Instructions:

Please rate your experience / frequency (within the last year) using the following scale (check the appropriate boxes below):

  • 0 = No Experience / Observed Only
  • 1 = Limited Experience / Rarely Done (<6 times/year)
  • 2 = May Need Some Review / Occasionally Done (1 - 2 times/month)
  • 3 = Experienced / Frequently Done (daily or weekly)
    		•
    AGE OF PATIENTS CARED FOR
    Newborn/Neonate (birth to 30 days)
    Infant (31 days to 12 months)
    Toddler/Preschool (13 months to 5 years)
    School Age Child/adolescent (6 years to 18 years)
    Young Adults Middle Adult (19 years to 64 years)
    Older Adults/Elderly (65+ years)
    GENERAL SKILLS
    Electronic Documentation
    Other Electronic Documentation:
    Ability to Initiate/Conduct BLS, ACLS, PALS, NRP as Indicated
    Aseptic Technique
    Universal Precautions
    Working with patients in isolation
    Working with patients in restraints
    Patient/Family teaching
    Patient Identification
    Specialty beds
    End of life care/palliative care
    Knowledge of "Do Not Use Abbreviations"
    Do you have charge/supervisor experience?
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    Quality Control of Equipment
    Sputum Specimen Collection
    Ventilator/Weaning
    Other Ventilator/Weaning:
    SETTINGS
    Adult Critical Care
    Pediatrics/PICU
    Neonatal ICU
    Emergency Room
    Home Health
    Sleep Lab
    Pulmonary Rehabilitation
    Transports( Air/Ambulance)
    MEDICATIONS
    Advair
    Aerobid
    Albuterol
    Aminophylline (Theophylline)
    Atropine
    Atrovent
    Amphotericin
    Anectine
    Artificial Surfactant
    Azmacort (Triamcinolone Acetonide)
    Bicarbonate
    Colistin
    Combivent
    Cromolyn Sodium (Intal)
    Corticosteroids
    Digitalis
    Digoxin
    Dopamine
    Duoneb
    Foradil
    Flonase
    Flovent
    Heliox
    Inhaled Steroids
    Isoetharine (Bronkosol)
    Isuprel
    Ketamine
    Lidocaine
    Morphine
    Metaproterenol ( Alupent)
    Maxair
    Naloxone (Narcan)
    Nasacort
    Nipride
    Nitric Oxide
    Pavulon
    Pentamide Isethionate
    Propofol
    Pulmicort (Budesonide)
    Pulmozyme (Dornase Alfa)
    Racemic Epinephrine (Vaponephrine)
    Ribaviran
    Sodium Bicarbonate
    Terbutaline Sulfate (Bricanyl)
    Theo-dur
    Tilade
    Tobramycin
    Valium
    Versed
    Xylocaine
    Xopenex
    CARE OF PATIENTS WITH
    Aspiration Pneumonia
    ARDS
    Asthma
    Status Asthmaticus
    Acute/Chronic Bronchitis
    Bronchopulmonary Dysplasia (BPD)
    Bacterial/Viral Pneumonia
    Bronchiectasis
    Bronchiolitis
    Chest Tubes
    Chronic Obstructive Pulmonary Disease (COPD)
    Congestive Heart Failure (CHF)
    Croup
    Cystic Fibrosis
    Cardiac Surgery
    Diabetic Ketoacidosis
    Epiglottitis
    Emphysema
    Empyema
    Failure to Thrive
    Guillian Barre
    Hyaline Membrane Disease
    Laryngospasm
    Lung Cancer
    Meconium Aspiration
    Myesthenia Gravis
    Myocardial Infarction
    Near Drowning
    Neonatal Pneumonia
    Pacemakers
    Persistent Fetal Circulation
    Pneumothorax
    Pulmonary Interstitial Emphysema (PIE)
    Pulmonary Edema
    Pulmonary Emboli
    Pulmonary Hypertension
    Respiratory Syncytial Virus (RSV)
    Smoke Inhalation
    Transient Tachypnea of the Newborn
    Transesophageal Fistula
    Thoracotomy
    Tuberculosis
    THERAPEUTICS AND PROCEDURES
    Conscious Sedation
    EKG
    Nasal
    Masks
    Trach
    Aerosol Set-up/Mask/Trach
    Aerosol Heated/Cool
    Oxygen Tank Set-up
    Croup Tent Set-up/Troubleshoot
    Infant Hood Set-up
    Analyze Oxygen
    Intubate Adult
    Intubate Infant
    Assist with Intubation
    Extubate
    Assist with Extubation
    Assist with High Risk Delivery
    Nasotracheal Suction
    Endotracheal Suction
    Ventilate Patient with Manual Resuscitator
    Check Intracuff Pressures
    Change/Clean Trach Tubes
    Oral Airway Placement
    Nasal Airway Placement
    Isolation Procedures
    Disinfection & Sterile Techniques
    Incentive Spirometry
    IPPB
    Hand Held Nebulizers
    Ultrasonic Nebulizer
    Chest Physiotherapy/Postural Drainage
    Splinting
    Medihaler
    Inhaler Reservoirs (Inspirease/Aerochamber)
    Pursed Lip Breathing
    Diaphragmatic Breathing
    Segmental Breathing
    Ventilator Set-up
    Troubleshoot Ventilators
    Negative Inspiratory Force
    Vital Capacity
    Nasal CPAP
    BiPap nasal/mask
    Assist/Control
    Control
    CPAP
    IMV
    SIMV
    PEEP
    High-Frequency Ventilator
    Inverse Ratio Ventilation
    Pulmonary Stress Testing
    Pulmonary Function Testing
    Bedside Screening
    Peak Flow Rate
    Apnea Monitor
    Oximetry
    Transcutaneous Monitoring
    Assist with Bronchoscopies
    ARTERIAL BLOOD GASES
    Allen Test
    Analyzing
    Interpretation
    Arterial Line
    Radial/Brachial Artery
    Femoral Artery
    Perform Blood Gas Collection (Venous, Arterial, Capillary)
    Umbilical Blood Gas
    TYPES OF ER EXPERIENCE
    Level 1 Trauma Center
    Level 2 Trauma Center
    Level 3 Trauma Center
    Pediatric ED
    TYPES OF NICU EXPERIENCE
    NICU Level 1
    NICU Level 2
    NICU Level 3
    NICU Level 4
    ASSESSMENTS
    Achieve and Maintain Adequate Respiratory Perfusion
    Auscultate Breath Sounds
    Blood Chemistry
    Cardiopulmonary Monitoring
    Chest X-Ray
    Comprehensive Physical Exam
    Cough and Sputum Assessment
    Palpitation
    Respiratory Rate
    Response to Respiratory Intervention
    Recommend Modification to Modality Based on Patient Response
    Troubleshooting High/Low Pressure Alarms
    Work of Breathing