CRITICAL CARE / INTENSIVE CARE CHECKLIST One program to handle all talent management needs from acquisition to development Personal Information This field is hidden when viewing the formOverall ScoreOut of 4Name(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) This field is hidden when viewing the formDate MM slash DD slash YYYY Key To Experience/Proficiency LevelsThe following is a list of equipment and/or procedures performed in rendering care to patients. Please indicate your level of experience/proficiency with each area and, where applicable, the types of equipment and/or systems you are familiar with. Use the following key as a guideline: 0 –Theory Only/No Experience - Didactic instruction only, no hands on experience 1 – Limited Experience - Knows procedure/has used equipment, but has done so infrequently or not within the last six months 2 – Moderate Experience - Able to demonstrate equipment/procedure, performs the task/skill independently with only resource assistance needed. 3 – Proficient/Competent - Able to demonstrate/perform the task/skill proficiently without any assistance and can instruct/teach.Cardiovascular1. Assessmenta. Abnormal heart sounds/murmurs/arrhythmias(Required) 0 1 2 3 b. Auscultation (rate, rhythm)(Required) 0 1 2 3 c. Blood pressure/non-invasive(Required) 0 1 2 3 d. Doppler(Required) 0 1 2 3 e. Pulses/circulation checks(Required) 0 1 2 3 2. Interpretation of lab resultsa. Cardiac enzymes & isoenzymes(Required) 0 1 2 3 b. Coagulation studies(Required) 0 1 2 3 3. Equipment & proceduresa. Assist with Arterial line insertion(Required) 0 1 2 3 b. Assist with Central line insertion(Required) 0 1 2 3 c. Assist with Open chest emergency(Required) 0 1 2 3 d. Assist with PA catheter/Swan-Ganz insertion(Required) 0 1 2 3 e. Assist with Pericardiocentesis(Required) 0 1 2 3 f. Assist with Transesophageal echocardiogram(Required) 0 1 2 3 g. Assist with intubation and extubation(Required) 0 1 2 3 h. Automatic internal cardioverter defibrillator(Required) 0 1 2 3 i. Cardioversion(Required) 0 1 2 3 j. CAVH-D(Required) 0 1 2 3 k. Hemodynamic monitoring: Cardiac index(Required) 0 1 2 3 l. Hemodynamic monitoring: Cardiac output(Required) 0 1 2 3 m. Hemodynamic monitoring: CVP monitoring(Required) 0 1 2 3 n. Hemodynamic monitoring: Femoral artery sheath removal(Required) 0 1 2 3 o. Hemodynamic monitoring: MAP(Required) 0 1 2 3 p. Hemodynamic monitoring: PA/Swan-Ganz(Required) 0 1 2 3 q. Hemodynamic monitoring: PCW pressure(Required) 0 1 2 3 r. Hemodynamic monitoring: PVR(Required) 0 1 2 3 s. Hemodynamic monitoring: Radial a-line(Required) 0 1 2 3 t. Hemodynamic monitoring: SVO2(Required) 0 1 2 3 u. Hemodynamic monitoring: SVR(Required) 0 1 2 3 v. Intra aortic balloon pump(Required) 0 1 2 3 w. Monitoring: 12 lead EKG interpretation(Required) 0 1 2 3 x. Monitoring: Arrhythmia interpretation(Required) 0 1 2 3 y. Monitoring: Lead placement(Required) 0 1 2 3 z. Monitoring: Rhythm strip assessment(Required) 0 1 2 3 aa. Monitoring: Set up and run 12 lead EKG(Required) 0 1 2 3 ab. Pacemaker: External(Required) 0 1 2 3 ac. Pacemaker: Permanent(Required) 0 1 2 3 ad. Pacemaker: Temporary(Required) 0 1 2 3 ae. Pacemaker: Transthoracic (epicardial)(Required) 0 1 2 3 af. Ventricular assist device (RVAD or LVAD)(Required) 0 1 2 3 4. Care of the patient witha. Abdominal aortic aneurysm repair(Required) 0 1 2 3 b. Acute MI(Required) 0 1 2 3 c. Cardiac arrest(Required) 0 1 2 3 d. Cardiac tamponade(Required) 0 1 2 3 e. Congestive heart failure (CHF)(Required) 0 1 2 3 f. EP study & ablation(Required) 0 1 2 3 g. Heart transplant(Required) 0 1 2 3 h. Immediate post open-heart surgery(Required) 0 1 2 3 i. Infective endocarditis(Required) 0 1 2 3 j. Myocardial contusion(Required) 0 1 2 3 k. Pericarditis(Required) 0 1 2 3 l. Post AICD insertion(Required) 0 1 2 3 m. Post arthrectomy (DCA)(Required) 0 1 2 3 n. Post commissurotomy, valve repair, valve replacement(Required) 0 1 2 3 o. Post intracoronary stent placement(Required) 0 1 2 3 p. Post percutaneous balloon valvuloplasty(Required) 0 1 2 3 q. Post rotoblade(Required) 0 1 2 3 r. Pre/post angioplasty(Required) 0 1 2 3 s. Pre/post cardiac cath(Required) 0 1 2 3 5. Medicationsa. Amiodarone (Cardarone)(Required) 0 1 2 3 b. Atropine(Required) 0 1 2 3 c. Bicarbonate(Required) 0 1 2 3 d. Bretylium (Bretylol)(Required) 0 1 2 3 e. Digoxin (Lanoxin)(Required) 0 1 2 3 f. Diltiazem (Cardizem)(Required) 0 1 2 3 g. Dobutamine (Dobutrex)(Required) 0 1 2 3 h. Dopamine (Intropin)(Required) 0 1 2 3 i. Epinephrine (Adrenalin)(Required) 0 1 2 3 j. Esmolol (Brevibloc)(Required) 0 1 2 3 l. Lidocaine (Xylocaine)(Required) 0 1 2 3 k. Inocor (Amrinone)(Required) 0 1 2 3 m. Nipride (Nitroprusside)(Required) 0 1 2 3 n. Metoprolol (Lopressor)(Required) 0 1 2 3 o. Nitroglycerine (Tridil)(Required) 0 1 2 3 p. Procainamide (Pronestyl)(Required) 0 1 2 3 q. Reteplase recombinant (Retavase)(Required) 0 1 2 3 r. Streptokinase(Required) 0 1 2 3 s. TPA (Alteplase)(Required) 0 1 2 3 t. Verapamil (Calan, Isoptin, Verelan)(Required) 0 1 2 3 Pulmonary1. Assessmenta. Adventitious breath sounds(Required) 0 1 2 3 b. Rate and work of breathing(Required) 0 1 2 3 2. Interpretation of Lab Resultsa. Arterial blood gases(Required) 0 1 2 3 3. Equipment & Proceduresa. Air leak troubleshooting: Mediastinal chest tube removal(Required) 0 1 2 3 b. Air leak troubleshooting: Pleural chest tube removal(Required) 0 1 2 3 c. Airway management devices/suctioning: Endotracheal tube/suctioning(Required) 0 1 2 3 d. Airway management devices/suctioning: Extubation(Required) 0 1 2 3 e. Airway management devices/suctioning: Nasal airway/suctioning(Required) 0 1 2 3 f. Airway management devices/suctioning: Oximetry(Required) 0 1 2 3 g. Airway management devices/suctioning: Sputum specimen collection(Required) 0 1 2 3 h. Airway management devices/suctioning: Tracheostomy/suctioning(Required) 0 1 2 3 i. Assist with: Bronchoscopy(Required) 0 1 2 3 j. Assist with: Chest tube insertion(Required) 0 1 2 3 k. Assist with: Emergency tracheostomy(Required) 0 1 2 3 l. Assist with: Thoracentesis(Required) 0 1 2 3 m. Establishing an airway: Assist with intubation(Required) 0 1 2 3 n. Establishing an airway: Oral airway insertion(Required) 0 1 2 3 o. Identification/intervention for respiratory complications: Aspiration(Required) 0 1 2 3 p. Identification/intervention for respiratory complications: Laryngospasm(Required) 0 1 2 3 q. Identification/intervention for respiratory complications: Tension pneumothorax(Required) 0 1 2 3 r. Identification/intervention for respiratory complications: Use of Pleurevac or Thoraclex drainage(Required) 0 1 2 3 s. Identification/intervention for respiratory complications: Use of water seal drainage(Required) 0 1 2 3 t. O2 therapy & medication delivery systems: Ambu bag and mask(Required) 0 1 2 3 u. O2 therapy & medication delivery systems: ET tube(Required) 0 1 2 3 v. O2 therapy & medication delivery systems: Face masks(Required) 0 1 2 3 w. O2 therapy & medication delivery systems: Nasal cannula(Required) 0 1 2 3 x. O2 therapy & medication delivery systems: Portable O2 tank(Required) 0 1 2 3 y. O2 therapy & medication delivery systems: Trach collar(Required) 0 1 2 3 z. Ventilator management: External CPAP(Required) 0 1 2 3 aa. Ventilator management: High frequency jet ventilation(Required) 0 1 2 3 ac. Ventilator management: PEEP(Required) 0 1 2 3 ab. Ventilator management: IMV(Required) 0 1 2 3 ad. Ventilator management: Pressure support(Required) 0 1 2 3 ae. Ventilator management: Weaning modes & T-piece weaning(Required) 0 1 2 3 4. Care of the patient witha. Acute pneumonia(Required) 0 1 2 3 b. ARDS(Required) 0 1 2 3 c. Chest trauma(Required) 0 1 2 3 d. COPD(Required) 0 1 2 3 e. Cor pulmonale(Required) 0 1 2 3 f. Fresh tracheostomy(Required) 0 1 2 3 g. Lobectomy(Required) 0 1 2 3 h. Lung transplant(Required) 0 1 2 3 i. Near drowning(Required) 0 1 2 3 j. Pneumonectomy(Required) 0 1 2 3 k. Pulmonary edema/hypertension(Required) 0 1 2 3 l. Pulmonary embolism(Required) 0 1 2 3 m. Status asthmaticus(Required) 0 1 2 3 n. Thoracotomy(Required) 0 1 2 3 o. Tuberculosis(Required) 0 1 2 3 5. Medicationsa. Alupent (Metaproterenol)(Required) 0 1 2 3 b. Aminophylline (Theophylline)(Required) 0 1 2 3 c. Bronkosol (Isoetharine hydrochloride)(Required) 0 1 2 3 d. Corticosteroids(Required) 0 1 2 3 e. Ventolin (Albuterol)(Required) 0 1 2 3 Neurological1. Assessmenta. Cranial nerves(Required) 0 1 2 3 b. Glasgow coma scale(Required) 0 1 2 3 c. Level of consciousness(Required) 0 1 2 3 d. Pathologic reflexes(Required) 0 1 2 3 e. Reflex/motor deficits(Required) 0 1 2 3 f. Visual or communication deficits(Required) 0 1 2 3 2. Equipment & proceduresa. Assist with lumbar puncture(Required) 0 1 2 3 b. Halo traction/cervical tongs(Required) 0 1 2 3 c. Intracranial pressure monitoring(Required) 0 1 2 3 d. Nerve stimulators(Required) 0 1 2 3 e. Rotating bed(Required) 0 1 2 3 f. Seizure precautions(Required) 0 1 2 3 g. Spinal precautions(Required) 0 1 2 3 h. Stryker frame(Required) 0 1 2 3 i. Use of hyper/hypothermia blanket(Required) 0 1 2 3 3. Care of the patient witha. Aneurysm precautions(Required) 0 1 2 3 b. Basal skull fracture(Required) 0 1 2 3 c. Closed head injury(Required) 0 1 2 3 d. Coma(Required) 0 1 2 3 e. CVA(Required) 0 1 2 3 f. DTs(Required) 0 1 2 3 g. Encephalitis(Required) 0 1 2 3 h. Externalized VP shunts(Required) 0 1 2 3 i. Increased ICP(Required) 0 1 2 3 j. Laminectomy(Required) 0 1 2 3 k. Meningitis(Required) 0 1 2 3 l. Metastatic tumor/intracranial tumor resection(Required) 0 1 2 3 m. Multiple sclerosis(Required) 0 1 2 3 n. Post craniotomy(Required) 0 1 2 3 o. Spinal cord injury(Required) 0 1 2 3 p. Ventriculostomy(Required) 0 1 2 3 4. Medicationsa. Barbiturate induced coma(Required) 0 1 2 3 b. Decadron (Dexamethasone)(Required) 0 1 2 3 c. Dilantin (Phenytoin)(Required) 0 1 2 3 d. Epidural administration(Required) 0 1 2 3 e. Phenobarbital(Required) 0 1 2 3 f. Valium (Diazepam)(Required) 0 1 2 3 GastroIntestinal1. Assessmenta. Abdominal/bowel sounds(Required) 0 1 2 3 b. Nutritional(Required) 0 1 2 3 2. Interpretation of lab resultsa. Serum ammonia(Required) 0 1 2 3 b. Serum amylase(Required) 0 1 2 3 c. LFTs(Required) 0 1 2 3 3. Equipment & proceduresa. Administration of tube feeding(Required) 0 1 2 3 b. Balloon tamponade (Sengstaken Blakemore)(Required) 0 1 2 3 c. Feeding pump(Required) 0 1 2 3 d. Flexible feeding tube (i.e., Corpak, Dobhoff)(Required) 0 1 2 3 e. Gravity feeding(Required) 0 1 2 3 f. Iced saline lavage(Required) 0 1 2 3 g. Management of: Gastrostomy tube(Required) 0 1 2 3 h. Management of: Jejunostomy tube(Required) 0 1 2 3 i. Management of: T-tube(Required) 0 1 2 3 j. Management of: TPN and lipids administration(Required) 0 1 2 3 k. Management of: PPN (peripheral parenteral nutrition)(Required) 0 1 2 3 l. Placement of nasogastric tube(Required) 0 1 2 3 m. Salem sump to suction(Required) 0 1 2 3 4. Care of the patient witha. Blunt trauma(Required) 0 1 2 3 b. Bowel obstruction(Required) 0 1 2 3 c. Colostomy(Required) 0 1 2 3 d. ERCP(Required) 0 1 2 3 e. Esophageal bleeding(Required) 0 1 2 3 f. GI bleeding(Required) 0 1 2 3 g. GI surgery(Required) 0 1 2 3 h. Hepatitis(Required) 0 1 2 3 i. Ileostomy(Required) 0 1 2 3 j. Inflammatory bowel disease(Required) 0 1 2 3 k. Liver failure(Required) 0 1 2 3 l. Liver transplant(Required) 0 1 2 3 m. Pancreatitis(Required) 0 1 2 3 n. Paralytic ileus(Required) 0 1 2 3 o. Penetrating trauma(Required) 0 1 2 3 5. Medicationsa. AquaMephyton (Vitamin K)(Required) 0 1 2 3 b. Inderal (Propranolol)(Required) 0 1 2 3 c. Kayexelate(Required) 0 1 2 3 d. Lactulose (Cephulac)(Required) 0 1 2 3 e. Pitressin (Vasopressin)(Required) 0 1 2 3 Renal / Genitourinary1. Assessmenta. A-V fistula/shunt(Required) 0 1 2 3 b. Fluid status(Required) 0 1 2 3 2. Interpretation of lab resultsa. BUN & creatinine(Required) 0 1 2 3 b. Serum electrolytes(Required) 0 1 2 3 3. Equipment & proceduresa. Bladder irrigation(Required) 0 1 2 3 b. Insertion & care of straight and Foley catheter: 3-way Foley(Required) 0 1 2 3 c. Insertion & care of straight and Foley catheter: Female(Required) 0 1 2 3 d. Insertion & care of straight and Foley catheter: Male(Required) 0 1 2 3 e. Supra-pubic(Required) 0 1 2 3 4. Care of the patient witha. Acute renal failure(Required) 0 1 2 3 b. CAVH dialysis(Required) 0 1 2 3 c. Hemodialysis(Required) 0 1 2 3 d. Nephrectomy(Required) 0 1 2 3 e. Peritoneal dialysis(Required) 0 1 2 3 f. Renal rejection syndrome(Required) 0 1 2 3 g. Renal transplant(Required) 0 1 2 3 h. TURP(Required) 0 1 2 3 i. Urinary diversion (ileal conduit nephrostomy)(Required) 0 1 2 3 j. Urinary tract infection(Required) 0 1 2 3 Endocrine / Metabolic1. Interpretation of lab resultsa. Blood glucose(Required) 0 1 2 3 b. Thyroid studies(Required) 0 1 2 3 2. Equipment & proceduresType of blood glucose measuring device:a. Blood glucose monitoring(Required) 0 1 2 3 b. Performing finger stick(Required) 0 1 2 3 3. Care of the patient witha. Diabetes mellitus(Required) 0 1 2 3 b. Diabetic ketoacidosis(Required) 0 1 2 3 c. Disorders of adrenal gland (e.g., Addison's disease)(Required) 0 1 2 3 d. Disorders of pituitary gland (e.g., DI)(Required) 0 1 2 3 e. Drug overdose(Required) 0 1 2 3 f. Hyperthyroidism (Grave's disease)(Required) 0 1 2 3 g. Hypothyroidism(Required) 0 1 2 3 h. Insulin shock(Required) 0 1 2 3 i. Thyroidectomy - disorders of thyroid gland(Required) 0 1 2 3 4. Medicationa. Insulin pump(Required) 0 1 2 3 Wound Management1. Assessmenta. Skin for impending breakdown(Required) 0 1 2 3 b. Stasis ulcers(Required) 0 1 2 3 c. Surgical wound healing(Required) 0 1 2 3 2. Equipment & proceduresa. Air fluidized, low airloss beds(Required) 0 1 2 3 b. Sterile dressing changes(Required) 0 1 2 3 c. Wound care/irrigations(Required) 0 1 2 3 3. Care of the patient witha. Burns(Required) 0 1 2 3 b. Pressure sores(Required) 0 1 2 3 c. Staged decubitus ulcers(Required) 0 1 2 3 d. Surgical wounds with drain(s)(Required) 0 1 2 3 e. Traumatic wounds(Required) 0 1 2 3 Phlebotomy / IV Therapy1. Equipment & proceduresa. Administration of blood/blood products: Cryoprecipitate(Required) 0 1 2 3 b. Administration of blood/blood products: Packed red blood cells(Required) 0 1 2 3 c. Administration of blood/blood products: Plasma/albumin(Required) 0 1 2 3 d. Administration of blood/blood products: Whole blood(Required) 0 1 2 3 e. Drawing blood from central line(Required) 0 1 2 3 f. Drawing venous blood(Required) 0 1 2 3 g. Starting IVs: Angiocath(Required) 0 1 2 3 h. Starting IVs: Butterfly(Required) 0 1 2 3 i. Starting IVs: Heparin lock(Required) 0 1 2 3 2. Care of the patient witha. Central line/catheter/dressing: Broviac(Required) 0 1 2 3 b. Central line/catheter/dressing: Groshong(Required) 0 1 2 3 c. Central line/catheter/dressing: Hickman(Required) 0 1 2 3 d. Central line/catheter/dressing: Portacath(Required) 0 1 2 3 e. Central line/catheter/dressing: Quinton(Required) 0 1 2 3 f. Peripheral line/dressing(Required) 0 1 2 3 Pain Managementa. Assessment of pain level/tolerance(Required) 0 1 2 3 Care of the patient witha. Epidural anesthesia/analgesia(Required) 0 1 2 3 b. IV conscious sedation(Required) 0 1 2 3 c. Patient controlled analgesia(Required) 0 1 2 3 MiscellaneuosCare of the patient witha. Anaphylactic shock(Required) 0 1 2 3 b. Disseminated intravascular coagulation (DIC)(Required) 0 1 2 3 c. Hypovolemic shock(Required) 0 1 2 3 d. Multi-system organ failure(Required) 0 1 2 3 e. Organ/tissue donation(Required) 0 1 2 3 f. Septic shock(Required) 0 1 2 3 Age Specific PracticeAble to adapt care to incorporate normal growth and development.(Required)Please check the box corresponding to each age group for which you have expertise in providing age-appropriate care. A. Newborn/Neonate (birth - 30 days) B. Infant (30 days - 1 year) C. Toddler (1 - 3 years) D. Preschooler (3 - 5 years) E. School age children (5 - 12 years) F. Adolescents (12 - 18 years) G. Young adults (18 - 39 years) H. Middle adults (39 - 64 years) I. Older adults (64+) Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.(Required)Please check the box corresponding to each age group for which you have expertise in providing age-appropriate care. A. Newborn/Neonate (birth - 30 days) B. Infant (30 days - 1 year) C. Toddler (1 - 3 years) D. Preschooler (3 - 5 years) E. School age children (5 - 12 years) F. Adolescents (12 - 18 years) G. Young adults (18 - 39 years) H. Middle adults (39 - 64 years) I. Older adults (64+) Can ensure a safe environment reflecting specific needs of various age groups.(Required)Please check the box corresponding to each age group for which you have expertise in providing age-appropriate care. A. Newborn/Neonate (birth - 30 days) B. Infant (30 days - 1 year) C. Toddler (1 - 3 years) D. Preschooler (3 - 5 years) E. School age children (5 - 12 years) F. Adolescents (12 - 18 years) G. Young adults (18 - 39 years) H. Middle adults (39 - 64 years) I. Older adults (64+) My experience is primarily in:Medical Yes No Year(s)Burn Yes No Year(s)Cardiothoracic Yes No Year(s)Cardiovascular Yes No Year(s)Coronary care Yes No Year(s)Neuro Yes No Year(s)Neurological Yes No Year(s)PACC Yes No Year(s)Trauma Yes No Year(s)Other Yes No Year(s)AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. 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