GeauxCareStaffing Respiratory Therapy Competency Checklist

PERSONAL INFORMATION Name: Date: Signature:

KEY TO COMPETENCY LEVELS 0 - No Experience 1 - Minimal experience, need review and supervision, have performed at least once 2 - Comfortable performing with resource available 3 - Competent to perform independently and safely 4 - Expert, able to act as resource to others

BASIC RESPIRATORY THERAPY & TREATMENTS 0 1 2 3 4 Aerosol for Medication Acom Nebulizers      Handheld Nebulizers      Twin Jet Nebulizers      Aerosol Set-up for Trach Patients Briggs      T-Pierce      Trach Masks      Chest Physical Therapy Flutter      Incentive Spirometry IPV      Percussion, Vibration & Postural Drainage      Therapy Vest      IPPB Treatments AP5: Bird      TV2P      Nebulizers Cold      Heated      Heated Aerosols      Ultrasonic Nebulizers      Oxygen Therapy Analyze Oxygen Fi02      Calculating Remaining Time in Individualized 02 Tank      Change Regulator from Empty Tank to Full Talk (any size)      Oxygen Set-Up      Aerosol      Mask      BASIC RESPIRATORY THERAPY & TREATMENTS Nasal Airway      Nasal Cannula      Oral Airway      Peak Flow Regulation      Trach      Venturi Masks      RESPIRATORY THERAPY MEDICATIONS 0 1 2 3 4 Albuterol (Proventil, Ventolin)      Anti-Asthmatics      IV (aminophylline)      Inhalers (Azmacort)      Atropine Sulfate      Coli-Mycin      Combivent      Cromolyn Sodium (Intal)      Decadron      D-Nase      Gentamycin      Intal      Isoetharine (Bronkosol)      Isoprotereonol (Isuprel)      Medihalers/Metered Dose Inhalers      Metraproterenal (Alupent)      Mucomyst      Petsmidine      Racemic Epinephrine (Vaponefrin)      Spacers (InsperEase, Aerochamber TM)      Steroids      Surfadant      Terbutaline Sulfate (Brickanyl)      Tobramycin      Vanceril     

SPECIFIC SKILLS 0 1 2 3 4 Complete Lab Work      Flow Volume Loop      Stress Testing      Suction Endotracheal Tubes      Tracheostomy Suctioning      Use 02 Analyzer      Ventilate Patient with Manual Resuscitator (BMV)     

VENTILATOR PROCEDURES 0 1 2 3 4 Assist Control      Page 2 Created: 10/6/17 VENTILATOR PROCEDURES Blowby      Bi-pap      CPAP      Flowby      IMV      Inverse Ratoio Ventilation      Mechanics of Ventilators F/VT      Negative Inspiratory Force      Tidal Volume      VE      Vital Capacity      PEEP      Pressure Support      Troubleshooting      Weaning: Negative Inspiratory Force      Tidal Volume      Vital Capacity     

VENTILATORS 0 1 2 3 4 8400 STI      Adult Star      Bear 1000      Bear 3      BiPAP (Non-Invasive Ventilator)      Bird      Emmerson      Helium/Oxygen (Heliox)      Non-Ventilated      Ventilated      IMT (Inspiratory Muscle Trainer)      Nellcor Puritan Bennet 7200 Series      Nellcor Puritan Bennet 740 Series      Newport E 150      Newport E 200      Passy Muir Valve (Talking Valve)      PB 840      PDP’s (Pathways, Protocols)      Servo 300      Servo 900C     

NEONATAL/PEDIATRIC ICU 0 1 2 3 4 Assist in High Risk Delivery      ECMO      Page 3 Created: 10/6/17 NEONATAL/PEDIATRIC ICU Nasal CPAP      Pressure Manometer      Transcutaneous Monitoring      Umbilical Artery Catheters     

AGE SPECIFIC PRACTICE CRITERIA Please check the box corresponding to each age group for which you have expertise in providing age-appropriate nursing care.  Newborn/Neonate (birth - 30 days)  Infant (31 days - 1 year)  Toddler (1 - 3 years)  Preschooler (3 - 5 years)  School age children (5 - 12 years)  Adolescents (12 - 18 years)  Young adults (18 - 39 years)  Middle adults (39 - 64 years)  Older adults (65+)

EXPERIENCE AREA WITH AGE GROUPS 0 1 2 3 4 Able to adapt care to incorporate growth and development      Able to adapt method and terminology to patient instructions to their age,      comprehension and maturity level Can ensure a safe environment reflecting specific needs of various ages     

CERTIFICATIONS Question Yes No Expiration Date Are you BCLS Certified? Are you ACLS Certified? Are you PALS Certified Are you NRP Certified?

CERTIFICATIONS Certification Expiration Date

Have you had one year of experience in this area within the last three years. Yes  No 

______Signature Date

______Agency (Name/Title) Date Page 4 Created: 10/6/17

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