Orthopedic – 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.

Skills-Casts-Fiberglass/ Synthetic

1.*

	A	B	C	D
Skills-Casts-Fiberglass/ Synthetic
Long arm in flexion with ulnar deviation w/3 point molding
Long arm pronation or supination
Short arm in neutral position
Short arm in flexion with ulnar deviation with 3 point molding
Short leg walking in neutral position
Short leg walking in equines
Short leg non weight bearing in equines
Short leg non weight bearing in neutral position
P.T.B. with correct molding
Long leg walker
Cylinder cast
Long leg non weight bearing in neutral position with correct knee flexion
Long leg non weight bearing with molding for widened mortise
Toe plates applied to short and long leg casts
Gauntlet with outrigger-hand
Gauntlet with outrigger and molding-hand
Long arm navicular thumb spica
Long arm thumb spica

2. Cast saw:*

Skills-Splints

1.*

	A	B	C	D
Short leg posterior
Short leg sugar tong
Thumb spica
Hand muff splint
Foot muff splint
Gutter splint lateral and medial
Short arm volar
Long arm posterior with side walls
Sugar tong double long arm
Sugar tong short arm
Other

Braces, Immobilizers

1.*

Traction

1. Assist in the management of anesthesia when indicated.*

Physical Therapy

1.*

Miscellaneous

1.*

	A	B	C	D
Removal of sutures
Making various casts and molds
Preparing plaster of Paris mix
Make alterations to casts to alleviate pressure points
Assisting with research projects
Assist with skin grafts
Assist with stump revisions
Assist with pin insertions
Assist with debridements
Application of Minerva/ Halo jacket
Sterile dressing techniques
Removal of orthopedic devices
Other

Age Specific:

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

Date*

	A	B	C	D
Remove cast
Trim casts
Wedging
Remove and replace cast blades
Window casts
Univalve casts
Other

	A	B	C	D
Wrist brace
Ace bandage
Shoulder immobilizer
Slings
Hinged knee brace
Velcro knee brace
Cervical collar - Hard
Cervical collar - Soft
Other

	A	B	C	D
Bucks
Bryant’s
Overhead bed frame
Splint Russells
Balanced suspension
Assist MD with fracture reduction
Cervical
Other

	A	B	C	D
Range of motion exercises
Gait training
Crutches and canes
Crutches and canes - Fitting
Crutches and canes - Instructions
Other

	A	B	C	D
Infant (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)

Orthopedic Skills Checklist