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CRITICAL CARE SKILLS CHECKLIST

DATE: ________________________

Applicant’s Name:___________________________________________________________________________ _____

FIRST MIDDLE INITIAL LAST

To IITR Professionals:

The purpose of the following checklist is to assist in matching your skills and interests with available assignments, thus meeting your needs and the needs of our clients as much as possible. Your employment is not dependant upon responses given in this checklist.

**Please make sure this Skills checklist is signed and dated. We will accept the form on email with your name typed in place of signature

The information I have given is true and accurate to the best of my knowledge.

Signature________________________________________________________________ Date ________________________

To IITR:

IITR has developed unique skills checklist for each nursing specialty. This checklist is not necessarily a valid indicator of clinical skills and should not be utilized as the sole measure of the ability of an individual to perform the duties of a registered nurse or therapist in your facility. It is intended to be used only as a guide in your screening procedures and in orientation to procedure within your institution.

PLEASE MARK YOUR LEVEL OF EXPERIENCE X

Limited Experience 1 2 3 4 Very Experienced

Mark One Mark One

|A. |Cardia|1 |2 |3 |4 | |

| |c | | | | | |

| |a. Aminophylline | | | | | | | |a. TURP | | | | | | | |b. Corticosteroids | | | | | | | |b. Shunts/Fistulas | | | | | | | |c. Nebulizer Treatments | | | | | | | |c. Nephrostomy/Supra-pubic Tubes | | | | | |C. |Neurological | | | | |d. Renal Failure (Acute/Chronic) | | | | | | |1. |Perform Neuro Assessment | | | | | | | |e. Renal Transplant | | | | | | |2. |Glasgow Coma Scale | | | | | | | |f. Renal Trauma | | | | | | |3. |Intracranial Pressure Monitoring (ICP) | | | | | |F. |Vascular | | |4. |Assist with Lumbar Puncture | | | | | | |1. |Peripheral Pulses | | | | | | |5. |Epidural Medication Administration | | | | | | |2. |Ultrasonic Doppler Use | | | | | | |6. |Care of the patient with: | | |3. |Start IV’s | | | | | | | |a. Halo Traction | | | | | | |4. |Central Line Maintenance | | | | | | | |b. Crutchfield Tongs | | | | | | |5. |Hickman/Broviac/Groshong Catheter | | | | | | | |c. CVA | | | | | | |6. |Infusion Pumps | | | | | | | |d. Coma | | | | | | |7. |Administration of Blood/Blood Products | | | | | | | |e. Neuro Injury Trauma | | | | | | |8. |Normal Serum Lab Values | | | | | | | |f. Pre-/Post-Neuro Surgery | | | | | | |9. |Hep Lock Maintenance | | | | | | | |g. Spinal Cord Injury | | | | | |G. |Miscellaneous | | | |h. Ventriculostomy | | | | | | |1. |Pain Management | | | | | | | |i. CNS Infections | | | | | | |2. |PCA pumps | | | | | | | |j. Seizure Activity and Precautions | | | | | | |3. |Chemotherapy | | | | | | | |k. Overdose | | | | | | |4. |HIV/AIDS | | | | | | |7. |Use and Administration of: | | |5. |Isolation Techniques | | | | | | | |a. Decadron (dexamethasone) | | | | | | |6. |Obtaining Cultures | | | | | | | |b. Dilantin (phenytoin) | | | | | | |7. |Conscious Sedation | | | | | | | |c. Magnesium Sulfate | | | | | | |8. |Diabetic Teaching | | | | | | | |d. Versed (midazolam) | | | | | | |9. |Accucheck / Blood glucose monitor | | | | | | | |e. Ephenobarbital | | | | | | |10. |Care of Oncology patients / chemo | | | | | | | |f. Steroids | | | | | | |11. |Hyperbaric Oxygenation | | | | | | | |g. Valium (Diazepam) | | | | | | |12. |Organ Procurement | | | | | |D. |Gastrointestinal | | |13. |Pyxis – computerized medical delivery | | | | | | |1. |NG Tube Insertion | | | | | | |14. |Use of Restraints | | | | | | |2. |Gastrostomy/Jejunostomy Tubes | | | | | | |15. |Cardiac Monitors: | | |3. |Enterostomal Care | | | | | | | |a. Hewlett-Packard | | | | | | |4. |Care of the Patient with: | | | | | | | |b. Space Lab | | | | | | | |a. Tube Feedings | | | | | | | |C. Siemens | | | | | |

APPLICANTS NAME: Mark One

|1 |2 |3 |4 | | | | | | | | | |d. Marquette | | | | | | | | | | | | | | | |e. Other: | | | | | | | | | | | | | | |16. |Ventilators: | | | | | | | | | | | |a. Bear-Type: | | | | | | | | | | | | | | | |b. Bennett 7200-Type: | | | | | | | | | | | | | | | |c. Servo | | | | | | | | | | | | | | | |d. Siemens | | | | | | | | | | | | | | | |e. Other: | | | | | | | | | | | | | | |17. |Blood Glucose Monitor Type:

| | | | | | | | | | | | | | |18. |Computer charting Type:

| | | | | | | | | | | | | |H. |Age of Patients Cared For | | | | | | | | | | |1. |Infants and Toddlers (ages 0-3 years) | | | | | | | | | | | | | | |2. |Young Children (ages 4-6 years) | | | | | | | | | | | | | | |3. |Older Children (ages 7-12 years) | | | | | | | | | | | | | | |4. |Adolescents (ages 13-20 years) | | | | | | | | | | | | | | |5. |Young Adults (ages 21-39 years) | | | | | | | | | | | | | | |6. |Middle Adults (ages 40-64) | | | | | | | | | | | | | | |7. |Older Adults (ages 65-79) | | | | | | | | | | | | | | |8. |Adults (ages>80) | | | | | | | | | | | | | |

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