Medical / Surgical Skills Checklist Name* First Last Email* Phone*Proficiency: 1 = Minimal Experience 2 = Limited Experience 3 = Competent 4 = Highly SkilledAge Specific CompetencyInfants & Toddlers (0 - 3 years)* 1 2 3 4 Young Children (4 - 6 years)* 1 2 3 4 Older Children (7 - 12 years)* 1 2 3 4 Adolescents (13 - 20 years)* 1 2 3 4 Young Adults (21 - 39 years)* 1 2 3 4 Middle Adults (40 - 64 years)* 1 2 3 4 Older Adults (65 - 79 years)* 1 2 3 4 Adults (>80 years)* 1 2 3 4 Medication AdministrationPouring from Stock Medications* 1 2 3 4 Narcotic Administration* 1 2 3 4 IV Push Medications* 1 2 3 4 IV Drip Medications* 1 2 3 4 IV Drip Antibiotics* 1 2 3 4 IV Drip Narcotics* 1 2 3 4 IV Drip Chemotherapy* 1 2 3 4 Phlebotomy / IV TherapyDraw Blood* 1 2 3 4 Draw Blood Arterial Line* 1 2 3 4 Draw Blood Central Line* 1 2 3 4 Insert IVs* 1 2 3 4 Mixing IVs* 1 2 3 4 Regulating IVs* 1 2 3 4 Discontinue Peripheral IV* 1 2 3 4 IV Infusion Pumps* 1 2 3 4 CVP Lines - Measurement of CVP* 1 2 3 4 Central Line Dressing Changes* 1 2 3 4 Blood / Blood Product Administration* 1 2 3 4 Administration of Total Parenteral Nutrition (TPN)* 1 2 3 4 Administration of Peripheral Parenteral Nutrition (PPN)* 1 2 3 4 Multi-Lumen Central Catheters* 1 2 3 4 Port-A-Caths (Infusa-Ports)* 1 2 3 4 Continuous Subcutaneous Infusion Pumps* 1 2 3 4 Patient Controlled Analgesia (PCA)* 1 2 3 4 Patients with Neurological ProblemsAssessing Levels of Consciousness* 1 2 3 4 Pupil Checks* 1 2 3 4 Seizure Precautions* 1 2 3 4 Aneurysm Precautions* 1 2 3 4 Assisting with Lumbar Puncture* 1 2 3 4 Administration of Anticonvulsant* 1 2 3 4 Administration of IV Drip Steroids* 1 2 3 4 Use of Hyper / Hypothermia Blanket* 1 2 3 4 Spinal Cord Injury - Acute* 1 2 3 4 Spinal Cord Injury - Long Term* 1 2 3 4 CVA - Stroke* 1 2 3 4 Neuromuscular Disease* 1 2 3 4 Alzheimer Disease* 1 2 3 4 Patients with Wound / Skin ProblemsDressing Changes* 1 2 3 4 Pressure Sores* 1 2 3 4 Leg Ulcers* 1 2 3 4 Burns* 1 2 3 4 Use of Special Pressure Relief Devices* 1 2 3 4 Air Fluidized, Low Airloss Beds* 1 2 3 4 Pressure Relief Mattress / Seat Cushion* 1 2 3 4 Patients with Endocrine ProblemsInsulin Administration* 1 2 3 4 Single Type Insulin* 1 2 3 4 Mixed Insulins* 1 2 3 4 Insulin Infusion* 1 2 3 4 Blood Glucose Monitoring* 1 2 3 4 Performing Fingersticks* 1 2 3 4 Use of Blood Glucose Meter Device* 1 2 3 4 Use of Visual Blood Glucose Strips* 1 2 3 4 Additional Medical / Surgical SkillsHemovacs* 1 2 3 4 Jackson-Pratt Tubes* 1 2 3 4 Penrose Drains* 1 2 3 4 T-Tubes* 1 2 3 4 Surgical Wound Irrigation & Dressings* 1 2 3 4 Universal Precautions* 1 2 3 4 Patients with Cardiovascular ProblemsCardiac Monitors* 1 2 3 4 Taking EKGs - 12 Lead* 1 2 3 4 Basic & Life-Threatening Dysrhythmias* 1 2 3 4 Recognizing Basic & Life-Threatening Dysrhythmias* 1 2 3 4 Cardiopulmonary Resuscitation (CPR)* 1 2 3 4 Defibrillation* 1 2 3 4 Cardioversion* 1 2 3 4 General Pulse Checks* 1 2 3 4 General Use of Doppler* 1 2 3 4 Use of Automatic BP Cuff (i.e. Dinamap)* 1 2 3 4 Administration of Nitrates (Oral, Topical)* 1 2 3 4 Administration of Antiarrhythmics (Oral)* 1 2 3 4 Administration of Antihypertensives (Oral)* 1 2 3 4 RespiratoryO2 Cannulas / Mask* 1 2 3 4 Nebulizer Set-up / Use* 1 2 3 4 Incentive Spirometry* 1 2 3 4 Chest PT* 1 2 3 4 Pulse Oximetry* 1 2 3 4 Suctioning* 1 2 3 4 Oral* 1 2 3 4 Tracheostomy Tube* 1 2 3 4 Care of the Ventilator Patient* 1 2 3 4 Mouth Care* 1 2 3 4 Suctioning - Endotracheal Tube* 1 2 3 4 Ambu Bags* 1 2 3 4 Weaning the Patient off the Ventilator* 1 2 3 4 Bronchodilator Administration* 1 2 3 4 Oral* 1 2 3 4 IV* 1 2 3 4 Inhaler* 1 2 3 4 Tracheostomy Tube* 1 2 3 4 COPD* 1 2 3 4 Asthma Exacerbation* 1 2 3 4 Pneumonia* 1 2 3 4 Pre / Post Thoracic Surgery* 1 2 3 4 Chest Tubes* 1 2 3 4 Patients with Renal / GU ProblemsInsertion of Catheter* 1 2 3 4 Female* 1 2 3 4 Male* 1 2 3 4 Bladder Irrigation* 1 2 3 4 Continuous* 1 2 3 4 Intermittent* 1 2 3 4 Peritoneal Dialysis* 1 2 3 4 Manual* 1 2 3 4 Automatic Cycler Machine* 1 2 3 4 Collection of Urine Specimens* 1 2 3 4 Care of Patient on Hemodialysis* 1 2 3 4 A-V Fistula / Shunt Care* 1 2 3 4 Pre- & Post-Dialysis Care* 1 2 3 4 Urinary Diversion* 1 2 3 4 Suprapubic Catheter* 1 2 3 4 Nephrostomy Tube* 1 2 3 4 Patients with Gastrointestinal ProblemsNasogastric Tubes (i.e. Salem Sump, Levine)* 1 2 3 4 Nasointestinal Tubes (i.e. Cantor, Miller-Abbot)* 1 2 3 4 Jejunostomy, Gastrostomy, Cecostomy Tubes* 1 2 3 4 Inserting Nasogastric Tubes* 1 2 3 4 Tube Feedings via Flexible Tubes* 1 2 3 4 Nasogastric* 1 2 3 4 by Gravity Infusion* 1 2 3 4 by Feeding Pump* 1 2 3 4 Collection of Stool Specimens* 1 2 3 4 Bowel Preparation & Cleansing Procedures* 1 2 3 4 Ileostomy* 1 2 3 4 Colostomy* 1 2 3 4 Inflammatory Bowel Disease* 1 2 3 4 Patients with Orthopedic ProblemsCast Care* 1 2 3 4 Circulation Checks* 1 2 3 4 Traction - Skin* 1 2 3 4 Traction - Skeletal* 1 2 3 4 Range of Motion* 1 2 3 4 Use of Assistive Devices* 1 2 3 4 Total Joint Replacement* 1 2 3 4 Rheumatic / Arthritic Disease* 1 2 3 4 Amputation* 1 2 3 4 Applications of Splints of Extremities* 1 2 3 4 Continuous Passive Motion Machine (CPM)* 1 2 3 4