Respiratory Therapy Self Assessment



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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 0 1 2 3 4 5 Adult critical care unit 0 1 2 3 4 5 Pediatric general floor care 0 1 2 3 4 5 Pediatrics ICU 0 1 2 3 4 5 Neonatal ICU Level II 0 1 2 3 4 5 Neonatal ICU Level III 0 1 2 3 4 5 Emergency department 0 1 2 3 4 5 Adult ED 0 1 2 3 4 5 Pediatric ED 0 1 2 3 4 5 Pulmonary function lab 0 1 2 3 4 5 Pulmonary rehabilitation 0 1 2 3 4 5 Sleep lab 0 1 2 3 4 5 Home care 0 1 2 3 4 5 Patient Transport Ambulance 0 1 2 3 4 5 Rotary wing 0 1 2 3 4 5 Fixed wing 0 1 2 3 4 5 Therapeutics & Procedures Pursed lip breathing 0 1 2 3 4 5 Diaphragmatic breathing 0 1 2 3 4 5 Oximetry 0 1 2 3 4 5 End-tidal CO2 monitoring 0 1 2 3 4 5 Oxygen administration 0 1 2 3 4 5 BiPAP nasal/mask 0 1 2 3 4 5 CPAP nasal/mask 0 1 2 3 4 5 Nitric oxide delivery 0 1 2 3 4 5 Incentive Spirometry (IS) 0 1 2 3 4 5 2012 Cross Country Healthcare, Inc. Rev. 03/13 F0071 Respiratory Therapy 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) Therapeutics & Procedures - cont. Metered dose inhaler 0 1 2 3 4 5 Sputum induction 0 1 2 3 4 5 Bronchial hygiene therapy 0 1 2 3 4 5 Intrapulmonary Percussive Ventilation (IPV) 0 1 2 3 4 5 Chest physical therapy/postural drainage 0 1 2 3 4 5 Flutter valve therapy 0 1 2 3 4 5 Acapella 0 1 2 3 4 5 Vest airway clearance 0 1 2 3 4 5 High flow system 0 1 2 3 4 5 Obtaining Arterial Blood Gases Radial/brachial artery 0 1 2 3 4 5 Femoral artery 0 1 2 3 4 5 Arterial line 0 1 2 3 4 5 ABG interpretation 0 1 2 3 4 5 ABG analyzer 0 1 2 3 4 5 Emergency Skills Intubate adult 0 1 2 3 4 5 Intubate infant 0 1 2 3 4 5 Assist with intubation 0 1 2 3 4 5 Extubate 0 1 2 3 4 5 Assist with extubation 0 1 2 3 4 5 Ventilate Patient with: Manual resuscitator 0 1 2 3 4 5 Manual inflating 0 1 2 3 4 5 Self inflating 0 1 2 3 4 5 Therapist driven protocols 0 1 2 3 4 5 Ventilators Ventilator set up 0 1 2 3 4 5 Troubleshoot ventilators 0 1 2 3 4 5 Ventilator set up/on tanks 0 1 2 3 4 5 Negative inspiratory force 0 1 2 3 4 5 Ventilator Modes: Volume controlled 0 1 2 3 4 5 Pressure 0 1 2 3 4 5 CPAP - Continuous Positive Airway Pressure 0 1 2 3 4 5 IMV - Intermittent Mandatory Ventilation 0 1 2 3 4 5 SIMV - Synchronized Intermittent Mandatory Ventilation 0 1 2 3 4 5 PEEP - Positive End Expiratory Pressure 0 1 2 3 4 5 2012 Cross Country Healthcare, Inc. Rev. 03/13 F0071 Respiratory Therapy 2 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) Therapeutics & Procedures - cont. PSV - Pressure Support Ventilation 0 1 2 3 4 5 PRVC - Pressure Regulated Volume Control 0 1 2 3 4 5 APRV - Airway Pressure Release Ventilation 0 1 2 3 4 5 Other PEEP studies determining optimal PEEP 0 1 2 3 4 5 EKG/ECG 0 1 2 3 4 5 Medications Advair (Fluticasone/Salmeterol) 0 1 2 3 4 5 Aerobid (Flunisolide) 0 1 2 3 4 5 Aerobid, vanceril 0 1 2 3 4 5 Amphocin (Amphotericin B) 0 1 2 3 4 5 Anectine 0 1 2 3 4 5 Artificial surfactant delivery 0 1 2 3 4 5 Survanta 0 1 2 3 4 5 Curosurf 0 1 2 3 4 5 Infosurf 0 1 2 3 4 5 Atropine sulfate 0 1 2 3 4 5 Atrovent (Ipratropium Bromide) 0 1 2 3 4 5 Colistin (Coly-mycin M) 0 1 2 3 4 5 Corticosteroids 0 1 2 3 4 5 Cremolyn sodium (Intal) 0 1 2 3 4 5 Decadron (Dexamethasone) 0 1 2 3 4 5 Digitalis 0 1 2 3 4 5 Digoxin 0 1 2 3 4 5 Dopamine 0 1 2 3 4 5 Duoneb (Albuterol/Ipratropium Bromide) 0 1 2 3 4 5 Flovent (Fluticasone) 0 1 2 3 4 5 Flonase 0 1 2 3 4 5 Foradil (Formoterol fumarate) 0 1 2 3 4 5 Inhaled Steroids 0 1 2 3 4 5 Isoetharine (Bronkosol) 0 1 2 3 4 5 Isoproterenol (Isuprel) 0 1 2 3 4 5 Lidocaine 0 1 2 3 4 5 Nipride 0 1 2 3 4 5 2012 Cross Country Healthcare, Inc. Rev. 03/13 F0071 Respiratory Therapy 3 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) Medications - cont. Maxair (Pirbuterol) 0 1 2 3 4 5 Metaproterenal (Alupent) 0 1 2 3 4 5 Mycomyst (Acetylcysteine) 0 1 2 3 4 5 Pavulon 0 1 2 3 4 5 Pulmicort (Budesonide) 0 1 2 3 4 5 Pulmozyme (Dornase Alfa) 0 1 2 3 4 5 Racemic epinephrine (Vaponephrine) 0 1 2 3 4 5 Ribaviran (Virazole) 0 1 2 3 4 5 Salbutamol (Albuterol, Proventil, Ventolin) 0 1 2 3 4 5 Terbutaline sulfate (Bricanyl) 0 1 2 3 4 5 Theo-dur 0 1 2 3 4 5 Tilade (Nedocromil sodium) 0 1 2 3 4 5 TOBI (Tobramycin) 0 1 2 3 4 5 Xopenex (levalbuterol) 0 1 2 3 4 5 Xylocaine (Lidocaine) 0 1 2 3 4 5 Knowledge & Care of Patients With: Asthma/status asthmatics 0 1 2 3 4 5 Acute/chronic bronchitis 0 1 2 3 4 5 Broncho-pulmonary dysplasia 0 1 2 3 4 5 Cardiac surgery 0 1 2 3 4 5 Epiglottitis 0 1 2 3 4 5 Tracheo-esophageal fistula 0 1 2 3 4 5 Hyaline Membrane Disease (HMD/IRDS) 0 1 2 3 4 5 Pulmonary Interstitial Emphysema (PIE) 0 1 2 3 4 5 Myasthenia gravis 0 1 2 3 4 5 Guillian barre 0 1 2 3 4 5 Thoracotomies 0 1 2 3 4 5 Fem-pop bypass 0 1 2 3 4 5 Pacer 0 1 2 3 4 5 Aspiration pneumonia 0 1 2 3 4 5 ARDS 0 1 2 3 4 5 Bacterial/viral pneumonia 0 1 2 3 4 5 Pneumothorax 0 1 2 3 4 5 Bronchiectasis 0 1 2 3 4 5 Bronchiolitis 0 1 2 3 4 5 2012 Cross Country Healthcare, Inc. Rev. 03/13 F0071 Respiratory Therapy 4 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) Knowledge & Care of Patients With: - cont. Congestive heart failure 0 1 2 3 4 5 Diabetic ketoacidosis 0 1 2 3 4 5 Near drowning 0 1 2 3 4 5 Emphysema 0 1 2 3 4 5 Empyema 0 1 2 3 4 5 Lung cancer 0 1 2 3 4 5 Myocardial infarction 0 1 2 3 4 5 Myasthenia gravis 0 1 2 3 4 5 Pleural effusion 0 1 2 3 4 5 Pulmonary edema 0 1 2 3 4 5 Pulmonary embolism 0 1 2 3 4 5 Tuberculosis 0 1 2 3 4 5 General Skills Patient/family teaching 0 1 2 3 4 5 Patients in restraint 0 1 2 3 4 5 Patients in isolation 0 1 2 3 4 5 Lift/transfer devices 0 1 2 3 4 5 Specialty beds 0 1 2 3 4 5 End of life care/palliative care 0 1 2 3 4 5 Computerized Charting Cerner 0 1 2 3 4 5 EPIC 0 1 2 3 4 5 McKesson 0 1 2 3 4 5 Meditech 0 1 2 3 4 5 National Patient Safety Goals Accurate patient identification 0 1 2 3 4 5 Effective communication 0 1 2 3 4 5 Pain assessment & management 0 1 2 3 4 5 Infection control 0 1 2 3 4 5 Universal precautions 0 1 2 3 4 5 Minimize risk of falls 0 1 2 3 4 5 Prevention of pressure ulcers 0 1 2 3 4 5 2012 Cross Country Healthcare, Inc. Rev. 03/13 F0071 Respiratory Therapy 5 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) Age Specific Competencies Infant (birth to 1 year) 0 1 2 3 4 5 Toddler (ages 2-3 years) 0 1 2 3 4 5 Preschooler (ages 4-5 years) 0 1 2 3 4 5 Childhood (ages 6-12 years) 0 1 2 3 4 5 Adolescents (ages 13-21 years) 0 1 2 3 4 5 Young Adults (ages 22-39 years) 0 1 2 3 4 5 Adults (ages 40-64 years) 0 1 2 3 4 5 Older Adults (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: 1. 2. 3. 4. Additional training: 1. 2. 3. 4. Additional equipment: 1. 2. 3. 4. Fax to: 1-888-298-3146 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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