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)*1234Young Children (4 - 6 years)*1234Older Children (7 - 12 years)*1234Adolescents (13 - 20 years)*1234Young Adults (21 - 39 years)*1234Middle Adults (40 - 64 years)*1234Older Adults (65 - 79 years)*1234Adults (>80 years)*1234Medication AdministrationPouring from Stock Medications*1234Narcotic Administration*1234IV Push Medications*1234IV Drip Medications*1234IV Drip Antibiotics*1234IV Drip Narcotics*1234IV Drip Chemotherapy*1234Phlebotomy / IV TherapyDraw Blood*1234Draw Blood Arterial Line*1234Draw Blood Central Line*1234Insert IVs*1234Mixing IVs*1234Regulating IVs*1234Discontinue Peripheral IV*1234IV Infusion Pumps*1234CVP Lines - Measurement of CVP*1234Central Line Dressing Changes*1234Blood / Blood Product Administration*1234Administration of Total Parenteral Nutrition (TPN)*1234Administration of Peripheral Parenteral Nutrition (PPN)*1234Multi-Lumen Central Catheters*1234Port-A-Caths (Infusa-Ports)*1234Continuous Subcutaneous Infusion Pumps*1234Patient Controlled Analgesia (PCA)*1234Patients with Neurological ProblemsAssessing Levels of Consciousness*1234Pupil Checks*1234Seizure Precautions*1234Aneurysm Precautions*1234Assisting with Lumbar Puncture*1234Administration of Anticonvulsant*1234Administration of IV Drip Steroids*1234Use of Hyper / Hypothermia Blanket*1234Spinal Cord Injury - Acute*1234Spinal Cord Injury - Long Term*1234CVA - Stroke*1234Neuromuscular Disease*1234Alzheimer Disease*1234Patients with Wound / Skin ProblemsDressing Changes*1234Pressure Sores*1234Leg Ulcers*1234Burns*1234Use of Special Pressure Relief Devices*1234Air Fluidized, Low Airloss Beds*1234Pressure Relief Mattress / Seat Cushion*1234Patients with Endocrine ProblemsInsulin Administration*1234Single Type Insulin*1234Mixed Insulins*1234Insulin Infusion*1234Blood Glucose Monitoring*1234Performing Fingersticks*1234Use of Blood Glucose Meter Device*1234Use of Visual Blood Glucose Strips*1234Additional Medical / Surgical SkillsHemovacs*1234Jackson-Pratt Tubes*1234Penrose Drains*1234T-Tubes*1234Surgical Wound Irrigation & Dressings*1234Universal Precautions*1234Patients with Cardiovascular ProblemsCardiac Monitors*1234Taking EKGs - 12 Lead*1234Basic & Life-Threatening Dysrhythmias*1234Recognizing Basic & Life-Threatening Dysrhythmias*1234Cardiopulmonary Resuscitation (CPR)*1234Defibrillation*1234Cardioversion*1234General Pulse Checks*1234General Use of Doppler*1234Use of Automatic BP Cuff (i.e. Dinamap)*1234Administration of Nitrates (Oral, Topical)*1234Administration of Antiarrhythmics (Oral)*1234Administration of Antihypertensives (Oral)*1234RespiratoryO2 Cannulas / Mask*1234Nebulizer Set-up / Use*1234Incentive Spirometry*1234Chest PT*1234Pulse Oximetry*1234Suctioning*1234Oral*1234Tracheostomy Tube*1234Care of the Ventilator Patient*1234Mouth Care*1234Suctioning - Endotracheal Tube*1234Ambu Bags*1234Weaning the Patient off the Ventilator*1234Bronchodilator Administration*1234Oral*1234IV*1234Inhaler*1234Tracheostomy Tube*1234COPD*1234Asthma Exacerbation*1234Pneumonia*1234Pre / Post Thoracic Surgery*1234Chest Tubes*1234Patients with Renal / GU ProblemsInsertion of Catheter*1234Female*1234Male*1234Bladder Irrigation*1234Continuous*1234Intermittent*1234Peritoneal Dialysis*1234Manual*1234Automatic Cycler Machine*1234Collection of Urine Specimens*1234Care of Patient on Hemodialysis*1234A-V Fistula / Shunt Care*1234Pre- & Post-Dialysis Care*1234Urinary Diversion*1234Suprapubic Catheter*1234Nephrostomy Tube*1234Patients with Gastrointestinal ProblemsNasogastric Tubes (i.e. Salem Sump, Levine)*1234Nasointestinal Tubes (i.e. Cantor, Miller-Abbot)*1234Jejunostomy, Gastrostomy, Cecostomy Tubes*1234Inserting Nasogastric Tubes*1234Tube Feedings via Flexible Tubes*1234Nasogastric*1234by Gravity Infusion*1234by Feeding Pump*1234Collection of Stool Specimens*1234Bowel Preparation & Cleansing Procedures*1234Ileostomy*1234Colostomy*1234Inflammatory Bowel Disease*1234Patients with Orthopedic ProblemsCast Care*1234Circulation Checks*1234Traction - Skin*1234Traction - Skeletal*1234Range of Motion*1234Use of Assistive Devices*1234Total Joint Replacement*1234Rheumatic / Arthritic Disease*1234Amputation*1234Applications of Splints of Extremities*1234Continuous Passive Motion Machine (CPM)*1234