ICU Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyCardiacDefibrillation/Cardioversion 1 2 3 4 Assisting with Insertion of Central Lines 1 2 3 4 Pacemakers‐External 1 2 3 4 Permanent or Temporary Pacemaker 1 2 3 4 Cardiac Arrest/CPR 1 2 3 4 A‐Line (Transducer setup‐D/C) 1 2 3 4 Swan Ganz (Transducer setup‐D/C) 1 2 3 4 Balloon Pump (IABP) 1 2 3 4 SVO2 Monitoring 1 2 3 4 Automatic Internal Cardioverter Defib 1 2 3 4 Care of Patient WithAneurysm 1 2 3 4 Acute MI/Unstable Angina 1 2 3 4 Cardiogenic/Hypovolemic Shock 1 2 3 4 Pre/Post Cardiac Surgery 1 2 3 4 Heart Transplant 1 2 3 4 PTCA 1 2 3 4 COPD 1 2 3 4 ARDS 1 2 3 4 Pulmonary Embolism 1 2 3 4 Pulmonary Edema 1 2 3 4 Pneumonia 1 2 3 4 Inhalation Injuries 1 2 3 4 CVA 1 2 3 4 Seizure Disorder 1 2 3 4 Overdose 1 2 3 4 Neuro Injury/Trauma 1 2 3 4 Pre/Post Neuro Surgery 1 2 3 4 Cranial Hemorrhage 1 2 3 4 Aphasia 1 2 3 4 Multiple Sclerosis 1 2 3 4 Pancreatitis 1 2 3 4 GI Bleed 1 2 3 4 Esophageal Bleeding 1 2 3 4 Bowel Obstruction 1 2 3 4 Liver Transplant 1 2 3 4 Paralitic Ileus 1 2 3 4 TURP 1 2 3 4 Shunts and Fistulas 1 2 3 4 Nephrectomy 1 2 3 4 Renal Transplant 1 2 3 4 Renal Trauma 1 2 3 4 Use and Administration of the FollowingAtropine 1 2 3 4 Bretylol 1 2 3 4 Bumex 1 2 3 4 Digoxin 1 2 3 4 Dopamine 1 2 3 4 Dobutrex 1 2 3 4 Inderal 1 2 3 4 Inocor 1 2 3 4 Isuprel 1 2 3 4 Lidocaine 1 2 3 4 Neosynephrine/Nipride 1 2 3 4 NTG 1 2 3 4 Pronestyl 1 2 3 4 Titrate Morphine 1 2 3 4 Verapamil 1 2 3 4 Thrombolitic Agents 1 2 3 4 Prep/Titration of Emergency Drugs 1 2 3 4 Aminophylline 1 2 3 4 Corticosteroids 1 2 3 4 Bronkosol 1 2 3 4 Ventolin 1 2 3 4 Alupent 1 2 3 4 Decadron 1 2 3 4 Dilantin 1 2 3 4 Magnesium Sulfate 1 2 3 4 Phenobarbital 1 2 3 4 Steroids 1 2 3 4 Valium 1 2 3 4 Versed 1 2 3 4 RespiratoryLung Transplant 1 2 3 4 Establishing an Airway 1 2 3 4 Pulse Oximetry 1 2 3 4 Interpretation of ABG 1 2 3 4 Drawing ABG Blood Sample from A‐Line 1 2 3 4 Incentive Spirometer 1 2 3 4 NeurologyAssessment of Neuro Signs 1 2 3 4 Use of Glascow Coma Scale 1 2 3 4 Seizure Precautions 1 2 3 4 Assist with Lumbar Puncture 1 2 3 4 ICP Monitoring 1 2 3 4 Crutchfield Tongs 1 2 3 4 Halo Traction 1 2 3 4 Stryker Frame 1 2 3 4 Assessment of Sensory‐Motor Function 1 2 3 4 Cervical Traction 1 2 3 4 Cranial Nerve Assessment 1 2 3 4 LOC Assessment 1 2 3 4 Pre/Post Neuro Surgical Care 1 2 3 4 Visual Acuity Measurement 1 2 3 4 VascularPeripheral Pulses 1 2 3 4 Fluid Overload 1 2 3 4 Starting IV's 1 2 3 4 Subcutaneous Central Line 1 2 3 4 Hickman/Broviac/Groshong Catheters 1 2 3 4 Maintenance of Heparin Lock 1 2 3 4 TPN/Hyperalimentation 1 2 3 4 Air Occlusive Dressing 1 2 3 4 Peritoneal Dialysis 1 2 3 4 Hemodialysis 1 2 3 4 Heparin Drip ‐ Precautions and Maintenance 1 2 3 4 GastrointestinalNG Tube Insertion 1 2 3 4 Gastronomy Tube 1 2 3 4 Jejunoostomy Tube 1 2 3 4 Enterostomal Care 1 2 3 4 Genito Urinary/RenalFoley Catheter Insertion 1 2 3 4 GU Irrigations 1 2 3 4 Nephrostomy Tube 1 2 3 4 Suprapubic Tube 1 2 3 4 Electrolyte Imbalance/Replacement 1 2 3 4 OtherOncology 1 2 3 4 Chemotherapy 1 2 3 4 Isolation Techniques 1 2 3 4 Hyperbaric Oxygenation 1 2 3 4 Fingerstick Blood Glucose Monitoring 1 2 3 4 EquipmentBear I 1 2 3 4 Bear II 1 2 3 4 Bear V 1 2 3 4 Bennett 7200 1 2 3 4 CPAP 1 2 3 4 Emerson 1 2 3 4 EMV 1 2 3 4 MA‐I 1 2 3 4 MA‐II 1 2 3 4 Monihan 1 2 3 4 Ohio 560 1 2 3 4 PEEP 1 2 3 4 Pressure Pre‐Set 1 2 3 4 Servo 900b 1 2 3 4 Servo 900c 1 2 3 4 Servo 900e 1 2 3 4 Siemens 1 2 3 4 Hewlett‐Packard 1 2 3 4 Spacelab 1 2 3 4 Marquette 1 2 3 4 Mennen 1 2 3 4 Lifecare 1 2 3 4 Nihon‐Koder 1 2 3 4 Age Specific CompetenciesInfant (Birth - 1 year) 1 2 3 4 Preschooler (ages 2-5 years) 1 2 3 4 Childhood (ages 6-12 years) 1 2 3 4 Adolescents (ages 13-21 years) 1 2 3 4 Young Adults (ages 22-39 years) 1 2 3 4 Adults (ages 40-64 years) 1 2 3 4 Older Adults (ages 65-79 years) 1 2 3 4 Elderly (ages 80+ years) 1 2 3 4 AuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this Emergency Room RN Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
