Adult ICU Skills Checklist
Name:
When completing this ckecklist, please indicate your level of proficiency in each area according to the scale below. Place a check mark in box which best describes your expertiese with each skill.

 

The scale is as follows:
1. Not performed   2. Intermittent experience   3. Very experienced.
CARDIOVASCULAR
  1. Assessment of CV system   1 2 3
  2. Use of cardiac montiors   1 2 3
  3. Telemetry   1 2 3
  4. Principles of 12 lead EKG   1 2 3
  5. Recognition of and treatment of arrhythmias:  
    1. Atrial   1 2 3
    2. Ventricular   1 2 3
    3. Heart blocks   1 2 3
    4. Ventricular tachycardia   1 2 3
    5. Ventricular fibrillation   1 2 3
    6. Asystole   1 2 3
  6. Pacemakers:  
    1. Temporary   1 2 3
    2. Permanent   1 2 3
    3. Determining EKG rhythm with pacer spikes   1 2 3
    4. Checking threshold   1 2 3
    5. Assisting with insertion/removal   1 2 3
  7. Use of defibrillator/cardioversion   1 2 3
  8. Use and administration of the following drugs:  
    1. Atropine   1 2 3
    2. Bretylol   1 2 3
    3. Calcium Chloride   1 2 3
    4. Digoxin   1 2 3
    5. Dobutrex   1 2 3
    6. Dopamine   1 2 3
    7. Epinephrine   1 2 3
    8. Inderal   1 2 3
    9. Isuprel   1 2 3
    10. Lidocaine   1 2 3
    11. Levophed/Regitine   1 2 3
    12. Nipride   1 2 3
    13. NTG   1 2 3
    14. Nubain   1 2 3
    15. Pronestyl   1 2 3
    16. Quinidine   1 2 3
    17. Verapamil   1 2 3
    18. Streptokinase   1 2 3
  9. CVP:  
    1. Knowledge of normal readings   1 2 3
    2. Assist with insertion/discontinuation   1 2 3
  10. Arterial line:  
    1. Assisting with insertion/discontinuation   1 2 3
    2. Ability to set up transducer and calibration   1 2 3
    3. Nursing care   1 2 3
  11. Swan Ganz:  
    1. Assisting with insertion/discontinuation   1 2 3
    2. Ability to set up transducer including calibration   1 2 3
    3. Knowledge of wave form and normal limits   1 2 3
    4. Cardiac output   1 2 3
  12. IABP:  
    1. Knowledge of general principles   1 2 3
    2. Assisting with insertion and removal   1 2 3
  13. Use of:  
    1. MAST trousers   1 2 3
    2. Ultrasonic doppler   1 2 3
    3. Pulse oximeter   1 2 3
  14. Care of patient with:  
    1. Acute MI   1 2 3
    2. Pre and post cardiac cath   1 2 3
    3. CHF   1 2 3
    4. Cardiogenic, hypovolemic shock   1 2 3
    5. Aneurysm   1 2 3
    6. Pre and post cardiovascular surgery   1 2 3
    7. Cardioveitic Defib   1 2 3
    8. Heart transplant   1 2 3
    9. Multiple drips  
      1. Maintenance and adjustment of dosage   1 2 3
      2. Maintenance and precautions of Heparin Drip   1 2 3
  15. Peripheral Pulses   1 2 3
  16. Broviac/Groskong/Hickman Catheters   1 2 3
  17. Sheath removal   1 2 3
GASTROINTESTINAL
  1. Use and care of patient with:  
    1. N/G tube   1 2 3
    2. Ewald tube   1 2 3
    3. Cantor tube   1 2 3
    4. Blakemore-Sengstaken tube including pressure measurement   1 2 3
    5. Feeding tube   1 2 3
    6. Bile tube   1 2 3
    7. Gastrostomy tube   1 2 3
    8. Miller-Abbott   1 2 3
    9. GI bleed   1 2 3
    10. Septic shock   1 2 3
    11. Dehiscence   1 2 3
    12. Pre and post surgery   1 2 3
GENITOURINARY
  1. Understanding of hemodialysis   1 2 3
  2. Understanding of peritoneal dialysis   1 2 3
  3. Care of patient with:  
    1. Shunts and fistulas   1 2 3
    2. Foley catheter   1 2 3
    3. Nephrostomy tube   1 2 3
    4. Renal transplant   1 2 3
    5. Nephrectomy   1 2 3
    6. Pre and post GU surgery   1 2 3
NEUROLOGY
  1. Assessment of neuro signs   1 2 3
  2. Understanding of Glasgow coma scale   1 2 3
  3. Use of:  
    1. Crutchfield tongs   1 2 3
    2. Halo traction   1 2 3
    3. Circo-electric bed   1 2 3
    4. Stryker frame   1 2 3
  4. Assisting with lumbar puncture   1 2 3
  5. Knowledge and care of ICP lines   1 2 3
  6. Care of patient with:  
    1. Various seizure activity   1 2 3
    2. Overdose   1 2 3
    3. Neuro trauma   1 2 3
    4. Pre and post neuro surgery   1 2 3
  7. Knowledge of use and administration of the following drugs:  
    1. Decadron   1 2 3
    2. Dilantin   1 2 3
    3. Magnesuim Sulfate   1 2 3
    4. Pitressin   1 2 3
    5. Phenobarbital   1 2 3
    6. Valium   1 2 3
PROCEDURES AND EQUIPMENT
  1. Starting IV's   1 2 3
  2. Care of TPN line/Hyperalimentation   1 2 3
  3. Knowledge of normal serum lab values   1 2 3
  4. Obtaining venous blood samples   1 2 3
  5. Administration of blood and blood products   1 2 3
  6. Restraints   1 2 3
  7. Straight cath   1 2 3
  8. Bladder irrigation   1 2 3
  9. Isolation technique   1 2 3
  10. Infusion pump   1 2 3
RESPIRATORY
  1. Ausculation - assessment of pulmonary system   1 2 3
  2. Principles of chest percussion   1 2 3
  3. Establishing an airway   1 2 3
  4. Ambuing technique   1 2 3
  5. Various types O2 administration:  
    1. NT suctioning   1 2 3
    2. ET intubation/extubation:  
      1. Suctioning technique   1 2 3
      2. Checking cuff pressures   1 2 3
  6. Ventilators:  
    1. Use and complications of PEEP   1 2 3
    2. Use and complications of CPAP   1 2 3
    3. Use and complications of IMV   1 2 3
    4. Use and complications of AC   1 2 3
    5. Weaning   1 2 3
  7. ABG:  
    1. Interpretation   1 2 3
    2. Drawing blood sample   1 2 3
  8. Chest Tube:  
    1. Assisting with insertion/discontinuation   1 2 3
    2. Understanding and care of H2O seal   1 2 3
    3. Principles and care of chest tube   1 2 3
    4. Use of pleurvac   1 2 3
    5. Use of emerson suction   1 2 3
  9. Assist with bronchoscopy   1 2 3
  10. Basic understanding and use of:  
    1. Aminophylline   1 2 3
    2. Atropine   1 2 3
    3. Bronkosol   1 2 3
    4. Terbutaline   1 2 3
  11. Care of patient with:  
    1. COPD   1 2 3
    2. ARDS   1 2 3
    3. Flail chest   1 2 3
    4. Pre and post thoracic surgery   1 2 3
    5. Acute respiratory distress   1 2 3
    6. Tracheostomy   1 2 3
    7. Pulmonary emboli   1 2 3
    8. Pulmonary edema   1 2 3
SPECIFIC PATHOLOGICAL CONDITIONS
  1. Care of patient with:  
    1. Oncologic disease   1 2 3
    2. Metabolic disease   1 2 3
    3. Collagen disease   1 2 3
    4. Infectious disease   1 2 3
    5. AIDS   1 2 3
    6. Burns   1 2 3
    7. Liver disease   1 2 3
    8. Liver transplant   1 2 3
PROFESSIONAL EXPERIENCE AND CERTIFICATIONS
  1. Are you BCLS certified? Yes No
  2. Are you ACLS certified? Yes No
  3. Have you had a formal critical care course? Yes No
  4. How many hours was the course?
  5. Do you have your CCRN? Yes No
  6. How many years have you worked in critical care?
  7. Do you have charge experience? Yes No
  8. Number of years?
  9. Is your experience primarily:
CCU SICU MICU
NICU IMCU PCU
ER CVICU PAR
TELEMETRY    
The information I have given is true and accurate to the best of my knowledge. Please sign and date below.
SIGNATURE: (Last 4 digits of your SSN)    Reenter your last 4 digits of your SSN   DATE

 

  
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