Candidate Name: Page 1 of 8

Aortofemoral Bypass Grafting 1 2 3 4

Abdominal Aortic Aneurysm Repair - Open 1 2 3 4

Assessment / Management of Fluid Balance 1 2 3 4

Axillofemoral Bypass Grafting 1 2 3 4

Assessment of Peripheral Pulses 1 2 3 4

CARDIOVASCULAR

Seizure Precautions 1 2 3 4

Embolectomy / Thrombectomy 1 2 3 4

Cardiac Arrest / CPR Pediatric 1 2 3 4

Cardiac Arrest / CPR Adult 1 2 3 4

Cardiac Valve Replacement (MVR, AVR) 1 2 3 4

Coronary Artery Bypass Graft (CABG) 1 2 3 4

Cardioversion / Defibrillation 1 2 3 4 Reversal Agents 1 2 3 4 Femoral 1 2 3 4 Epidural 1 2 3 4 Intrathecal 1 2 3 4 Spinal 1 2 3 4 Retrobulbular 1 2 3 4 Brachial 1 2 3 4

GENERAL SKILLS

Ambulatory / Outpatient Surgery 1 2 3 4

Paralytics 1 2 3 4

National Patient Safety Goals 1 2 3 4

Phlebotomy - Peripheral / Central Lines 1 2 3 4

Restraints 1 2 3 4

Regional Block 1 2 3 4

Management of Patient with Malignant Hyperthermia 1 2 3 4

Conscious Sedation / Protocols & Procedures 1 2 3 4

Blood Glucose Monitoring 1 2 3 4

Lift / Transfer Devices 1 2 3 4

Local Anesthetics 1 2 3 4

Oral / NT Suctioning 1 2 3 4

Oral / NT Airway 1 2 3 4

Non-Rebreather / Partial Non-Rebreather Mask 1 2 3 4

Use of Ambu Bag 1 2 3 4

SVO2 Monitoring 1 2 3 4

Pulse Oximetry 1 2 3 4

Laryngeal Mask Airway (LMA) 1 2 3 4

Endotracheal Tube 1 2 3 4

Nasal Cannula 1 2 3 4

Measuring Tidal Volume 1 2 3 4

Mask 1 2 3 4

Use of CO2 Monitoring Devices 1 2 3 4

Ventilator Management 1 2 3 4

Assisting with Extubation 1 2 3 4

Arterial Line 1 2 3 4

Set Up & Interpretation of Hemodynamic Monitoring:

Post Operative Myocardial Infarction 1 2 3 4

Use of Broslow System 1 2 3 4

PA Catheter 1 2 3 4

CVC (Central Venous Catheter) 1 2 3 4

Interpretation of Lab Values 1 2 3 4

CARDIOVASCULAR, con't.

Assisting with Intubation 1 2 3 4

Permanent Pacemaker / AICD Insertion 1 2 3 4

Performing 12 Lead EKG's 1 2 3 4

Percutaneous Transluminal Coronary Angioplasty (PTCA) 1 2 3 4

Vena Cava Filter 1 2 3 4

Pleural Chest Tubes 1 2 3 4

Radical Neck Dissection 1 2 3 4

Laryngectomy 1 2 3 4 Airway Management: Tracheostomy 1 2 3 4 Sinus Surgery 1 2 3 4 Laryngeal Procedures 1 2 3 4 Adenotonsillectomy 1 2 3 4

PULMONARY

Ventricular Peritoneal Shunt 1 2 3 4

Tether Cords 1 2 3 4

Spinal Tumor Excision 1 2 3 4

Intracranial Tumor Excision 1 2 3 4

Intracranial / Cerebral Perfusion Pressure Monitoring (ICP / CPP) 1 2 3 4

Spinal Fusion 1 2 3 4

Neurological Assessment 1 2 3 4

Laminectomy 1 2 3 4

GASTROINTESTINAL

Abdominal Trauma 1 2 3 4

Evacuation of Hematoma (Subdural, Epidural) 1 2 3 4

Bronchoscopy 1 2 3 4

Thoracotomy for:

Radial 1 2 3 4

Pneumonectomy 1 2 3 4

Penetrating / Open Chest Trauma 1 2 3 4

Bullectomy 1 2 3 4

Arterial Blood Gas Interpretation / Analysis:

PULMONARY, con't.

Glasgow Coma Scale 1 2 3 4

Femoral 1 2 3 4

Brachial 1 2 3 4

Obtaining ABG Blood Sample (Art Line) 1 2 3 4

Pulmonary Resection / Wedge 1 2 3 4

Carotid Endarterectomy 1 2 3 4

Burr Holes 1 2 3 4

Aneurysm Coiling 1 2 3 4

Craniotomy 1 2 3 4

Cranial Nerve Assessment 1 2 3 4

Cervical Spine Precautions 1 2 3 4

Resection / Lobectomy 1 2 3 4

Aneurysm Clipping / Subarachnoid Hemorrhage 1 2 3 4

Ileal Conduit 1 2 3 4 Foley Catheter 1 2 3 4 Cystectomy 1 2 3 4 Renal Transplant 1 2 3 4 Nephrostomy Tube 1 2 3 4 Nephrectomy 1 2 3 4

RENAL / GENITOURINARY

AV Fistulas, Shunts & Dialysis Catheters 1 2 3 4

AortoRenal Bypass 1 2 3 4

Suprapubic Tube 1 2 3 4

Ureteral Stent Insertion 1 2 3 4

Whipple Procedure 1 2 3 4

Esophagectomy 1 2 3 4

Esophageal Dilatation 1 2 3 4

ERCP 1 2 3 4

Gastrectomy (Partial / Complete) 1 2 3 4

Exploratory Laparotomy 1 2 3 4 Esophagogastrostomy 1 2 3 4 Cholecystectomy 1 2 3 4

GASTROINTESTINAL, con't.

Gastric Bypass (Bariatric Surgery) 1 2 3 4

Nissen Fundoplication 1 2 3 4

Nasogastric Tube / G Tube / J Tube 1 2 3 4

T Tube 1 2 3 4

Vagotomy 1 2 3 4

Pyloroplasty 1 2 3 4

Pyloric Stenosis Repair 1 2 3 4

Maintenance of Wound Care:

Hernia Repair 1 2 3 4

Gastroplasty (Stapling) 1 2 3 4

Self Suction (Jackson-Pratt / Hemovac) 1 2 3 4

Irrigation Drains (Axiom) 1 2 3 4

Blephoplasty 1 2 3 4

Acoustic Neuroma Removal 1 2 3 4

EYE & EAR

Keratoplasty (Corneal Transplant) 1 2 3 4

Cochlear Implant 1 2 3 4

Cataract Extraction 1 2 3 4

Open Reduction & Internal Fixation 1 2 3 4

Management of Orthopedic Traction 1 2 3 4

Total Joint Replacement / Arthroplasty 1 2 3 4

Laser Eye Surgery 1 2 3 4

Myringotomy 1 2 3 4

Amputation 1 2 3 4

Hysterectomy 1 2 3 4

Dilation & Curettage (D&C) 1 2 3 4

REPRODUCTIVE

Adrenalectomy 1 2 3 4

ENDOCRINE

Management of Continuous Passive Motion Device 1 2 3 4

Transsphenoidal Hypophysectomy 1 2 3 4

Thyroidectomy 1 2 3 4

Parathyroidectomy 1 2 3 4

Laparoscopic 1 2 3 4

Transurethral Resection of the Prostate 1 2 3 4

TAH-BSO 1 2 3 4 Salpingectomy 1 2 3 4

ORTHOPEDIC

Diuretics (Lasix, Edecrin Sodium, Bumex) 1 2 3 4

Care of Patients with Latex Allergies 1 2 3 4

Calcium Channel Blockers (Cardizem) 1 2 3 4

Glycoprotein IIb / IIIa Receptor Inhibitors (Integrilin, Aggrastat) 1 2 3 4

Fibrinolytics 1 2 3 4

Emergency Meds (ACLS protocols) 1 2 3 4

Phenergan 1 2 3 4

Droperidol (Inapsine) 1 2 3 4

Antihypertensives (Nipride) 1 2 3 4

Zofran 1 2 3 4

Vistaril / Ephedrine IM 1 2 3 4

H2 Receptor Antagonists (Zantac, Pepcid, Carafate) 1 2 3 4

Anticonvulsants (Dilantin, Phenobarbital) 1 2 3 4

Wound Vac 1 2 3 4

Wound Debridement 1 2 3 4

Skin Grafts 1 2 3 4

Care of Patients Following Plastic Surgery 1 2 3 4

SKIN / WOUND MANAGEMENT

Antiemetics:

Skin Flaps 1 2 3 4

Incision & Drainage 1 2 3 4

Cleft Lip / Palate Repair 1 2 3 4

PHLEBOTOMY / IV THERAPY

USE AND ADMINISTRATION OF MEDICATION

Anticoagulation Therapy (Heparin, Coumadin) 1 2 3 4

Antiarrhythmics (Amiodarone, Lidocaine, Procan) 1 2 3 4

Anaphylaxis 1 2 3 4

Care of Patient with PICC Groshong / Hickman 1 2 3 4

Autotransfusion of Blood / Blood Products 1 2 3 4

Administration of Volume Expanders (Albumin, Dextran, etc) 1 2 3 4

Starting Peripheral IV's 1 2 3 4

Rural Hospital Y N Community Hospital Y N Trauma Y N Teaching Hospital Y N Cardiovascular Y N Cardiothoracic Y N Surgical Y N

Recovery Room / PACU Y N

Coronary Care Y N

Vasodilators (Nitroglycerin) 1 2 3 4

Steroids (Decadron, Solumedrol) 1 2 3 4

Romazicon 1 2 3 4

Dilaudid 1 2 3 4

Demerol 1 2 3 4

Pain Management:

Inotropes / Vasoactive Drips 1 2 3 4

USE AND ADMINISTRATION OF MEDICATION, con't.

EXPERIENCE

Nebulizer Treatments (Ventolin, Atrovent, Racemic, Epinephrine) 1 2 3 4

Narcan 1 2 3 4

Insulin (SQ, IV, and IV Drip) 1 2 3 4

Fentanyl 1 2 3 4 Ativan 1 2 3 4 Sedatives: Morphine 1 2 3 4 Versed 1 2 3 4 Valium 1 2 3 4 Propofol 1 2 3 4

ACLS Y N

CERTIFICATIONS / COURSES / SKILLS

CCRN Y N

BLS Y N

CNOR Y N

Computerized Charting Y N

Critical Care Course Y N

Medication Administration System Y N

IV Certification Y N

PALS Y N

NRP Y N

Arrhythmia Course Y N

TNCC Y N

comprehension and maturity level A B C D E F G H I

[D] = Young Children (4 to 6 years) [C] = Toddler (1 to 3 years)

[F] = Adolescents (13 to 20 years) [E] = Older Children (7 to 12 years)

LEGEND KEY FOR AGE SPECIFIC CRITERIA

Can ensure a safe environment reflecting specific needs of various age groups A B C D E F G H I

[B] = Infant (30 days to 1 year) [A] = Newborn (Birth to 30 days)

[G] = Young Adults (21 to 39 years)

AGE SPECIFIC CRITERIA

Able to adapt method and terminology of patient instructions to their age

Able to adapt care to incorporate normal growth and development A B C D E F G H I

[I] = Older Adults (61+ years) [H] = Middle Adults (40 to 60 years)

Initials

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