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Skills Checklist Med Surg by 9X1VW9K


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Please write the number that reflects your proficiency in each skill or patient care situation.
    Levels of Proficiency:
    0 = Unfamiliar with                                                    3 = Some experience; need minimal review
    1 = Theory; no practice                                                4 = Frequent experience; performs well
    2 = Familiar with; need review

AGE SPECIFIC COMPETENCY/                        CARE OF PATIENT WITH:                             CARE OF THE PATIENT WITH:
KNOWLEDGE                                             Asthma                                          Aortic Dissection
   Adolescent (13-18 years)                           Tuberculosis (TB)                               Femoral-Popliteal Bypass Graft
   Young Adult (19-39 years)                          Pleural Effusion                                Deep Vein Thrombophlebitis (DVT)
   Middle Adult (40-64 years)                         Pneumonia                                       Lower Extremity Arterial Disease
   Older Adult (65 plus)                              Pneumothorax                                     (LEAD)
                                                      Pulmonary Edema                                 Venous Stasis Ulcers
PULMONARY SYSTEM                                      Acute/Chronic COPD (Chronic
   Assessment                                           Obstructive Pulmonary Disease)            HEMODYNAMIC MONITORING
   Oxygen Saturation Monitoring/                      Acute Respiratory Failure                      Central Venous Catheter Care
     Interpretation (Pulse Ox)                        Pulmonary Embolus                              Central Venous Pressure
   Interpret Arterial Blood Gases                     Thoracic Surgery                               (Obtain and Interpret Values)
     (ABG’s)                                          Laryngectomy
    Interpret Respiratory Lab Values                                                              HEMATOLOGIC SYSTEM
                                                CARDIOVASCULAR SYSTEM                                Interpret Hematology Lab Work
MODES OF OXYGEN DELIVERY                           Assessment                                        Assist with Bone Marrow Biopsy
  Mask/Cannula                                     Use of Telemetry Monitor
  Ambu Bag (Manual Self Inflating                  Recognize Arrhythmias                          CARE OF PATIENT WITH:
    Resuscitation Bag)                             Obtain 12 Lead EKG                                 Thrombocytopenia
  T-Tube                                           Interpret Cardiac Lab Values                       Neutropenia
  Endotracheal Tube                                Use of Doppler                                     Anemia
  Tracheostomy Mask                                Peripheral Vascular Limb                           Blood & Blood Component Admin.
  Nasal Pharyngeal Airway (Trumpet)                  Assessment                                       Transfusion Reaction Management
  Oral Airway                                      Measuring Ankle/Brachial Index                     Anticoagulation Therapy
  Aerosol Mask
    100% Rebreather                             CARE OF THE PATIENT WITH:                         NEUROLOGIC SYSTEM
    Bi-PAP                                            Acute Myocardial Infarction                    Assessment
    CPAP                                              Cardiopulmonary Arrest                         Glasgow Coma Scale
    Nebulizer Set Up                                  Angina                                         Assist with Lumbar Puncture
    Assist with Thoracentesis                         Arteriosclerosis
    Assist with Chest Tube Insertion/                 Carotid Endarterectomy                      CARE OF PATIENT WITH:
      Removal                                         Pre & Post Cardiac Catheterization              Transient Ischemic Attack (TIA)
    Chest Tube Care                                   Pre & Post Angioplasty                          Cerebrovascular Accident (CVA)
    Closed Chest Drainage System                      Heart Failure (Congestive Heart                 Cerebral Aneurysm
    Chest Physiotherapy                               Failure)                                        Seizures/Seizure Activity
    Manual Pronation Therapy                          Hypertensive Crisis                             Spinal Cord Injury
    Tracheostomy Care                                 Endocarditis                                    Head Injury
    Incentive Spirometry                              Automatic Implanted Cardiac                     Pre & Post Craniotomy
    Oropharyngeal Suctioning                            Defibrillator (AICD)                          Ventriculoperitoneal Shunt
    Nasopharyngeal Suctioning                         Permanent Pacemaker                               (V-P Shunt)
    Endotracheal Suctioning                           Transcutaneous Pacemaker                        Post Op Laminectomy
    Yankauer Suctioning                               Post Operative Aortic Aneurysm                  Post-Op Anterior/Posterior Fusion

         Please check box to attest that all above information is true and correct.

         Signature:                                                                                 Date:
                                                                                                                       Page 2 of 3
CARE OF PATIENT WITH: (cont.)                 GASTROINTESTINAL SYSTEM (cont.)          ORTHOPEDICS (cont)
   Post-Op Disectomy/Fusion                      N/G Lavage                              Skeletal
   Central Nervous System Infections             Maintenance & Care of N/G Tube          External Fixation Device (EFD)
   Guillain-Barre Syndrome                       Percutaneous Endoscopic Gastrostomy     Ice Therapy (Cryocuff)
   Degenerative Neuromuscular                    Tube (PEG) Care                         Use of Assistive Devices
     Diseases (Multiple Sclerosis &              Insertion of Small-Bore Nasoenteric     Rehab of Orthopedic Patients
     Parkinson’s)                                  Feeding Tube
   Rehabilitation of Neuro Patients              Gastrostomy/Jejunostomy Tube Care     CARE OF PATIENT WITH:
   Hypo/Hyperthermia Blankets                    Tube Feedings                           Total Knee Arthroplasty
   Halo Traction                                                                         Total Hip Arthroplasty
   Cervical Tongs                                                                        Total Joint Replacement
                                              CARE OF PATIENT WITH:                      Open Reduction-Internal
RENAL SYSTEM                                       GI Bleed                              Fixation (ORIF)
  Assessment                                       Esophageal Varices                    Rotator Cuff Repair
  Insertion of Urinary Catheter-female             Acute Pancreatitis                    Amputation
  Insertion of Urinary Catheter-male               Liver Disease                         Trauma
  Bladder Irrigation (CBI)                         Hepatitis                             Rheumatic/Arthritic Disease
  Bladder Scan                                     Cirrhosis                             Osteomyelitis
                                                   Liver Failure
CARE OF PATIENT WITH:                              Ascites                             IV THERAPY
   Renal Failure (Acute/Chronic)                   Inflammatory Bowel Disease (IBD)       Phlebotomy
   Pre & Post Op Nephrectomy                       Abdominal Wounds                       Obtaining Blood Cultures
   Hemodialysis                                    Abdominal Surgery                      Insertion of Peripheral IV Line
   Peritoneal Dialysis                             Acute Intestinal Obstruction           IV Site Care
   Arteriovenous Fistulas                          Abdominal Infections                   Calculating IV Drip Rate
   Renal Calculi                                   Jejunostomy/Gastrostomy                Discontinuance of IV Therapy
   Nephrostomy Tube                                Fistulas                               Multiple Lumen/Triple Lumen
   Renal Surgery                                   Ostomy Care                              Catheter Line Care & Dressing
   Nephrectomy                                                                            PICC Line Insertion
   Cystectomy                                 ONCOLOGY/IMMUNOLOGIC                        PICC Care
   Urinary Diversion                          DISORDERS                                   Admin. of Hyperalimentation
   Radical Prostatectomy                         Administration of Chemotherapy           Total Parenteral Nutrition (TPN)
   Transurethral Prostatectomy (TURP)                                                     Access/Care of Implanted Vascular
   Suprapubic Catheter                        CARE OF PATIENT WITH:                         Access (Portacath/Infusaport)
   Fluid & Electrolyte Imbalances                  Immunocompromise                       Use of Infusion Pumps
   Acid/Base Abnormalities                         HIV
ENDOCRINE SYSTEM                                   Bone Marrow Transplant              INTEGUMENTARY
  Diabetic Glucose Monitoring                      Receiving Chemotherapy                Assessment
  Insulin Administration                           Receiving Radiation Therapy           Assessment of Wound Healing
                                                   Lupus                                 Pressure Ulcer Risk Assessment
CARE OF PATIENT WITH:                                                                      (Braden Scale)
   Diabetes Type 1 & Type 2                   ORTHOPEDICS                                Pressure Ulcer Prevention
   Thyroid Disease                               Neurovascular Assessment                Use of Specialty Beds
   Diabetes Insipidus                            Cast Care                               Diabetic Ulcers
   Syndrome of Insufficient Anti-                Pin Care                                Wound Irrigation
     diuretic Hormone (SIADH)                    Continuous Passive Motion Machine       Dressing Wounds with Drains
   Hypoglycemic Hyperosmolar                     (CPM)                                   Dressing & Pouching Wounds
     Nonketotic Coma (HHNK)                      TENS Unit                               Partial Thickness Burn
   Diabetic Ketoacidosis (DKA)                                                           Full Thickness Burn
                                              Traction:                                  Care of Skin Graft
GASTROINTESTINAL SYSTEM                               Bucks                              Care of Donor Sites
  Assess GI System                                    Cervical                           Knowledge of Surgical Drains
  Interpretation of Liver Enzymes                     Pelvic                             Hemovac
  Insertion of Nasogastric (N/G) Tube                                                    Autotransfusion Systems

       Please check box to attest that all above information is true and correct.
                                                                                                                                  Page 3 of 3
PAIN MANAGEMENT                                  MEDICATION PREPARATION,                             OTHER SKILLS / CARE
   With Epidural Catheters                       CALCULATION & ADMINISTRATION                        EXPERIENCE (list):
   Patient Controlled Analgesia                  (cont.)
     (PCA)                                            IV Piggybacks
                                                      IV Push Medication
SHOCK STATES                                          Auto Syringe Pump
   Anaphylactic                                       Unit Dose System
   Neurogenic                                         Automated Medication Delivery
   Septic                                               (Pyxis)
   Cardiogenic                                   KNOWLEDGE OF ACTION /
                                                 INTERACTIONS & SIDE EFFECTS
ISOLATION PATIENTS                               OF:
   Body Substance Isolation                          Cardizem
   Reverse/Protective Isolations                     Dopamine
   Universal Precautions                             Heparin
   Tuberculosis Isolation                            Insulin Drips
CARE OF PATIENT WITH:                                Dilantin
    Drug Overdose                                    Dopamine (Renal Dose)
    Delirium Tremens (DT’s)                          Dobutamine (Renal Dose)
    Victim of Sexual Abuse                           Nitroglycerin Drips (Non-Tritrated)
    Victim of Domestic Abuse
    Victim of Child Abuse                        MISCELLANEOUS
                                                    Normal Serum Lab Values
MEDICATION PREPARATION,                               Organ Donation
CALCULATION & ADMINISTRATION                          Advance Directives
   Calculate mcg/min                                  Withholding/Withdrawing
   Calculate mcg/kilo/min                             Treatment
   Calculate mcg/kilo/hour
   Calculate mg/min
   Calculate mg/kilo/min
   Calculate units/min
   Calculate units/hour
   Calculate units/ml

          I certify that all of the above information is correct and that any misrepresentation or falsification of fact may be
          considered sufficient cause for immediate dismissal from _______________. I have filled out this skills checklist
          to the best of my knowledge and agree that all of the information provided is correct (please check box).

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