Aortic Ballon Pump

CRITICAL CARE SKILLS CHECKLIST Name______Date______Key: 1 = No Experience (Have never performed) 2 = Some Experience (Performed very infrequently) CHECK PROFICIENCY 1 2 3 4 3 = Moderate Experience (May need some reorienting for a brief time) CV/ CIRCULATORY: Shock (Continued) 4 = Experienced (Comfortable performing task with minimal resources) Normal Anatomy of Heart CHECK PROFICIENCY 1 2 3 4 Post Angiogram Care CV/ CIRCULATORY Post Open Heart Care Aortic Ballon Pump Removal Arterial / Venous Sheaths Care Resuscitation: monitoring Perform Defirilation Arterial Line/ Swan Ganz Set-up Perform/Setup Emergency Obtain blood sample from line Cardioversion Remove arterial line Prep and administer meds Assess Heart Sounds Team Member Assist in: SVO2 Monitoring Arterial line insertion Interpretation Swan Ganz Insertion w/ or W/o Troubleshooting fluroscopy Setup, Run, Interpret 12 Lead EKG Assist with Pacemaker Insertion Swan Ganz Hemodynamic Pacemaker care Knowledge of Paceport Swan Ganz Monitoring Recognize pacemaker Troubleshooting Waveforms malfunction Use of cardiac Monitor Temporary / Single / Double Lumen Proper lead placement Assist with pericardiocententesis Use of Doppler Blood Pressure NEUROLOGICAL SYSTEM Monitoring / Automatic Assessing Sensory – Motor Machine Function Extremities Care of patients with: Assist with Lumbar Puncture Acute Aneurysm Care of Patient with: Acute MI Aphasia Angina CVA CHF Closed Head injury Deep vein thrombosis Multiple Sclerosis Post TPA Multiple Trauma Patient Pulmonary Edema Overdose Patient Shock Seizure Disorder cardiogenic Spinal Cord Injury hypovolemic Cervical Traction septic Cranial Nerve Assessment Transplant / cardiac Crutchfield Tongs Dysrhythmia Recognition and Halo Traction Intervention LOC Assessment External Pacemaker Maintenance Monitoring ICU

MCNW-F-007, R3 (8/04) Page 1 of 12 CRITICAL CARE SKILLS CHECKLIST CHECK PROFICIENCY 1 2 3 4 CHECK PROFICIENCY 1 2 3 4 Appropriate Interventions for changes PULMONARY: Care of Patients with Pre/Post Neuro Surgical care (Continued Assist with Emergency Trach NEUROLOGICAL SYSTEM: Care of Patients with – (Continued) Changing of Trach or Tube Seizure Precautions Dressing Changes Use of Glascow Coma Scale Skin care Visual Acuity Measurement Trach Tray set up PULMONARY Use of Apnea Monitor Administer Oxygen Ventilator Management Ambu Bag Techniques Patient Assessment Asses Lung Sounds Troubleshooting with Vents Assist in Intubation / Extubation Weaning from Vent Nasopharyngeal airway List Types of Vents and Oropharyngeal airway Experience Care of Patients with: GI/ GU/ REPRODUCTIVE / ENDOCRINE AIDS AV Shunt / Fistula Care Acute Respiratory Distress Administer Meds via NG / G Tube Asthma Assist with Vas-Cath Insertion COPD Care of Burn Patients Collapsed Lung Care of Patients with: DIC Acute Cholecystitis Hemothrax Acute Renal Failure Pneumonia Bowel Obstruction Pulmonary Embolism Diabetes TB GI Bleed Transplant / Pulmonary Hyper / Hypoglycemia Chest Physiotherapy Multiple Abdominal Wonds Complications of Renal Transplant Chest tube Insertion (assist in) Pacreatitis ECMO: Care Transplant - Kidney Monitoring Catheter Insertion Incentive Spirometer Male Nebulizer Female Normal Physiology of Pulmonary Dialysis: Vascularture Hemo Obtain ABGs Peritoneal Results interpretation Equipment Used Pavulonized Patient Jejunostomy Care Pulse Oximetry NG Tube Insertaion / Lavage Suctioning Normal Physiology of Renal & Use of emergency equipment GI System Thoracentesis GI/ GU/ REPRODUCTIVE / ENDOCRINE (Continued) Tracheostomy Ostomy / Stoma Care

MCNW-F-007, R3 (8/04) Page 2 of 12 CRITICAL CARE SKILLS CHECKLIST CHECK PROFICIENCY 1 2 3 4 CHECK PROFICIENCY 1 2 3 4 Peritoneal Lavage SL Administration Poison Control Use of the following medications: Wond Care Irrigations Activase Insulin Prep and Adminsitration Aminodarone Blood Glucose Monitoring Atropine IV THERAPY Bicarbonate Adminstration of Chemothrapy Bretylium Meds Cardizem Administration of Antibiotic Meds Dextrose Administration / mixing IV meds Digitalis Meds via IV push Dopamine Administration of Continuous Epinephrine Fluids Esmolal Blood / Blood Products Inderal Adminsitration / Precautions Inocor Autotransfusion Insulin Calculate Doses Isuprel Calculate Rates KCI mcg/min Levophed mcg/kg/min Lidocaine Hand IV Piggybacks Mannitol Hyperaliminatation Magnesium Sulfate Caloric and Fluid Requirements Neo Synephrine Knowledge of Solutions Nipride Peripheral / Central Line Nitroglycerin Insertion of Central Line Nitroprusside CVP Tray Set up Phenobarbital Dressing Changes Pavulon Implanted Venous Access Ports Prednisone Use of Broviac and Hickman Catheters Pitressin Insertion of Peripheral line Procainamide Discontinuing Line Protoglandins Dressing Change Streptokinanse Pump Operations Verapamil IMED PSYCHIATRIC CONSIDERATIONS IVAC Psychiatric Patient Assessment Other Specify: Administer psychiatric medications Other Specify: Care of Acute Psychotic Care of Violent Patient MEDICATION ADMINISTRATION 1 2 3 4 Use of Restraints Injections OTHER NURSINING RESPONSIBILITIES Preparation of meds/syringe Admission Site selection (ie SQ vs IM) P.O. Administration MCNW-F-007, R3 (8/04) Page 3 of 12 CRITICAL CARE SKILLS CHECKLIST

MCNW-F-007, R3 (8/04) Page 4 of 12 CRITICAL CARE SKILLS CHECKLIST

MCNW-F-007, R3 (8/04) Page 10 of 12 CRITICAL CARE SKILLS CHECKLIST CHECK PROFICIENCY 1 2 3 4 Initial Assessment and Documentation Charge Nurse Responsibilities Lab Value Interpretation

OTHER NURSINING RESPONSIBILITIES (Continued) Organ Procurement Pain Management PCA Pumps Use of IV Narcotics Post Mortem Procedures Problem Orient Medical Records Universal Precautions Wound Collection

CHECK PROFICIENCY 1 2 3 4 AGE SPECIFIC EXPERIENCE Care of patients in these age ranges: Neonatal (birth to 1 month) Infant (1 month to 1 year) Pediatric (1 year to 12 years) Adolescent (12 years to 18 years) Adult (18 years to 65 years) Geriatric (65 years and older) YEARS OF CRITICAL CARE EXPERIENCE Critical Care (ICU/CCU): Cardiovascular (CVICU): TOTAL YEARS OF EXPERIENCE:

The information I have provided is true and accurate to the best of my knowledge. I authorize MedCall NorthWest,Inc. to release this Skills Checklist to client hospitals as needed in relation to my employment.

Please enter your full legal name as it appears on your Social Security Card.

First Name* Middle Name * Last Name*

Last 4 of Social Security Number * Date * (mm/dd/yyyy)

Email: Month/year CCU skills were last used: /

* Electronic Signature Agreement. By signing and typing the last 4 of your Social Security Number (SSN) on this document, you are signing the Document electronically. You agree your electronic signature is the legal equivalent of your manual signature on the Agreement Reviewed by:______Title:______

MCNW-F-007, R3 (8/04) Page 11 of 12 CRITICAL CARE SKILLS CHECKLIST Registered Nurse Job Description Critical Care ICU/MICU/SICU/CVICU/CCU Name: ______Date: ______

Essential duties and responsibilities include:

1.One year critcal care experience in a hospital setting 2.Current RN License (in good standing, without disciplinary investigation or actions) 3.Current BLS/BCLS, ACLS 4.Head-to-toe assessments - knowledge of normal vs. abnormal findings and reporting of abnormal findings to Charge Nurse, M.D., if warranted 5.Critical thinking to intervene with appropriate intervention for urgent/emergent care. Care of the acute and chronically ill patients. 6.Knowledge of hemodynamics 7.Basic IV and central line skills 8.Phlebotomy skills 9.Identifying and managing life sustaining physiologic functions in unstable patients 10.Basic understanding of cardiac monitoring equipment 11.Able to care for patient on IV drips (i.e., Nitroglycerin, Dopamine) 12.Care of cardiac cath patient (diagnostic and interventional) 13.Care of post acute MI 14.Care of general acute and sub-acute patients 15.Other duties, as assigned

The information I have provided is true and accurate to the best of my knowledge. I authorize MedCall NorthWest,Inc. to release this ICU Job Description to client hospitals as needed in relation to my employment.

Please enter your full legal name as it appears on your Social Security Card.

First Name* Middle Name * Last Name*

Last 4 of Social Security Number * Date * (mm/dd/yyyy)

* Electronic Signature Agreement. By signing and typing the last 4 of your Social Security Number (SSN) on this document, you are signing the Document electronically. You agree your electronic signature is the legal equivalent of your manual signature on the Agreement

MCNW-F-007, R3 (8/04) Page 12 of 12