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Name
Phone Number
Email Address

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

1 - No Experience / Theory Only
2 - Limited Experience / Need Review
3 - Frequent Experience / May Need Some Review
4 - Experienced / Perform Well

1 - Observed Only / Never Done
2 - Rarely Done (<6 times/year)
3 - Occasionally Done (1 - 2 times/month)
4 - Frequently Done (daily or weekly)

	Experience				Frequency
AGE SPECIFIC COMPETENCY	1	2	3	4	1	2	3	4
Neonates/Newborns (birth - 30 days)
Infants (30 days - 1 year)
Toddler (1 - 3 years)
Preschooler (3 - 5 years)
Older Children (5 - 12 years)
Adolescents (12 - 18 years)
Young Adults (18 - 39 years)
Middle Adults (39 - 64 years)
Older Adults/Geriatrics (64+ Years)
EXPERIENCE	1	2	3	4	1	2	3	4
Admission to PACU
Physical Assessment of Body Systems
Pulmonary/Abnormal Breathing
Perform Suctioning
O2 Administration
Care of Patient with Chest Tube
Post-Operative Patient Care
Care of Patient with Tubes/Drains
Cardiovascular
Operate & Monitor Unit Equipment
Anesthesia Equipment
CHARTING	1	2	3	4	1	2	3	4
Computer
DARE
APIE
SOAPIE
FOCUS
Discharge Planning
Utilization Review
Chart Review/Audit
ADMISSION TO PACU	1	2	3	4	1	2	3	4
Initial Assessment
Airway Management
Proper Positioning
Vital Signs
Skin Color, Temp, Turgor
Neurological Status
PHYSICAL ASSESSMENT OF BODY SYSTEMS	1	2	3	4	1	2	3	4
Respiratory
Cardiovascular
Neurologic
Gastrointestinal
Genitourinary
Integumentary
Monitor Recovery of Patient From
General Anesthesia
Regional Anesthesia
Local Anesthesia
PULMONARY	1	2	3	4	1	2	3	4
Auscultate Breath Sounds
Recognize Abnormal Breath Sounds (e.g. rales, rhonchi)
Implement Appropriate Nursing Intervention for Abnormal Breath Sounds
Reposition Patient
Pulmonary Toilet
Bronchodilators, Diuretics
Suction, O2
Airway Insertion/Management
Recognize Abnormal Breathing
Assess Respiratory Rate, Rhythm, Depth, & Symmetry
Labored, Dyspneic
Obstructed
Laryngospasm
Insufficient Reversal
PERFORM SUCTIONING	1	2	3	4	1	2	3	4
Oral
Nasal
Endotracheal
Tracheal
O2 ADMINISTRATION	1	2	3	4	1	2	3	4
Face-trach Mask
Nasal Cannula
T-Piece
ETT Mechanical Ventilator
Care of Patient with CHEST TUBE
Set-up Closed Drainage System
Recognize Air Leak
Assess for Subcutaneous Emphysema
Measure Drainage
Troubleshoot Problems
POST-OPERATIVE CARE FOR THE FOLLOWING PATIENT POPULATIONS	1	2	3	4	1	2	3	4
Thoracic Surgery
Vascular Surgery
Orthopedic Surgery
Neurosurgery
Tonsillectomy/P.E. Tubes
Major Abdominal Surgery
ENT Surgery
Breast Surgery
Genitourinary Surgery
Hypospadias
Circumcision
Gynecological Surgery
Post-Angiogram
Liver Biopsy
Eye Surgery
Cardiac Surgery

	Experience				Frequency
Care of Patient with TUBES/DRAINS	1	2	3	4	1	2	3	4
Penrose Drain
Salem
Sump
Davol
Colostomy
Jejunostomy
IIeostomy
Jackson Pratt
T-Tube
Foley Catheter
Urethral
Suprapubic
Cystotomy
NG Tube
CARDIOVASCULAR	1	2	3	4	1	2	3	4
Placement & Care of a Patient on a Cardiac Monitor
Arrhythmia Analysis
Cardioversion & Defibrillation
Assist with Insertion of Temporary Pacemaker
Care of Patient with Permanent/Temporary Pacemaker
Use of Non-Invasive Temporary Pacing Equipment
Care of Patient with Intravascular Hemodynamic Monitoring Equipment
Pulmonary Artery Catheters
Arterial Catheters
Swan-Ganz Catheters
Central Venous Catheters
Subclavian Lines
Epidural Catheters
Hemodynamic Monitoring
Equipment Maintenance
Dressing Changes
Prevention of Complications
Leveling Waveform Analysis
Obtain & Interpret
Cardiac Output
PA Pressure
PCWP/PAWP
CVP
LAP
Identify Usual Dosage, Actions & Side Effects for
Antiarrhythmics
Ionotropes
Vasopressors
Vasodilators
Reversal Agents
Muscle Relaxants
Betablockers
Calcium Channel Blockers
Inhalation Agents
Calculate Infusion Rates in Dosages Ordered
Interpret Blood Lab Values for
Electrolyte Imbalances/ABG's
OPERATE & MONITOR UNIT EQUIPMENT	1	2	3	4	1	2	3	4
Portable Suction Machine
Transport Monitor
Automatic BP Monitor
Blanket Warmer/Bear Hugger
Sequential Compression Device
Pulse Oximeter
Pee Wee Weighing Scale
Hyper/Hypothermia Blanket
Blood Warmer
PACU Stretcher
IV Pumps
Invasive Pressure Monitors
Implements Physician Orders
Collaborate with Surgeon & Anesthesiologist with Regard to Patient Care
Utilizes Appropriate Infection Control Measures
Practice Universal Precautions
Document Interventions, Outcomes, Lab Studies, MD Notifications & Follow-up Care
Perform a Discharge Physical Assessment
Level of Consciousness
Pupillary Reactions
Motor & Sensory Function
Muscular Strength (eg: Hand grasps, Head lift)
ANESTHESIA EQUIPMENT	1	2	3	4	1	2	3	4
Blood Warmer
BP Monitor
Dinamap
Omeda
Defibrillator
SAO2 Monitor
Nitrogen Controls
Tanks
Wall Units
Thermia Blankets

I attest that the information I have given is true and accurate to the best of my knowledge and that I am the indivdual completing this form. I hereby authorize Texas Select Staffing to release this Skills Checklist to its client facilities for consideration of employment as a contractor at those facilities.