Directions for Completing Skills Checklist

Cardiovascular

Pulmonary

Gastrointestinal

Neurology

Endocrine

Renal

Multisystem

Labs

CCU Pharmacology

Patient Education

Patient Advocacy

Age Specific: