24 Hour Staffing Solutions
24 Hour
Solutions Inc.
Nursing Agency
415-648-6091
Last Name: ____________________ First Name:
_______________ Middle Initial: _____
Classification: __________________ Total Years of Experience: ___________
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Clinical Skill Competency: |
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Indicate clinical skill competency and level of proficiency for all procedures/equipment in the last 12 months. |
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SKILL LEVELS: |
0 = No experience. Theory only. |
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1 = Limited competence/proficiency. Supervision required. |
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2 = Acceptable competence/proficiency. |
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3 =
Competent/proficient. Have performed frequently |
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AGE SPECIFIC COMPETENCY: |
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Neonates/Newborns (birth - 30 days) |
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Adolescents (12 - 18 years) |
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Infants (30 days - 1 year) |
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Toddler (1 - 3 years) |
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Preschooler (3 - 5 years) |
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Older Children (5 - 12 years) |
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Young Adults (18 - 39 years) |
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Middle Adults (39 - 64 years) |
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Older Adults/Geriatrics (64+ years) |
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EXPERIENCE: |
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Neuro (NEURO) |
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Cardiovascular (CARDIO) |
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Telemetry (TELE) |
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Respiratory (RESP) |
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GastroIntestinal (GI) |
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Renal (GU) |
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Substance Abuse |
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Orthopedic (ORTHO) |
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Burns |
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Abuse/Violence |
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CHARTING: |
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Computer |
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DARE |
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APIE |
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SOAPIE |
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FOCUS |
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Discharge Planning |
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Utilization Review |
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Chart Review/Audit |
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NEUROLOGICAL PROBLEMS: |
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Perform advanced neuro assessment: |
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Cranial nerves |
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Reflexes |
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Visual or communication deficits |
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Intracranial pressure monitoring and care of patient: |
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Positioning |
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Temperature regulation |
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Medications |
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Recognition/intervention of complications: |
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CSF leak |
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Clot |
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Herniation |
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Use of rotating bed, Stryker frame |
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Care of patient with halo traction/ |
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Care of patient with barbiturate- |
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CARDIOVASCULAR PROBLEMS: |
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Obtaining 12 lead EKG |
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Arrhythmia interpretation |
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Arrest - initial resuscitation |
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CPR and emergency drug therapy |
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Defibrillation/cardioversion |
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Titration of vasoactive drugs |
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Assist with the insertion/care of: |
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Arterial line, SG cath |
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Care of patient with pacemakers: |
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Assist with insertion |
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Permanent and/or temporary |
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Care of patient withe acute myocardial |
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TPA administration |
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Prepare for PTCA |
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Management of cardiogenic shock |
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Care of patient with intra aortic |
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Care of patient with CAVH-D |
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Care of patient on ventricular assist |
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(RVAD or LVAD) |
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Titrating cardiovascular drugs: |
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DOPAMINE |
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DOBUTREX |
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ISUPREL |
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EPINEPHRINE |
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LEVOPED |
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NIPRIDE |
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TRIDIL |
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LIDOCAINE |
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DIGITALIS |
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Streptokinase |
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PTCA |
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Care of an open heart patient: |
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Immediate post-op |
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24-48 hour post-op |
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Care of heart transplant patient |
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Assist with open chest procedure |
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Care of patient with MAST suit/rotating |
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Care of patient with abdominal aortic |
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Computation of cardiac outputs |
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Interpretation of Swan Ganz reading: |
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P.A. pressure |
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PCWP |
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Care of patient in shock: |
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Septic |
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Hypovolemic |
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Cardiogenic |
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RESPIRATORY PROBLEMS: |
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Identify/Intervene in respiratory complications: |
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Pneumothorax |
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Aspiration |
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Pulmonary edema |
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Laryngospasm |
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Assisting with intubation/extubation |
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Obtaining arterial blood gases from |
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Arterial blood gases interpretation |
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Arterial puncture for ABG's |
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Care of intubated patient: |
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Suctioning |
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Aspiration |
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ETT care |
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Cuff pressures |
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Use of volume ventilators |
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Use of pressure ventilators |
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Troubleshoot ventilator complications: |
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High pressure alarm |
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Low exhale volume |
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Weaning patient from ventilator |
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Modes of ventilation: |
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IMV |
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CPAP |
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PEEP |
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Assist-control |
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Blowby |
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Pressure support |
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High frequency jet ventilation |
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Care of patient after thoracic surgery |
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Assist with chest tube |
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Assist with thoracentesis |
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Assist with bronchoscopy |
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Care of patient with tracheostomy |
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Care of patient in pulmonary edema |
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Care of patient with ECMO |
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Care of patient with ARDS |
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Care of patient with lung transplant |
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Use of chest drainage system |
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GASTROINTESTINAL PROCEDURE |
GASTROINTESTINAL PROBLEMS: |
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Sengstaken-Blakemore tubes |
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Miller/Abbott tubes |
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Multiple abdominal surgeries |
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Care of patient with multiple |
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CVVHD |
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RENAL PROBLEMS: |
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Care of patient in acute renal failure |
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Care of patient on hemodialysis |
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Care of patient with ileal/conduit |
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Perform Peritoneal dialysis |
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SUBSTANCE ABUSE: |
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Care of EWAL tube |
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Closed system lavage |
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Administration of activated |
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ORTHOPEDIC: |
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Casts |
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Splints |
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Immobilizing joints/extremities |
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First aid |
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Bier block or IV Xylocaine uses |
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Insertion of pins/external fixation |
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Application of: |
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Clavical strap |
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Shoulder immobilizer |
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Knee immobilizer |
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Ace wrap to joints |
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MISCELLANEOUS: |
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Administration of total parenteral nutrition |
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Care of patient on universal |
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Hypothermia management |
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Reverse isolation |
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Care of burn patients: |
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1st degree |
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2nd degree |
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3rd degree |
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EXPERIENCE WITH SPECIAL EQUIPMENT: |
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EKG machines |
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02 Equipment: |
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Ventilators |
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H cylinders |
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E cylinders |
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Compressed air |
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Nebulizer set-up |
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T-tube |
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Ventimask |
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Nasal Cannula |
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BIPAP |
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Continuous aerosol |
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Nonrebreather |
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Ambu Bag |
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Oximizer |
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EXPERIENCE SETTING UP TRAYS: |
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Suture set |
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Cut down |
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C.V.P./A Line |
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Chest tube |
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Peritioneal Lavage |
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Pelvic exam |
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Trach tray |
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Procto/endo/bronchotray |
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EXPERIENCE WITH SPECIAL PROCEDURES: |
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Chest Tubes: |
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Emerson |
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Pleur-Evac |
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Laryngoscope |
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Endo tubes |
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Ambu bags |
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Tracheotomy |
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Pacemakers: |
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Trans-thoracic |
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Percutaneous |
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Rotating tourniquets |
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Hickman-Broviac catheters |
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Cardioversion/defibrillation |
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Cardiac Monitoring/Drugs |
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I am certifying that the information provided in this Clinical
Skills Checklist is true, correct and complete. I understand that any
misrepresentation, omission or falsification on this application is sufficient
cause for termination of employment.
PRINT NAME: _______________________ SIGNATURE: _____________________ DATE: _______