TELEMETRY / MEDICAL - SURGICAL 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.
CARDIOVASCULAR AND/OR TELEMETRY
  1. Cardiovascular assessment   1 2 3
  2. Vital signs   1 2 3
  3. Electrolyte imbalance assessment   1 2 3
  4. Telemetry   1 2 3
  5. Recognition and treatment of dysrythmias:  
    1. Atrial   1 2 3
    2. Ventricular   1 2 3
    3. Heart blocks   1 2 3
    4. Ventricular tachycardia   1 2 3
    5. Asystole   1 2 3
  6. Central venous pressure:  
    1. Assist with insertion/discontinuation   1 2 3
    2. Set-up and leveling of manometer   1 2 3
  7. Use and administration of these drugs:  
    1. Atropine   1 2 3
    2. Digoxin   1 2 3
    3. Epinephrine   1 2 3
    4. Inderal   1 2 3
    5. Lidocaine   1 2 3
    6. NTG   1 2 3
    7. Verapamil   1 2 3
    8. Pronestyl   1 2 3
    9. Quinidine   1 2 3
    10. Thombolotic medications   1 2 3
  8. Care of patients with:  
    1. Post MI   1 2 3
    2. CHF   1 2 3
    3. Pre/post cardiac catherization   1 2 3
    4. Pre/st cardiovascular surgery   1 2 3
    5. Subacute bacterial endocarditis   1 2 3
    6. Pacemaker   1 2 3
    7. Data Critical Monitoring   1 2 3
    8. DVT   1 2 3
    9. Heart transplant   1 2 3
    10. Heparin drip   1 2 3
    11. Multi-systems failure   1 2 3
GASTROINTESTINAL
  1. Assessment of bowel sounds   1 2 3
  2. Colostomy care   1 2 3
  3. Care of patient with:  
    1. Gastrostomy tube   1 2 3
    2. Jejunostomy tube   1 2 3
    3. Dobhoff feeding tube 1 2 3
    4. T tube   1 2 3
    5. Feeding pumps   1 2 3
    6. GI bleed   1 2 3
    7. Abdominal surgery   1 2 3
    8. Liver disease   1 2 3
    9. Liver transplant   1 2 3
    10. Bowel obstruction   1 2 3
  4. Wound care   1 2 3
  5. Insertion and/or care of :  
    1. Salem sump   1 2 3
    2. Levine tube   1 2 3
    3. Blakemore-Sengstaken tube   1 2 3
    4. Cantor tube   1 2 3
  6. Gastric gavage and lavage   1 2 3
  7. Assisting with paracentesis   1 2 3
  8. Administration of TPN and care of line   1 2 3
GENITOURINARY
  1. Assessment   1 2 3
  2. Knowledge and care of catheters:  
    1. Insertion of foley   1 2 3
    2. Suprapubic   1 2 3
    3. Nephrostomy tube   1 2 3
    4. Hickman   1 2 3
    5. Infusaports   1 2 3
    6. Subclavians   1 2 3
  3. Care of dialysis patient with:  
    1. Shunts and fistulas   1 2 3
    2. Hemodialysis   1 2 3
    3. Peritoneal - CAPD   1 2 3
  4. Procedures:  
    1. Irrigations  
      1. Continuous bladder irrigation   1 2 3
      2. Bladder instillation   1 2 3
      3. Sterile specimen collection   1 2 3
      4. Sugar and acetone   1 2 3
      5. Blood glucose levels with gluometer   1 2 3
  5. Care of patients with:  
    1. Pre and post operative kidney transplant   1 2 3
    2. Acute renal disease   1 2 3
    3. End stage renal disease   1 2 3
    4. TURP   1 2 3
    5. Nephrectomy   1 2 3
    6. Renal transplant   1 2 3
GYNECOLOGY
  1. PAP exam   1 2 3
  2. Care of patient with:  
    1. Hysterectomy   1 2 3
    2. Tubal ligation   1 2 3
    3. Mastectomy   1 2 3
    4. Endometriosis   1 2 3
    5. Miscarriage   1 2 3
NEUROLOGY
  1. Assessment of neuro signs  
    1. Orientation to person, place and time   1 2 3
    2. Glasgow coma scale   1 2 3
  2. Seizure precautions   1 2 3
  3. Assisting with lumbar puncture   1 2 3
  4. 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
    5. Clinitron bed   1 2 3
  5. Range of motion:  
    1. Active   1 2 3
    2. Passive   1 2 3
  6. Care of patients with:  
    1. Craniotomy   1 2 3
    2. Laminectomy   1 2 3
    3. Seizure disorders   1 2 3
    4. CVA   1 2 3
    5. Paralysis   1 2 3
    6. Status epilepticus   1 2 3
    7. Spinal cord shock   1 2 3
    8. Spinal cord injury   1 2 3
    9. Conscious sedation   1 2 3
    10. Closed head trauma   1 2 3
    11. AV - Shunt   1 2 3
ORTHOPEDICS
  1. Pre and post operative care  
    1. Total hip replacement   1 2 3
    2. Knee replacement   1 2 3
    3. Joint replacement   1 2 3
    4. Laminectomy   1 2 3
    5. Amputation   1 2 3
  2. Traction  
    1. Overhead bar and frame assembly   1 2 3
    2. Skeletal   1 2 3
    3. Bucks   1 2 3
    4. Cervical   1 2 3
    5. Pelvic   1 2 3
  3. Range of motion  
    1. Active   1 2 3
    2. Passive   1 2 3
  4. Hoyer lift   1 2 3
  5. Antiembolic stockings   1 2 3
  6. CPM   1 2 3
  7. Hemovac   1 2 3
  8. CMS checks   1 2 3
PROCEDURES AND EQUIPMENT
  1. Starting IV’s   1 2 3
  2. Knowledge of normal lab values   1 2 3
  3. Drawing venous blood samples   1 2 3
  4. Administration of:  
    1. Blood and blood products   1 2 3
    2. Chemotherapy   1 2 3
    3. IV medications   1 2 3
  5. Infusion Pumps  
    1. PCA   1 2 3
  6. Medications:  
    1. Unit dose   1 2 3
    2. Dosage calculations   1 2 3
    3. Initiate multiple drips   1 2 3
    4. Maintain multiple dosages   1 2 3
  7. Experience in:  
    1. Team leading   1 2 3
    2. Primary care   1 2 3
    3. SOAP charting   1 2 3
    4. Initiating care plans   1 2 3
  8. Hyper/hypothermic blanket   1 2 3
  9. K pads   1 2 3
  10. Heat lamps   1 2 3
  11. Restraints   1 2 3
  12. O2 wall set-up   1 2 3
  13. Portable O2 tank   1 2 3
  14. Organ donor protocol   1 2 3
  15. PIC line insertion   1 2 3
  16. Patients’ Directive   1 2 3
  17. Patients’ rights/confidentiality   1 2 3
RESPIRATORY
  1. Establish airway   1 2 3
  2. O2 administration   1 2 3
  3. Tracheostomy care   1 2 3
  4. Chest tube  
    1. Assisting with insertion/discontinuation   1 2 3
    2. Understanding and care of H2O seal   1 2 3
  5. Use of incentive spirometry   1 2 3
  6. Throat culture   1 2 3
  7. Care of patient on ventilator   1 2 3
  8. Use of ambu   1 2 3
  9. Care of patient with:  
    1. Pre and post operative thoracic surgery   1 2 3
    2. COPD   1 2 3
    3. Acute respiratory distress   1 2 3
    4. Pneumocystic disease   1 2 3
    5. Tuberculosis   1 2 3
    6. Pulmonary embolism   1 2 3
    7. Emphysema   1 2 3
    8. Pneumonia   1 2 3
    9. Pulmonary edema   1 2 3
    10. Asthma   1 2 3
  10. ABG interpretation   1 2 3
  11. Sputum specimen collection   1 2 3
  12. Use of IPPB   1 2 3
SPECIFIC CONDITIONS
  1. Care of patient with:  
    1. Oncology diseases   1 2 3
    2. Infectious diseases   1 2 3
    3. AIDS   1 2 3
    4. Drug addiction/withdrawals   1 2 3
    5. Burns   1 2 3
    6. Diabetes   1 2 3
    7. Overdose   1 2 3
    8. Integument problems   1 2 3
PROFESSIONAL EXPERIENCE AND CERTIFICATIONS
  1. Are you CPR certified? Yes   No
  2. Are you BCLS certified? Yes   No
  3. Are you ACLS certified? Yes   No
  4. Have you had a dysrhythmia course? Yes   No
  5. How many years have you worked Med/Surg?  
  6. Do you have charge nurse experience? Number of years?
  7. State primary experience and number of years in each.
    • Medical  GYN
    • Surgical  Urology
    • Ortho  Oncology
    • Neuro  Telemetry
    • Stepdown  Other
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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