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Name:

Date:

RN/LVN Experience & Skill Checklist

Emergency Department

Instructions: In the following sections, we ask you to rate yourself on your skill and experience level for nursing/medical procedures. The rating system is as follows:

0=No experience

1=Minimal experience; review and/or supervision required

2=Experienced; able to perform without supervision

3=Extensive experience; can assist others; well skilled

TRAUMA

0 / 1 / 2 / 3
Air Transport of Trauma Patient
Major Trauma Patient
Minor Trauma Patient
Assisting with Diagnostic Peritoneal Lavage
Assisting with Unstable Airways

BURNS

0 / 1 / 2 / 3 / Care of Patient with…
First Degree Burns
Second Degree Burns
Third Degree Burns
Electrocution
Dressing Procedures
Hazardous Materials Exposure
Radiation Exposure

RESPIRATORY

0 / 1 / 2 / 3 / Care of patient with…
ARDS
Pulmonary Edema
COPD
Assisting with Chest Tube Insertion
Maintenance of Chest Tubes
Use of Pleurovac Water Seal and Suction Drainage
Pneumothorax
Hemothorax
Auto-Transfusion
Assisting with Intubation
Assisting with Extubation
Tracheotomy
Trach Tube
T-Piece
Assessment of Lung Sounds
Obtaining Arterial Blood Gases from Radial Artery
Obtaining Blood Gases from Arterial Lines
Interpreting Arterial Blood Gases
Setting up an Arterial Line
Use and Complications related to Ventilators
Use and Complications related to Bi Pap Ventilator
Ability to use Ventilator or Bi Pap Independently without a Respiratory Therapist
Oxygen Masks
Oxygen Cannulas
Venturi Masks
Ventilating Patients with Ambu Bags
Oxygen Cylinders
Hand Held Nebulizer Set Up/Treatment
Continuous Nebulizer Set Up/Treatment
Oropharyngeal Suction
Nasotracheal Suction
Endotracheal Suction
Use of Incentive Spirometry
Obtaining Sputum Specimen
Obtaining Sputum Specimen with Leukens (induced specimen)
Pulse Oximetry

CARDIOVASCULAR

0 / 1 / 2 / 3 / Care of Patient with…
Acute MI
CHF
Angina
Abdominal or Thoracic Aortic Aneurysm/Dissecting
Pre Angiogram
Cardiac Monitoring
Assessing Heart Sounds
Recognizing Arrhythmias
Asystole
Atrial Arrhythmias
Heart Blocks
Ventricular Arrhythmias
Ventricular Tachycardia
Ventricular Fibrillation
Pulseless Electical Activity (Electromechanical Dissociation)
Junctional Arrhythmias
Treatment of Arrhythmias
Working with Vasoactive Drips
Emergency Drug Therapy
Obtaining 12 Lead EKG
Interpreting 12 Lead EKG reading
Cardiopulmonary Arrest/Resuscitation
Cardioversion
Defibrillation
External Cardiac Pacing
Open Chest Heart Massage/Defibrillation
Cardiac Tamponade/Pericardiocentesis
Assist with Insertion of Temporary Pacemaker
Familiarity with Temporary Pacemaker Settings/Controls
Set up and use of CVP Line
Interpretation of CVP Reading/Pressure
Thrombolytic Therapy
Anaphalactic Shock
Cardiogenic Shock
Septic Shock
Neurogenic Shock
Hypovolemic Shock
Administration of Blood and Blood Products
Use of Doppler
Anti-embolic Hose Application/Use
Assisting with Thoracentesis
Assessing Peripheral Pulses
Assessing for Fluid Overload
Weighing Scale (Pediatric and/or Adult)

NEUROLOGICAL

0 / 1 / 2 / 3 / Care of Patient with…
Performing a Neuro Assessment
Monitoring Neuro Signs
Use of Glascow Coma Scale
Acute Head Injury
Acute TIA vs. CVA
Acute Spinal Cord Injury
Seizures Precautions
Observing for Increased Intracranial Pressure
Transport of Patient with Spinal Cord Injury
Assisting with Spinal Immobilization
Eggcrate Mattress
Assist with Lumbar Puncture
Post Lumbar Puncture Procedural Care
Bell’s Palsy
Guillian-Barre Syndrome
Multiple Sclerosis
Congenital Neurological Defects
Knowledge and use of Dilantin
Knowledge and use of Phenobarbital
Knowledge and use of Decadron
Knowledge and use of Mannitol
Knowledge and use of High doses of Solu Medrol
Conscious Sedation

GASTROINTESTINAL

0 / 1 / 2 / 3 / Care of Patient with…
Gastrointestinal Bleed
Pancreatitis
Esophageal Varices
Bowel Obstruction
Whipple Procedure
Paralytic Ileus
E.R.C.P.
Abdominal Wounds
Gastrointestinal Tubes (Gastrostomy Tubes and Jejunostomy Tubes)
Acute Abdominal Disorders
Insertion and Maintenance of Nasogastric Tubes
Gastric Lavage for GI Bleeds
Gastric Lavage for Overdose patients
Assessment of Abdomen
Assessment of Bowel Sounds
Collection of Stool Specimen
Gastrocult Procedure
Hemocult Procedure
Insertion of Rectal Tube
Administration of Soap Suds Enema
Administration of Fleets Enema
Administration of Oil Retention Enema
Administration of Return Flow Enema (Harris Flush)
Enterostomal/Colostomy Care
Assisting with Pericentesis

RENAL

0 / 1 / 2 / 3 / Care of Patient with…
Acute Renal Failure
Chronic Renal Failure
Hemodialysis
Peritoneal Dialysis
Renal Colic
Insertion of Foley Catheter
Insertion of Straight Catheter
Insertion of Coude Catheter
Insertion of Supra Pubic Catheter
Bladder Irrigation
Nephrostomy Tube
Electrolyte Imbalance/Replacement
T.U.R.P.
Shunts and Fistulas
Obtaining Sterile Urine Specimen
Collecting Mid Stream Urine Specimen
Straining Urine Specimen
Obtaining 24 hour Urine Specimen
Calculating and Documenting Intake and Output

ORTHOPEDIC

0 / 1 / 2 / 3
Set up for Cast Appication
Set up for OCL Splinting
Cast and Splint Care
Patient Teaching related to Cast and Splint Care
Checking CMST distal to injury (Capillary Refill, Movement, Sensation and Temperature, Pulses)
Patient Teaching related to Crutch Walking
Set up for Insertion of Steinman Pin/K-Wire Insertion
Assistance with Closed Fracture/Dislocation Reduction
Conscious Sedation Monitoring/Procedures and Protocols-Adults
Conscious Sedation Monitoring/Procedures and Protocols-Peds
Application of External Traction Devices:
Bucks Traction
Sager Traction
Hare Traction
Body Mechanics
Use of Assistive Devices: Walkers, Canes, Wheelchairs
ROM Exercises
Care of patient with Amputation (Digit or Extremity)

EENT DISORDERS

0 / 1 / 2 / 3 / Care of Patient with…
Foreign Body in Eye
Foreign Body in Ear
Foreign Body in Nose
Foreign Body in Throat
Epistaxis and Anterior Nasal Packing
Epistaxis and Posterior Nasal Packing
Set up for Flourescein/Woods Lamp Exam
Use of Morgan Lens Irrigation
Ear Irrigation
Eye Patch Application
Removal of Contact Lens
Obtaining Visual Acuity
Obtaining Throat Culture

INTEGUMENTARY

0 / 1 / 2 / 3
Setting up Suture Tray
Assist with Suturing
Assist with Stapling
Suture Removal
Staple Removal
Steri Strip Application
Wound Drainage Systems
Hemovac Drainage System
Jackson Pratt Drainage System
Dressing Application
Dressing Changes
Wet to Dry Dressings
Packing of Wounds/Iodoform Guaze
Decubitus Ulcers

PEDIATRIC

0 / 1 / 2 / 3 / Care of Patient with…
Pediatric Arrest/Resuscitation
Assisting with Insertion of Intra Osseous Needles
Use of Intra Osseous Needles
Use of Braslow Tape
Epiglottitis
Overdose/Poison Ingestion
Near Drowning
Child Abuse
Reporting Suspected Abuse
Knowledge of Necessity of Reporting Suspected Abuse
Calculating Emergency Medication Doses
Knowledge of Normal Serum Lab Values

OBSTETRICS/GYNECOLOGY

0 / 1 / 2 / 3 / Care of Patient with…
Spontaneous Abortion
Vaginal Hemorrhage
Placenta Previa
Abruptio Placenta
Pre-Eclampsia/Eclampsia
Emergency Delivery
Mother/Infant Identification Procedures
Baby Warmer
Communicable Diseases
Obtaining Cultures from cervix, vagina, or penis
Assisting with Culdocentesis
Obtaining Fetal Heart Tones
Breast Feeding Education
New Mother Education
Infant Abduction Policy and Procedure
Infant Abdandonment Policy and Procedure

PSYCHIATRIC

0 / 1 / 2 / 3 / Care of Patient with…
Suicidal/Homicidal Ideations
Auditory/Visual Hallucinations
Altered Mental Status Related to Chemical Impairment
Overdose
Chemical Restraints
Physical Restraints
Documentation of Patient in Seclusion/Restraints
5150 Holds
Crisis Intervention
Upholding Patient’s Rights

ENDOCRINE

0 / 1 / 2 / 3 / Care of patient with…
Diabetes
Diabetes Diet Education
Diabetes Wound Care Education
Administration of Insulin
Mixing Insulin Drips
Blood Glucose Monitoring
Use of Accu check Machine
Thyroid Storm
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis

ENVIRONMENTAL

0 / 1 / 2 / 3 / Care of Patient with…
Hypothermia
Hyperthermia
Use of Hypothermia/Hyperthermia Blanket
Heat Stroke
Heat Exhaustion
Snake Bite
Administration of Anti-Venom
Animal Bite
Poison Index/Contacting Poison Control

SEXUAL ASSAULT/ABUSE CASES

0 / 1 / 2 / 3 / Care of Patient with…
Alledged Sexual Assault
Rape Kit/Performing Sexual Exam/Evidence Collection
Reporting Procedures for Acts of Violence
Reporting Procedures of Acts of Abuse: Child or Elder
Necessity of Reporting suspected Violence or Abuse

PHARMACOLOGY

0 / 1 / 2 / 3 / Preparation, Calculation, Administration of Following Drugs…
Lidocaine
Bretylium
Nipride
Dopamine
Isuprel
Digoxin
Sodium Bicarbonate
Rapid Sequence Induction
Heparin Bolus
Heparin Drip (Precautions and Maintenance)
TPA
Integrillin
Inocor
Morphine
Lopressor
IV Antibiotics
Magnesium Sulfate
Reglan
Theophylline
Octreotide
Vasopressin
Amiodarone
Pronestyl
Verapamil
Adenosine
Atropine
Epinephrine
Dobutamine
Tridil-Nitroglycerine
Levophed
Tylenol dosing for febrile pediatric patients
Advil dosing for febrile pediatric patients
Narcotic Wasting Policy/2 Nurse Witnessed Waste
2 RN Check on All Insulin Administration
Post Blood and Body Fluids Exposure Prophylaxis

INTRAVENOUS ACCESS LINES

0 / 1 / 2 / 3
Initiating Peripheral IV Access on Adults
Initiating Peripheral IV Access on Peds
Initiating External Jugular IV Access
Heparin/Saline Lock
Inserting PICC line
Accessing Mediport/Port-a-Cath Line
Assistance with Insertion of Central Lines
Care of Central Lines (including Cortis’s and TLC’s)
Discontinuing Central Lines
Discontinuing Peripheral IV Lines
Use of Infusion Control Devices/Pumps
PCA Pumps
Performing and Assisting with IV Cut downs

NURSING INTERVENTION

0 / 1 / 2 / 3 / Accurate administration of Therapeutic Agents:
Therapeutic PT/PTT/INR Levels
Blood and Blood Products Transfusion Procedures
Medication Administration Procedures-5 Rights
Heparin Protocol
Potassium Protocol
Pain Management Procedures and Documentation
Hypertonic Saline Administration

NURSING INTERVENTION/NUTRITION

0 / 1 / 2 / 3
Performing a Nutritional Assessment
Calorie Count

NURSING INTERVENTION/DISCHARGE PLANNING

0 / 1 / 2 / 3
Admission Assessment of Discharge Needs
Interdisciplinary Documentation/Collaboration
Patient Teaching
Transfer/Discharge Procedures
EMTALA Regulations
COBRA Regulations

MISCELLANEOUS SKILLS/PROCEDURES

0 / 1 / 2 / 3
Isolation Procedures
Reverse Isolation Procedures
Taking care of Patients with Radiation Implants
Triage Procedures
Triage Categorization
Identifying Emergent Patients
Identifying Urgent Patients
Identifying Non-Urgent Patients
Knowledge of Hospital Policy regarding Pregnant Females who present to Triage (i.e. Over 20 weeks gestation to OB etc.)
Reporting Critical Lab Values
Understanding Lab Values
Emergency Dept-Necessity of Medical Screening Exam (MSE)
Procedure for Patient Leaving Hospital AMA
Procedure for Patient Leaving Hospital Without Being Seen
Consent for Treatment of a Minor
Multi-Victim Casuality Incidents
Knowledge of Triage Categories for Multi-Victim Casuality Incidents
HEICS (Hospital Emergency Incident Command System)
Use of Universal Precautions
Care of Patients with AIDS, Hepatitis or any other Communicable Disease
Organ Donation/Procurement Documentation Related to Policy/Law
Designated Requestor for Organ and Tissue Donation
Post Mortem Care
Policy and Procedure for Deceased Patient’s Belongings

OTHER SKILLS/PROCEDURES/SPECIAL TRAINING/SEMINARS:

EXPERIENCE:

Total number of years as a RN Total number of years as a LVN

Please indicate the number of years of experience for the following areas of expertise:

Administration
Supervision
Teaching
Emergency Department
Urgent Care
ER Observation Area
Trauma
ICU
SICU
MICU
PICU
NICU
CCU
DOU
Telemetry
Medical Floor
Surgical Floor
Recovery Room
Operating Room
Circulating Nurse OR
Open Heart Operating Room
Neurology
Chemical Dependency
Geriatrics
Psychiatic
Oncology
Orthopedics
Critical Care Transport RN
MICN
Rehabilitation
Pediatrics
Labor and Delivery
Mother/Baby/Post-partum
Home Health / Public Health
Research / Medical Sales
Clinic/Urgent Care
Nurses Aide/Tech
Paramedic / EMT
Other (specify)

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