RESPIRATORY THERAPIST 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. Intermitten experience   3. Very experienced.
ACCREDITING AGENCY
  1. NBRC   1 2 3
  2. OTHER   1 2 3
ASSESSMENTS:
  1. Breath sounds   1 2 3
  2. Rate and work of breathing   1 2 3
  3. Abnormal breeathing   1 2 3
  4. Dyspnea   1 2 3
  5. Coarse breath sounds   1 2 3
  6. Rhonchi breath sounds   1 2 3
  7. Transcutaneous monitoring   1 2 3
CARE OF THE PATIENT WITH:
  1. Acute/chronic bronchitis   1 2 3
  2. ARDS (adult repiratory distress syndrome)   1 2 3
  3. Aspiration   1 2 3
  4. Asthma   1 2 3
  5. Bronchoscopy   1 2 3
  6. CHF (Congestive heart failure)   1 2 3
  7. COPD (Chronic obstructive pul diseasse)   1 2 3
  8. Cystic fibrosis   1 2 3
  9. Chest trauma   1 2 3
  10. Fresh Tracheostomy   1 2 3
  11. Gullian Barre   1 2 3
  12. Hemopneumothorax   1 2 3
  13. Larynospasm   1 2 3
  14. Myasthenia gravis   1 2 3
  15. Pneumonia   1 2 3
  16. Pulmonary edema   1 2 3
  17. Pulmonary Embolism   1 2 3
  18. Smoke inhalation   1 2 3
  19. Status asthmaticus   1 2 3
  20. Tension pneumothorax   1 2 3
  21. Thoracotomy   1 2 3
  22. Tracheo-esophageal fistula   1 2 3
  23. Tuberculosis   1 2 3
  24. Restrictive Pulmonary disease   1 2 3
  25. Croup   1 2 3
  26. Epiglottis   1 2 3
  27. Infant Respiratory disease syndrome   1 2 3
  28. Meconuim Aspiration   1 2 3
  29. Persistent fetal circulation   1 2 3
CERTIFICATION Yes No Exp.
  1. BLS   1 2 3
  2. ACLS   1 2 3
  3. EKG Technician   1 2 3
  4. EEG Technician   1 2 3
  5. Arterial blood gas technician   1 2 3
  6. NRP   1 2 3
  7. RRT   1 2 3
  8. CRT   1 2 3
EQUIPMENT & PROCEDURES:
  1. Airway management devices/suctioning   1 2 3
  2. Check intracuff pressure   1 2 3
  3. Nasal airway placement   1 2 3
  4. Nasal airway/suctioning   1 2 3
  5. Oral airway placemnt   1 2 3
  6. Oropharygeal/suctioning   1 2 3
  7. Sputum specimen collection   1 2 3
  8. Tracheostomy/suctioning   1 2 3
  9. Pulmonary function testing   1 2 3
  10. Pulmonary drainage   1 2 3
  11. Respiratory treatments   1 2 3
  12. Drawing arterial blood gases   1 2 3
  13. Brachial artery   1 2 3
  14. Femoral artery sticks   1 2 3
  15. Arterial line blood draws/maintenance   1 2 3
  16. Incentive spirometry   1 2 3
  17. Intubation assistance   1 2 3
  18. Extubation assistance   1 2 3
  19. Thoracentesis assistance   1 2 3
  20. Chest-tube insertion assistance   1 2 3
EXPERIENCE IN PRIMARY AREAS:
  1. General Adult Inpatient   1 2 3
  2. Home Care   1 2 3
  3. ICU   1 2 3
  4. Long term care   1 2 3
  5. Neonatal ICU   1 2 3
  6. Pediatrics   1 2 3
  7. Pulmonary Rehab   1 2 3
  8. Sleep lab   1 2 3
  9. Subacute   1 2 3
  10. Long-term Ventilator care   1 2 3
  11. Doctor's Office   1 2 3
EXPERIENCE WITH THE FOLLOWING VENTILATORS:
  1. Bear   1 2 3
  2. Bird   1 2 3
  3. BP   1 2 3
  4. Hamilton Amadeus, Veolar   1 2 3
  5. MA   1 2 3
  6. Newport   1 2 3
  7. Sechrist   1 2 3
  8. Servo   1 2 3
  9. Drager Infant   1 2 3
  10. Emerson   1 2 3
  11. Engstrom   1 2 3
  12. Puritian Bennett 7200 series   1 2 3
INTERPRETATION OF LAB RESULTS:
  1. Arterial blood gases   1 2 3
  2. Basic EKG   1 2 3
  3. Peak Flow Monitor   1 2 3
  4. Pulmonary Function Testing   1 2 3
  5. Blood chemistry   1 2 3
  6. Chest X-ray   1 2 3
MEDICATION ADMINISTRATION:
  1. Aerobid, Vanceril   1 2 3
  2. Aminophylline (Theophylline)   1 2 3
  3. Azmacort   1 2 3
  4. Bicarbonate   1 2 3
  5. Combivent   1 2 3
  6. Cromolyn sodium (Intal)   1 2 3
  7. Flonase   1 2 3
  8. Flovent   1 2 3
  9. Inhaled steroids   1 2 3
  10. Ipratropium bromide (Atrovent   1 2 3
  11. Isoproterenol (Isuprel)   1 2 3
  12. Metaproterenol (Alupent)   1 2 3
  13. Salbutamol (Albuterol, Proventil, Ventolin)   1 2 3
MEDICATION DELIVERY SYSTEMS:
  1. Aerosol heated/cool   1 2 3
  2. Aerosol set up -mask   1 2 3
  3. Aerosol set up -trach   1 2 3
  4. IPPB   1 2 3
  5. Medihaler   1 2 3
  6. Metered close inhalers   1 2 3
NEONATAL/PEDIATRICS:
  1. Asssit with high risk delivery   1 2 3
  2. Capillary blood gases   1 2 3
  3. ECMO   1 2 3
  4. O2 to tent   1 2 3
  5. Umbilical blood gases   1 2 3
  6. Bronchopulmonary dysplasia (BPD)   1 2 3
  7. Near drowning   1 2 3
  8. Persistent pulmonary hypertension(PPHN)   1 2 3
  9. Tranient tachypnea of the newborn   1 2 3
  10. Respiratory distress syndrome (RDS)   1 2 3
O2 THERAPY:
  1. Bag and mask   1 2 3
  2. ET tube   1 2 3
  3. External CPAP   1 2 3
  4. Face masks   1 2 3
  5. Nasal cannula   1 2 3
  6. Nebulizer   1 2 3
  7. Portable O2 tanks   1 2 3
  8. T-piece   1 2 3
  9. Trach collar   1 2 3
VENTILATOR SET UP AND CARE:
  1. Asssit/control   1 2 3
  2. CPAP   1 2 3
  3. Flow-by   1 2 3
  4. High frequency jet ventilaor   1 2 3
  5. High frequency oscillator   1 2 3
  6. IMV   1 2 3
  7. Inverse ratio ventilaor   1 2 3
  8. Pressure support   1 2 3
  9. Pressure vents   1 2 3
  10. PEEP   1 2 3
  11. Trouble shooting high pressure alarms   1 2 3
  12. Trouble shooting low pressure alarms   1 2 3
  13. Time cycled ventilaors   1 2 3
  14. EMCO assistance   1 2 3
  15. EMCO operation   1 2 3
  16. Volume vents   1 2 3
  17. Weaning   1 2 3
AGE APPROPRIATE NURSING CARE
Please check the appropriate box(es) for each age group and activity for which you have had experience within the last year.

Age Specific Experiences Adolescent(13-18 yrs)Young Adult(19-39 yrs) Middle Adults(40-64 yrs)Older Adult(65+ yrs)
1. Understands the normal growth and development for each age group and adapts care accordingly
2. Understands the different communication needs for each age group and changes communication methods and terminology accordingly
3. Understands the different safety risks for each age group and alters the environment accordingly
4. Understands the different medications, dosages and possible side effects for each age group and administers medications appropriately

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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