Candidate Name: Page 1 of 8

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Cori Jacobs
8 years ago
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1 Candidate Name: Page 1 of 8 Experience GENERAL SKILLS Aldrette Scoring Ambulatory / Outpatient Surgery Assessment of Dermatomes: Brachial Epidural Femoral Intrathecal Retrobulbular Spinal Blood Glucose Monitoring Conscious Sedation / Protocols & Procedures Lift / Transfer Devices LMA Local Anesthetics Management of Patient with Malignant Hyperthermia National Patient Safety Goals Paralytics Phlebotomy - Peripheral / Central Lines Regional Block Restraints Reversal Agents Scalene Seizure Precautions CARDIOVASCULAR Abdominal Aortic Aneurysm Repair - Open Aortofemoral Bypass Grafting Assessment / Management of Fluid Balance Assessment of Peripheral Pulses Axillofemoral Bypass Grafting Cardiac Arrest / CPR Adult Cardiac Arrest / CPR Pediatric Cardiac Valve Replacement (MVR, AVR) Cardioversion / Defibrillation Coronary Artery Bypass Graft (CABG) Embolectomy / Thrombectomy Endoluminal Stenting External / Temporary Pacemaker Interpretation of Arrhythmias

Anesthetics 1 2 3 4 Management of Patient with Malignant Hyperthermia 1 2 3 4 National Patient Safety Goals 1 2 3 4 Paralytics 1 2 3 4 Phlebotomy - Peripheral / Central Lines 1 2 3 4 Regional Block 1

2 Candidate Name: Page 2 of 8 Experience CARDIOVASCULAR, con't. Interpretation of Lab Values Percutaneous Transluminal Coronary Angioplasty (PTCA) Performing 12 Lead EKG's Permanent Pacemaker / AICD Insertion Post Operative Myocardial Infarction Set Up & Interpretation of Hemodynamic Monitoring: Arterial Line CVC (Central Venous Catheter) PA Catheter Use of Broslow System Vena Cava Filter PULMONARY Adenotonsillectomy Laryngeal Procedures Laryngectomy Radical Neck Dissection Pleural Chest Tubes Sinus Surgery Tracheostomy Airway Management: Assisting with Extubation Assisting with Intubation Endotracheal Tube Laryngeal Mask Airway (LMA) Mask Measuring Tidal Volume Nasal Cannula Non-Rebreather / Partial Non-Rebreather Mask Oral / NT Airway Oral / NT Suctioning Pulse Oximetry SVO2 Monitoring Use of Ambu Bag Use of CO2 Monitoring Devices Ventilator Management

Myocardial Infarction 1 2 3 4 Set Up & Interpretation of Hemodynamic Monitoring: Arterial Line 1 2 3 4 CVC (Central Venous Catheter) 1 2 3 4 PA Catheter 1 2 3 4 Use of Broslow System 1 2 3 4 Vena

3 Candidate Name: Page 3 of 8 Experience PULMONARY, con't. Arterial Blood Gas Interpretation / Analysis: Obtaining ABG Blood Sample (Art Line) Brachial Femoral Radial Thoracotomy for: Bronchoscopy Bullectomy Penetrating / Open Chest Trauma Pneumonectomy Pulmonary Resection / Wedge Resection / Lobectomy NEUROLOGY Aneurysm Clipping / Subarachnoid Hemorrhage Aneurysm Coiling Burr Holes Carotid Endarterectomy Cervical Spine Precautions Cranial Nerve Assessment Craniotomy Evacuation of Hematoma (Subdural, Epidural) Glasgow Coma Scale Intracranial / Cerebral Perfusion Pressure Monitoring (ICP / CPP) Intracranial Tumor Excision Laminectomy Neurological Assessment Spinal Fusion Spinal Tumor Excision Tether Cords Ventricular Peritoneal Shunt GASTROINTESTINAL Abdominal Trauma Appendectomy Biliary Atresia Bowel / Colon Resection

Penetrating / Open Chest Trauma 1 2 3 4 Pneumonectomy 1 2 3 4 Pulmonary Resection / Wedge 1 2 3 4 Resection / Lobectomy 1 2 3 4 NEUROLOGY Aneurysm Clipping / Subarachnoid Hemorrhage 1 2 3 4 Aneurysm

4 Candidate Name: Page 4 of 8 Experience GASTROINTESTINAL, con't. Cholecystectomy Colonoscopy Colostomy / Ileostomy EGD ERCP Esophageal Dilatation Esophagectomy Esophagogastrostomy Exploratory Laparotomy Gastrectomy (Partial / Complete) Gastric Bypass (Bariatric Surgery) Gastroplasty (Stapling) Hernia Repair Maintenance of Wound Care: Biliary Tube Irrigation Drains (Axiom) Self Suction (Jackson-Pratt / Hemovac) T Tube Nasogastric Tube / G Tube / J Tube Nissen Fundoplication Pyloric Stenosis Repair Pyloroplasty Vagotomy Whipple Procedure RENAL / GENITOURINARY AortoRenal Bypass AV Fistulas, Shunts & Dialysis Catheters Bladder Irrigation Cystectomy Foley Catheter Ileal Conduit Nephrectomy Nephrostomy Tube Renal Transplant Suprapubic Tube Ureteral Stent Insertion

Laparotomy 1 2 3 4 Gastrectomy (Partial / Complete) 1 2 3 4 Gastric Bypass (Bariatric Surgery) 1 2 3 4 Gastroplasty (Stapling) 1 2 3 4 Hernia Repair 1 2 3 4 Maintenance of Wound Care: Biliary Tube 1

5 Candidate Name: Page 5 of 8 Experience ENDOCRINE Adrenalectomy Parathyroidectomy Thyroidectomy Transsphenoidal Hypophysectomy REPRODUCTIVE Dilation & Curettage (D&C) Hysterectomy Laparoscopic Vaginal Lumpectomy Mastectomy / Mammoplasty Oophorectomy Penal Implant Radical Prostatectomy Salpingectomy TAH-BSO Transurethral Resection of the Prostate ORTHOPEDIC Amputation Management of Continuous Passive Motion Device Management of Orthopedic Traction Open Reduction & Internal Fixation Total Joint Replacement / Arthroplasty EYE & EAR Acoustic Neuroma Removal Blephoplasty Cataract Extraction Cochlear Implant Keratoplasty (Corneal Transplant) Laser Eye Surgery Myringotomy Retrobulbar Anesthesia / Blockade Scleral Buckling (for Retinal Detachment)

Salpingectomy 1 2 3 4 TAH-BSO 1 2 3 4 Transurethral Resection of the Prostate 1 2 3 4 ORTHOPEDIC Amputation 1 2 3 4 Management of Continuous Passive Motion Device 1 2 3 4 Management of Orthopedic

6 Candidate Name: Page 6 of 8 Experience SKIN / WOUND MANAGEMENT Care of Patients Following Plastic Surgery Cleft Lip / Palate Repair Incision & Drainage Skin Flaps Skin Grafts Wound Debridement Wound Vac PHLEBOTOMY / IV THERAPY Administration of Volume Expanders (Albumin, Dextran, etc) Autotransfusion of Blood / Blood Products Care of Patient with PICC Groshong / Hickman Initiating & Care of Patient with Patient Controlled Analgesia (PCA) Starting Peripheral IV's USE AND ADMINISTRATION OF MEDICATION Anaphylaxis Antiarrhythmics (Amiodarone, Lidocaine, Procan) Anticoagulation Therapy (Heparin, Coumadin) Anticonvulsants (Dilantin, Phenobarbital) Antiemetics: Droperidol (Inapsine) Phenergan Vistaril / Ephedrine IM Zofran Antihypertensives (Nipride) Calcium Channel Blockers (Cardizem) Care of Patients with Latex Allergies Diuretics (Lasix, Edecrin Sodium, Bumex) Emergency Meds (ACLS protocols) Fibrinolytics Glycoprotein IIb / IIIa Receptor Inhibitors (Integrilin, Aggrastat) H2 Receptor Antagonists (Zantac, Pepcid, Carafate)

Care of Patient with PICC Groshong / Hickman 1 2 3 4 Initiating & Care of Patient with Patient Controlled Analgesia (PCA) 1 2 3 4 Starting Peripheral IV's 1 2 3 4 USE AND ADMINISTRATION OF MEDICATION

7 Candidate Name: Page 7 of 8 Experience USE AND ADMINISTRATION OF MEDICATION, con't. Inotropes / Vasoactive Drips Insulin (SQ, IV, and IV Drip) Narcan Nebulizer Treatments (Ventolin, Atrovent, Racemic, Epinephrine) Romazicon Steroids (Decadron, Solumedrol) Vasodilators (Nitroglycerin) Pain Management: Demerol Dilaudid Fentanyl Morphine Sedatives: Ativan Propofol Valium Versed EXPERIENCE Cardiothoracic Cardiovascular Coronary Care Recovery Room / PACU Surgical Trauma Community Hospital Rural Hospital Teaching Hospital

4 Romazicon 1 2 3 4 Steroids (Decadron, Solumedrol) 1 2 3 4 Vasodilators (Nitroglycerin) 1 2 3 4 Pain Management: Demerol 1 2 3 4 Dilaudid 1 2 3 4 Fentanyl 1 2

8 Candidate Name: Page 8 of 8 Experience LEGEND KEY FOR AGE SPECIFIC CRITERIA [A] = Newborn (Birth to 30 days) [B] = Infant (30 days to 1 year) [C] = Toddler (1 to 3 years) [D] = Young Children (4 to 6 years) [E] = Older Children (7 to 12 years) [F] = Adolescents (13 to 20 years) [G] = Young Adults (21 to 39 years) [H] = Middle Adults (40 to 60 years) [I] = Older Adults (61+ years) AGE SPECIFIC CRITERIA Able to adapt care to incorporate normal growth and development Able to adapt method and terminology of patient instructions to their age comprehension and maturity level Can ensure a safe environment reflecting specific needs of various age groups A B C D E F G H I A B C D E F G H I A B C D E F G H I CERTIFICATIONS / COURSES / SKILLS ACLS BLS CCRN CNOR NRP PALS TNCC Arrhythmia Course Critical Care Course Computerized Charting IV Certification Medication Administration System Print Name Date Signature

CRITERIA Able to adapt care to incorporate normal growth and development Able to adapt method and terminology of patient instructions to their age comprehension and maturity level Can ensure a safe

PACU/Recovery Room Competency Self Assessment

PACU/Recovery Room Competency Self Assessment Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values