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 1 2 3 4 Retrobulbular 1 2 3 4 Spinal 1 2 3 4 Blood Glucose Monitoring 1 2 3 4 Conscious Sedation / Protocols & Procedures 1 2 3 4 Lift / Transfer Devices 1 2 3 4 LMA 1 2 3 4 Local 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 3 4 Restraints 1 2 3 4 Reversal Agents 1 2 3 4 Scalene 1 2 3 4 Seizure Precautions 1 2 3 4 CARDIOVASCULAR Abdominal Aortic Aneurysm Repair - Open 1 2 3 4 Aortofemoral Bypass Grafting 1 2 3 4 Assessment / Management of Fluid Balance 1 2 3 4 Assessment of Peripheral Pulses 1 2 3 4 Axillofemoral Bypass Grafting 1 2 3 4 Cardiac Arrest / CPR Adult 1 2 3 4 Cardiac Arrest / CPR Pediatric 1 2 3 4 Cardiac Valve Replacement (MVR, AVR) 1 2 3 4 Cardioversion / Defibrillation 1 2 3 4 Coronary Artery Bypass Graft (CABG) 1 2 3 4 Embolectomy / Thrombectomy 1 2 3 4 Endoluminal Stenting 1 2 3 4 External / Temporary Pacemaker 1 2 3 4 Interpretation of Arrhythmias 1 2 3 4
Candidate Name: Page 2 of 8 Experience CARDIOVASCULAR, con't. Interpretation of Lab Values 1 2 3 4 Percutaneous Transluminal Coronary Angioplasty (PTCA) 1 2 3 4 Performing 12 Lead EKG's 1 2 3 4 Permanent Pacemaker / AICD Insertion 1 2 3 4 Post Operative 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 Cava Filter 1 2 3 4 PULMONARY Adenotonsillectomy 1 2 3 4 Laryngeal Procedures 1 2 3 4 Laryngectomy 1 2 3 4 Radical Neck Dissection 1 2 3 4 Pleural Chest Tubes 1 2 3 4 Sinus Surgery 1 2 3 4 Tracheostomy 1 2 3 4 Airway Management: Assisting with Extubation 1 2 3 4 Assisting with Intubation 1 2 3 4 Endotracheal Tube 1 2 3 4 Laryngeal Mask Airway (LMA) 1 2 3 4 Mask 1 2 3 4 Measuring Tidal Volume 1 2 3 4 Nasal Cannula 1 2 3 4 Non-Rebreather / Partial Non-Rebreather Mask 1 2 3 4 Oral / NT Airway 1 2 3 4 Oral / NT Suctioning 1 2 3 4 Pulse Oximetry 1 2 3 4 SVO2 Monitoring 1 2 3 4 Use of Ambu Bag 1 2 3 4 Use of CO2 Monitoring Devices 1 2 3 4 Ventilator Management 1 2 3 4
Candidate Name: Page 3 of 8 Experience PULMONARY, con't. Arterial Blood Gas Interpretation / Analysis: Obtaining ABG Blood Sample (Art Line) 1 2 3 4 Brachial 1 2 3 4 Femoral 1 2 3 4 Radial 1 2 3 4 Thoracotomy for: Bronchoscopy 1 2 3 4 Bullectomy 1 2 3 4 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 Coiling 1 2 3 4 Burr Holes 1 2 3 4 Carotid Endarterectomy 1 2 3 4 Cervical Spine Precautions 1 2 3 4 Cranial Nerve Assessment 1 2 3 4 Craniotomy 1 2 3 4 Evacuation of Hematoma (Subdural, Epidural) 1 2 3 4 Glasgow Coma Scale 1 2 3 4 Intracranial / Cerebral Perfusion Pressure Monitoring (ICP / CPP) 1 2 3 4 Intracranial Tumor Excision 1 2 3 4 Laminectomy 1 2 3 4 Neurological Assessment 1 2 3 4 Spinal Fusion 1 2 3 4 Spinal Tumor Excision 1 2 3 4 Tether Cords 1 2 3 4 Ventricular Peritoneal Shunt 1 2 3 4 GASTROINTESTINAL Abdominal Trauma 1 2 3 4 Appendectomy 1 2 3 4 Biliary Atresia 1 2 3 4 Bowel / Colon Resection 1 2 3 4
Candidate Name: Page 4 of 8 Experience GASTROINTESTINAL, con't. Cholecystectomy 1 2 3 4 Colonoscopy 1 2 3 4 Colostomy / Ileostomy 1 2 3 4 EGD 1 2 3 4 ERCP 1 2 3 4 Esophageal Dilatation 1 2 3 4 Esophagectomy 1 2 3 4 Esophagogastrostomy 1 2 3 4 Exploratory 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 2 3 4 Irrigation Drains (Axiom) 1 2 3 4 Self Suction (Jackson-Pratt / Hemovac) 1 2 3 4 T Tube 1 2 3 4 Nasogastric Tube / G Tube / J Tube 1 2 3 4 Nissen Fundoplication 1 2 3 4 Pyloric Stenosis Repair 1 2 3 4 Pyloroplasty 1 2 3 4 Vagotomy 1 2 3 4 Whipple Procedure 1 2 3 4 RENAL / GENITOURINARY AortoRenal Bypass 1 2 3 4 AV Fistulas, Shunts & Dialysis Catheters 1 2 3 4 Bladder Irrigation 1 2 3 4 Cystectomy 1 2 3 4 Foley Catheter 1 2 3 4 Ileal Conduit 1 2 3 4 Nephrectomy 1 2 3 4 Nephrostomy Tube 1 2 3 4 Renal Transplant 1 2 3 4 Suprapubic Tube 1 2 3 4 Ureteral Stent Insertion 1 2 3 4
Candidate Name: Page 5 of 8 Experience ENDOCRINE Adrenalectomy 1 2 3 4 Parathyroidectomy 1 2 3 4 Thyroidectomy 1 2 3 4 Transsphenoidal Hypophysectomy 1 2 3 4 REPRODUCTIVE Dilation & Curettage (D&C) 1 2 3 4 Hysterectomy 1 2 3 4 Laparoscopic 1 2 3 4 Vaginal 1 2 3 4 Lumpectomy 1 2 3 4 Mastectomy / Mammoplasty 1 2 3 4 Oophorectomy 1 2 3 4 Penal Implant 1 2 3 4 Radical Prostatectomy 1 2 3 4 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 Traction 1 2 3 4 Open Reduction & Internal Fixation 1 2 3 4 Total Joint Replacement / Arthroplasty 1 2 3 4 EYE & EAR Acoustic Neuroma Removal 1 2 3 4 Blephoplasty 1 2 3 4 Cataract Extraction 1 2 3 4 Cochlear Implant 1 2 3 4 Keratoplasty (Corneal Transplant) 1 2 3 4 Laser Eye Surgery 1 2 3 4 Myringotomy 1 2 3 4 Retrobulbar Anesthesia / Blockade 1 2 3 4 Scleral Buckling (for Retinal Detachment) 1 2 3 4
Candidate Name: Page 6 of 8 Experience SKIN / WOUND MANAGEMENT Care of Patients Following Plastic Surgery 1 2 3 4 Cleft Lip / Palate Repair 1 2 3 4 Incision & Drainage 1 2 3 4 Skin Flaps 1 2 3 4 Skin Grafts 1 2 3 4 Wound Debridement 1 2 3 4 Wound Vac 1 2 3 4 PHLEBOTOMY / IV THERAPY Administration of Volume Expanders (Albumin, Dextran, etc) 1 2 3 4 Autotransfusion of Blood / Blood Products 1 2 3 4 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 Anaphylaxis 1 2 3 4 Antiarrhythmics (Amiodarone, Lidocaine, Procan) 1 2 3 4 Anticoagulation Therapy (Heparin, Coumadin) 1 2 3 4 Anticonvulsants (Dilantin, Phenobarbital) 1 2 3 4 Antiemetics: Droperidol (Inapsine) 1 2 3 4 Phenergan 1 2 3 4 Vistaril / Ephedrine IM 1 2 3 4 Zofran 1 2 3 4 Antihypertensives (Nipride) 1 2 3 4 Calcium Channel Blockers (Cardizem) 1 2 3 4 Care of Patients with Latex Allergies 1 2 3 4 Diuretics (Lasix, Edecrin Sodium, Bumex) 1 2 3 4 Emergency Meds (ACLS protocols) 1 2 3 4 Fibrinolytics 1 2 3 4 Glycoprotein IIb / IIIa Receptor Inhibitors (Integrilin, Aggrastat) 1 2 3 4 H2 Receptor Antagonists (Zantac, Pepcid, Carafate) 1 2 3 4
Candidate Name: Page 7 of 8 Experience USE AND ADMINISTRATION OF MEDICATION, con't. Inotropes / Vasoactive Drips 1 2 3 4 Insulin (SQ, IV, and IV Drip) 1 2 3 4 Narcan 1 2 3 4 Nebulizer Treatments (Ventolin, Atrovent, Racemic, Epinephrine) 1 2 3 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 3 4 Morphine 1 2 3 4 Sedatives: Ativan 1 2 3 4 Propofol 1 2 3 4 Valium 1 2 3 4 Versed 1 2 3 4 EXPERIENCE Cardiothoracic Cardiovascular Coronary Care Recovery Room / PACU Surgical Trauma Community Hospital Rural Hospital Teaching Hospital
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