Respiratory Therapy Self Assessment
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1 Respiratory Therapy 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 confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional. 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Print Name Last 4 Digits of SS# Date Work Settings Medical-surgical general floor care Adult critical care unit Pediatric general floor care Pediatrics ICU Neonatal ICU Level II Neonatal ICU Level III Emergency department Adult ED Pediatric ED Pulmonary function lab Pulmonary rehabilitation Sleep lab Home care Patient Transport Ambulance Rotary wing Fixed wing Therapeutics & Procedures Pursed lip breathing Diaphragmatic breathing Oximetry End-tidal CO2 monitoring Oxygen administration BiPAP nasal/mask CPAP nasal/mask Nitric oxide delivery Incentive Spirometry (IS) Cross Country Healthcare, Inc. Rev. 03/13 F0071 Respiratory Therapy 1 of 6
2 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Therapeutics & Procedures - cont. Metered dose inhaler Sputum induction Bronchial hygiene therapy Intrapulmonary Percussive Ventilation (IPV) Chest physical therapy/postural drainage Flutter valve therapy Acapella Vest airway clearance High flow system Obtaining Arterial Blood Gases Radial/brachial artery Femoral artery Arterial line ABG interpretation ABG analyzer Emergency Skills Intubate adult Intubate infant Assist with intubation Extubate Assist with extubation Ventilate Patient with: Manual resuscitator Manual inflating Self inflating Therapist driven protocols Ventilators Ventilator set up Troubleshoot ventilators Ventilator set up/on tanks Negative inspiratory force Ventilator Modes: Volume controlled Pressure CPAP - Continuous Positive Airway Pressure IMV - Intermittent Mandatory Ventilation SIMV - Synchronized Intermittent Mandatory Ventilation PEEP - Positive End Expiratory Pressure Cross Country Healthcare, Inc. Rev. 03/13 F0071 Respiratory Therapy 2 of 6
3 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Therapeutics & Procedures - cont. PSV - Pressure Support Ventilation PRVC - Pressure Regulated Volume Control APRV - Airway Pressure Release Ventilation Other PEEP studies determining optimal PEEP EKG/ECG Medications Advair (Fluticasone/Salmeterol) Aerobid (Flunisolide) Aerobid, vanceril Amphocin (Amphotericin B) Anectine Artificial surfactant delivery Survanta Curosurf Infosurf Atropine sulfate Atrovent (Ipratropium Bromide) Colistin (Coly-mycin M) Corticosteroids Cremolyn sodium (Intal) Decadron (Dexamethasone) Digitalis Digoxin Dopamine Duoneb (Albuterol/Ipratropium Bromide) Flovent (Fluticasone) Flonase Foradil (Formoterol fumarate) Inhaled Steroids Isoetharine (Bronkosol) Isoproterenol (Isuprel) Lidocaine Nipride Cross Country Healthcare, Inc. Rev. 03/13 F0071 Respiratory Therapy 3 of 6
4 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Medications - cont. Maxair (Pirbuterol) Metaproterenal (Alupent) Mycomyst (Acetylcysteine) Pavulon Pulmicort (Budesonide) Pulmozyme (Dornase Alfa) Racemic epinephrine (Vaponephrine) Ribaviran (Virazole) Salbutamol (Albuterol, Proventil, Ventolin) Terbutaline sulfate (Bricanyl) Theo-dur Tilade (Nedocromil sodium) TOBI (Tobramycin) Xopenex (levalbuterol) Xylocaine (Lidocaine) Knowledge & Care of Patients With: Asthma/status asthmatics Acute/chronic bronchitis Broncho-pulmonary dysplasia Cardiac surgery Epiglottitis Tracheo-esophageal fistula Hyaline Membrane Disease (HMD/IRDS) Pulmonary Interstitial Emphysema (PIE) Myasthenia gravis Guillian barre Thoracotomies Fem-pop bypass Pacer Aspiration pneumonia ARDS Bacterial/viral pneumonia Pneumothorax Bronchiectasis Bronchiolitis Cross Country Healthcare, Inc. Rev. 03/13 F0071 Respiratory Therapy 4 of 6
5 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Knowledge & Care of Patients With: - cont. Congestive heart failure Diabetic ketoacidosis Near drowning Emphysema Empyema Lung cancer Myocardial infarction Myasthenia gravis Pleural effusion Pulmonary edema Pulmonary embolism Tuberculosis General Skills Patient/family teaching Patients in restraint Patients in isolation Lift/transfer devices Specialty beds End of life care/palliative care Computerized Charting Cerner EPIC McKesson Meditech National Patient Safety Goals Accurate patient identification Effective communication Pain assessment & management Infection control Universal precautions Minimize risk of falls Prevention of pressure ulcers Cross Country Healthcare, Inc. Rev. 03/13 F0071 Respiratory Therapy 5 of 6
6 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Age Specific Competencies Infant (birth to 1 year) Toddler (ages 2-3 years) Preschooler (ages 4-5 years) Childhood (ages 6-12 years) Adolescents (ages years) Young Adults (ages years) Adults (ages years) Older Adults (ages years) Elderly (ages 80+ years) Please list any Additional Skills: Additional training: Additional equipment: Fax to: The information on this and all preceding pages is true and correct. Signature Date 2012 Cross Country Healthcare, Inc. Rev. 03/13 F0071 Respiratory Therapy 6 of 6
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