PACU/Recovery Room Competency Self Assessment

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Sophie Oliver
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1 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 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 General Skills Advanced directives Awareness of HCAHPS Patient/family teaching Lift/transfer devices Specialty beds Restrictive devices (restraints) End of life care/palliative care Wound assessment & care Automated Medication Dispensing System, Pyxis, Omnicell, or other Bar coding for medication administration Diabetic care & education Blood Glucose Monitoring (BGM) Insulin administration National Patient Safety Goals Accurate patient identification Effective communication Interpretation & communication of lab values Medication administration Labeling (medications & specimens) Medication reconciliation Anticoagulation therapy Pain assessment & management Monitoring conscious sedation Infection control Universal precautions Isolation Minimize risk for falls Prevention of pressure ulcers Universal protocol (site/side verification) Normothermia Beta blocker (preop) Cross Country Healthcare, Inc. Rev. 09/13 F0045 PACU / RR 1 of 6

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 General Skills

2 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Anesthesia: General Knowledge Moderate sedation/protocols & procedures Local anesthetics Regional blocks (intrathecal/epidural/spinal) General anesthesia (IV anesthetic agents/inhalation anesthesia agents) Administer & monitor paralytic agents Administer & monitor reversal agents Assessment of dermatomes Neuromuscular blocking agents (depolarizing, non-depolarizing, reversal agents) Benzodiazepines/reversal Opioids/reversal Pulmonary Assessment of breath sounds/rate/effort Airway Management, Care & Maintenance Head positioning to ensure airway patency Oral/NT airway Laryngeal Mask Airway (LMA) Endotracheal tube Tracheostomy Use of ambu bag O2 therapy (NC/mask) Use of CO2 monitoring devices SVO2 monitoring Oral/NT suctioning Assisting with intubation Assisting with extubation Measuring tidal volume Arterial blood gas interpretation/analysis Obtaining ABG blood sample (art line, arterial puncture) Pulse oximetry Mechanical ventilation Pleural chest tubes Postoperative Care (Respiratory) Tracheostomy Laryngeal procedures/laryngectomy Lung transplant Video-assisted thoracoscopic surgery (VATS) Radical neck dissection Penetrating/open chest trauma Cross Country Healthcare, Inc. Rev. 09/13 F0045 PACU / RR 2 of 6

Administer & monitor paralytic agents 0 1 2 3 4 5 Administer & monitor reversal agents 0 1 2 3 4 5 Assessment of dermatomes 0 1 2 3 4 5 Neuromuscular blocking agents (depolarizing, non-depolarizing,

3 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Pulmonary - cont. Sinus surgery Adenotonsillectomy (T&A) Thoracotomy/lobectomy/pneumonectomy Cardiovascular Cardiovascular assessment Interpretation of arrhythmias Performing 12 lead EKG's Care of patient with VAD (ventricular assist device) Set Up & Interpretation of: Hemodynamic monitoring (CVC/aline/PA catheter) External/temporary pacemaker Cardiac arrest/cpr Cardioversion/defibrillation Postoperative Care (Cardiovascular) Permanent pacemaker/aicd insertion Vascular bypass/grafting Embolectomy/thrombectomy Abdominal aortic aneurysm (AAA) repair Thoracic aortic aneurysm repair Endoluminal stenting Vena cava filter Postoperative myocardial infarction Neurology Baseline neurological assessment Glasgow coma scale Cranial nerve assessment Seizure precautions Cervical spine precautions Postoperative Care (Neuro Surgery) Craniotomy Burr holes Aneurysm clipping/coiling Evacuation of hematoma (subdural, epidural) Carotid endarterectomy Intracranial tumor excision Spinal tumor excision Cross Country Healthcare, Inc. Rev. 09/13 F0045 PACU / RR 3 of 6

3 4 5 Performing 12 lead EKG's 0 1 2 3 4 5 Care of patient with VAD (ventricular assist device) 0 1 2 3 4 5 Set Up & Interpretation of: Hemodynamic monitoring (CVC/aline/PA catheter) 0 1 2 3 4 5

4 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Neurology - cont. Laminectomy Spinal fusion Ventricular peritoneal shunt Tether Cords Set Up & Care of Intracranial/Cerebral Perfusion Pressure Monitoring (ICP/CPP) via: Ventriculostomy Subarachnoid screw/bolt Gastrointestinal Care of Patient with: Gastric tubes (NG/G) Jejunostomy tube Assessment & management of wound drains (self-suction/irrigation/drainage) Endoscopic procedures Postoperative Care (GI) Laparoscopic Exploratory laparotomy Nissen fundoplication Esophageal procedures Abdominal trauma Gastroplasty/bypass (bariatric surgery) Gastrectomy (partial/complete) Whipple procedure Pyloroplasty Vagotomy Appendectomy Bowel/colon resection Colostomy/ileostomy Hernia repair Endocrine Transphenoidal hypophysectomy Adrenalectomy Thyroidectomy Parathyroidectomy Cross Country Healthcare, Inc. Rev. 09/13 F0045 PACU / RR 4 of 6

Ventriculostomy 0 1 2 3 4 5 Subarachnoid screw/bolt 0 1 2 3 4 5 Gastrointestinal Care of Patient with: Gastric tubes (NG/G) 0 1 2 3 4 5 Jejunostomy tube 0 1 2 3 4 5 Assessment & management of wound

5 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Intravenous Management Starting peripheral IV's Care of patient with peripherally-inserted central catheter (PICC) Groshong/Hickman Administration of blood/blood products Autotransfusion of blood/blood products Administration of volume expanders (albumin, dextran, etc) Miscellaneous Aldrette scoring with level 1 trauma patients Management of patient with malignant hyperthermia Anaphylaxis Care of patients with latex allergies Phlebotomy: peripheral Drawing blood from invasive lines Pharmacology - Use & Administration of: H2 receptor antagonists: (Zantac, Pepcid, Carafate) Antiemetics (Zofran, Phenergan, Reglan) Steroids: (decadron, Solu-Medrol) Emergency meds (ACLS protocols) Anticonvulsants: (Dilantin, phenobarbital) Inotropes/vasoactive drips Calcium channel blockers: (Cardizem) Antihypertensives: (nipride) Antiarrhythimics: (amiodarone, lidocaine, procan) Diuretics: (Lasix, edecrin sodium, Bumex) Fibrinolytics Glycoprotein IIb/IIIa receptor inhibitors: (Integrilin, Aggrastat) Nebulizer treatments: (Ventolin, Atrovent, racemic, ephinephrine) Other Procedures Post orthopedic/musculoskeletal procedures Post ENT procedures Post breast procedures (mastectomy/lumpectomy) Post GYN procedures Post prostate procedures Post wound care (I&D/debridement) Cross Country Healthcare, Inc. Rev. 09/13 F0045 PACU / RR 5 of 6

5 Administration of volume expanders (albumin, dextran, etc) 0 1 2 3 4 5 Miscellaneous Aldrette scoring 0 1 2 3 4 5 with level 1 trauma patients 0 1 2 3 4 5 Management of patient with malignant

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 Newborn/neonate (birth-30 days) Infant (31 days-1 year) Toddler (2-3 years) Preschool (ages 4-5 years) School age (ages 6-12 years) Adolescents (ages years) Young adult (ages years) Adults (ages years) Older adult (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. 09/13 F0045 PACU / RR 6 of 6

4 5 Young adult (ages 22-39 years) 0 1 2 3 4 5 Adults (ages 40-64 years) 0 1 2 3 4 5 Older adult (ages 65-79 years) 0 1 2 3 4 5 Elderly (ages 80+ years) 0 1 2 3 4 5 Please list any Additional Skills:

Candidate Name: Page 1 of 8

Candidate Name: Page 1 of 8 Experience GENERAL SKILLS Aldrette Scoring 1 2 3 4 Ambulatory / Outpatient Surgery 1 2 3 4 Assessment of Dermatomes: Brachial 1 2 3 4 Epidural 1 2 3 4 Femoral 1 2 3 4 Intrathecal