|
Peri-Operative RN Skill Checklist | ||||||
| NAME | |||||||
| LAST 4 OF SSN | |||||||
| DATE | |||||||
| I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination. | |||||||
| Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below. | |||||||
| Proficiency Scale: |
1 = No Experience 2 = Need Training 3 = Able to perform with supervision 4 = Able to perform independently |
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| Rating Stars (Click) | IV Therapy | 1 | 2 | 3 | 4 | ||
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Start peripheral IV - angio cath | ||||||
| Rating Stars (Click) | IV Therapy - Assist with: | 1 | 2 | 3 | 4 | ||
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Insertion of A-lines | ||||||
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Insertion of CVP - jugular | ||||||
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Insertion of CVP - sublavian | ||||||
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Insertion of Swan-Ganz | ||||||
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Drawing blood from central line | ||||||
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Drawing venous blood | ||||||
| Rating Stars (Click) | Administration of blood and products | 1 | 2 | 3 | 4 | ||
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Packed red blood cells | ||||||
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Plasma/Albumin | ||||||
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Whole blood | ||||||
| Rating Stars (Click) | General Surgery | 1 | 2 | 3 | 4 | ||
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Abdominal perineal resection | ||||||
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Adrenalectomy | ||||||
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Anal fissurectomy | ||||||
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Appendectomy | ||||||
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Bowel resection | ||||||
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Breast biopsy | ||||||
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Cholecystectomy (open) | ||||||
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Colectomy | ||||||
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Colostomy/ileostomy | ||||||
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Esophogeal resection | ||||||
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Exploratory laparotomy | ||||||
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Gastrectomy | ||||||
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Gastroplasty | ||||||
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Hemorrhoidectomy | ||||||
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Hemicolectomy | ||||||
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Hepatic resection | ||||||
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Herniorrhaphy - femora | ||||||
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Herniorrhaphy - inguina | ||||||
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Herniorrhaphy - umbilical | ||||||
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Herniorrhaphyhiatal transabdominal/transthoracic | ||||||
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Hiatal hernia repair | ||||||
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Hepatic resection | ||||||
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Insertion - Hickman | ||||||
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Insertion - Groshong | ||||||
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Insertion - Portacath | ||||||
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Hydroceletomy | ||||||
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Imperforate anus reconstruction | ||||||
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Lumbar sympathectomy | ||||||
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Omphalocele repair | ||||||
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Pancreatectomy / pancreatogram | ||||||
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Pilonidal cystectomy | ||||||
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Portal caval shunt | ||||||
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Pyloric stenosis | ||||||
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Radical mastectomy | ||||||
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Saphenous vein ligation and stripping | ||||||
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Sentinel node biopsy | ||||||
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Splenectomy | ||||||
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Tenchknoff duct cyst excision | ||||||
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Thyroglossal duct cyst excision | ||||||
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Thryoidectomy | ||||||
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Vagotomy | ||||||
| Rating Stars (Click) | Thoracic and Open Heart | 1 | 2 | 3 | 4 | ||
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Cervical rib excision | ||||||
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Chamberlain procedure | ||||||
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Closed thoracotomy | ||||||
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Correction pectus excavatum | ||||||
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Esophagectomy | ||||||
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Heller procedure | ||||||
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Mitral commissurotomy | ||||||
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Mitral or aortic valve replacement | ||||||
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IAPB insertion | ||||||
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CABG | ||||||
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Cardiac valve replacement | ||||||
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Patent ductus arteriosus repair | ||||||
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Septal defect repairs | ||||||
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Pacemaker implanation - endocardial | ||||||
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Pacemaker implanation - myocardia | ||||||
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Pacemaker - temporary | ||||||
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Pericardiectomy | ||||||
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Pericardial window | ||||||
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Resection coarctation aorta | ||||||
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Portocaval shunt | ||||||
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Tetrology of fallot | ||||||
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Thoracoplasty | ||||||
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Tracheal resection | ||||||
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Transthoracic diaphragmatic heniorrhaphy | ||||||
| Rating Stars (Click) | Vascular | 1 | 2 | 3 | 4 | ||
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A-V access graft | ||||||
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Aortic aneurysm with graft replacement | ||||||
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Endarterectomy/carotid - femoral | ||||||
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Fem-pop bypass | ||||||
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Peripheral vascular bypass procedures | ||||||
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Resection carotid aneurysm with graft | ||||||
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Thrombectomy/embolectomy | ||||||
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Vena cava filter/umbrella | ||||||
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Vena cava ligation | ||||||
| Rating Stars (Click) | Neurology | 1 | 2 | 3 | 4 | ||
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A-V malformation | ||||||
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Anterior cervical fusion | ||||||
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Anterior laparoscopic spine procedures | ||||||
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Anterior lumbar interbody fusion (ALIF) | ||||||
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Burr holes for subdural hematoma | ||||||
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Carotid ligation | ||||||
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Cervical sympathectomy | ||||||
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Craniectomy for decompression fracture | ||||||
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Discetomy | ||||||
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Hypophysectomy | ||||||
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Insertion nerve stimulators | ||||||
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Insertion
medication pumps |
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Laminectomy | ||||||
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Myelomeningocele repair | ||||||
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Pedicle screw insertion | ||||||
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Posterior lumbar interbody fusion (PLIF) | ||||||
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Shunt procedure/VP, VA/LP | ||||||
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Spine fusion | ||||||
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Ulnar nerve transfer | ||||||
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Ventriculography / ventriculoscopy | ||||||
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Ventriculostomy | ||||||
| Rating Stars (Click) | Neurology - Cranioplasty/craniotomy | 1 | 2 | 3 | 4 | ||
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Clipping of aneurysm | ||||||
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Tumor excision | ||||||
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Stealth crainiotomy | ||||||
| Rating Stars (Click) | Urology | 1 | 2 | 3 | 4 | ||
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Adult circumcision | ||||||
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Cystectomy | ||||||
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Cystoscopy/ureteroscopy | ||||||
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Hypospadias repair | ||||||
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Ileal loop | ||||||
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Implants - penile and testicular | ||||||
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Lithotripsy | ||||||
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Nephrectomy | ||||||
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Nephrolithotomy | ||||||
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Orchiopexy | ||||||
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Prostatectomy - perineal | ||||||
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Prostatectomy - supra-pubic | ||||||
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Pyleoplasty | ||||||
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Radical node dissection | ||||||
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Scott incontinence device | ||||||
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TURP | ||||||
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Ureterolithotomy | ||||||
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Vasectomy | ||||||
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Vasovasostomy | ||||||
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Waterhouse procedure | ||||||
| Rating Stars (Click) | Gynecology | 1 | 2 | 3 | 4 | ||
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Cesarean section | ||||||
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Colpotomy | ||||||
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Dilation and curettage (DandC) | ||||||
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Hysterectomy - abdominal | ||||||
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Hysterectomy - vaginal | ||||||
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Marshall - Marchetti | ||||||
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Marsupialization, Bartholin cyst | ||||||
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Ovarian cystectomy | ||||||
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Radium insertion | ||||||
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Salpingo-oophorectomy | ||||||
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Sacral spinus fixation | ||||||
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Shirodkar procedure | ||||||
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Suction curettage | ||||||
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Termination of pregnancy | ||||||
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Tubal ligation | ||||||
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Vaginal recontruction | ||||||
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Vaginectomy/vulvectomy | ||||||
| Rating Stars (Click) | Orthopedics | 1 | 2 | 3 | 4 | ||
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Acetabular/pelvic ORIF | ||||||
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Achilles tendon repair | ||||||
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Amputation- leg, arm | ||||||
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Anterior cruciate ligament repair | ||||||
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Application of external fixators - extremeties | ||||||
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Application of external fixators - pelvis | ||||||
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Application of halo traction | ||||||
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Arthrotomy | ||||||
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Bipolar/unipolar hips | ||||||
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Bunionectomy | ||||||
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Calcanel reconstruction | ||||||
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Capsulorrhaphy | ||||||
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Carpal tunnel release | ||||||
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Closed reduction fracture | ||||||
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Hand surgery with implants | ||||||
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Harrington rod instrumentation and / or Dwyer procedure | ||||||
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Heel cord lengthening | ||||||
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Laminectomy | ||||||
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Olecranon bursa, excision of | ||||||
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ORIF, internal fixation with compression set | ||||||
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Patellectomy | ||||||
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PuttiPlatt/Bankart procedure/rotator cuff repair | ||||||
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Reduction with compression sets | ||||||
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Reimplanation of digits | ||||||
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Repair hammer toes | ||||||
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Sacro-iliac (SI) joint screws | ||||||
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Sharrard procedure | ||||||
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Spica cast, application | ||||||
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Spinal fusion | ||||||
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Tendon transplants (hand and foot) | ||||||
| Rating Stars (Click) | Orthopedics - Arthroscopy | 1 | 2 | 3 | 4 | ||
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Ankle | ||||||
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Elbow | ||||||
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Knee | ||||||
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Shoulder | ||||||
| Rating Stars (Click) | Orthopedics - Hip compression nails and lag screws | 1 | 2 | 3 | 4 | ||
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Jewett | ||||||
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Kuntscher rod | ||||||
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Lottes | ||||||
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Rush | ||||||
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Schneider | ||||||
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Zimmer | ||||||
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Iliac crest bone graft | ||||||
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Insertion Austin Moore hip prosthesis | ||||||
| Rating Stars (Click) | Orthopedics - Intramedullary rods | 1 | 2 | 3 | 4 | ||
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Extraction | ||||||
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Femoral | ||||||
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Humeral | ||||||
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Insertion | ||||||
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Supracondylar | ||||||
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Tibal | ||||||
| Rating Stars (Click) | Orthopedics - Total joint replacements/revisions | 1 | 2 | 3 | 4 | ||
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Hip | ||||||
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Knee | ||||||
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Shoulder | ||||||
| Rating Stars (Click) | Plastics | 1 | 2 | 3 | 4 | ||
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Abdominal lipectomy | ||||||
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Abdominalplasty | ||||||
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Blepharoplasty | ||||||
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Cleft lip repair | ||||||
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Dermabrasion | ||||||
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Face lift | ||||||
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Mentoplasty | ||||||
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Otoplasty | ||||||
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Pedicle grafts | ||||||
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Rhytidectomy | ||||||
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Scar revisions | ||||||
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Split thickness skin grafting | ||||||
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Tissue expanders | ||||||
| Rating Stars (Click) | Plastics - Mammoplasty | 1 | 2 | 3 | 4 | ||
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Augmentation | ||||||
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Reduction | ||||||
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Tramflaps with reconstructive mammoplasty | ||||||
| Rating Stars (Click) | Ear, Nose and Throat | 1 | 2 | 3 | 4 | ||
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Adenoidectomy | ||||||
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Caldwell - Luc | ||||||
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Cleft lip/palate repair | ||||||
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Closed reduction nasal fx | ||||||
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Ethmoidectomy | ||||||
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Excision of salivary gland tumor | ||||||
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Fenestration procedure | ||||||
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Frontal flap sinus procedure | ||||||
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Glossectomy | ||||||
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Laryngectomy | ||||||
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Mandibulectomy | ||||||
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Mastoidectomy | ||||||
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Maxillary advancement with graft | ||||||
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Maxillectomy | ||||||
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Myringoplasty | ||||||
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Myringotomy with PE tube insertion | ||||||
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Nasal polypectomy | ||||||
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Open reducation facial fx | ||||||
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Open reducation nasal fx | ||||||
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Parotidectomy | ||||||
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Pharyngeal flap procedure | ||||||
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Radical neck dissection | ||||||
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Ranulectomy | ||||||
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Rhinoplasty/septoplasty | ||||||
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Selective osteotomy of maxilla/mandible | ||||||
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Sinus endoscopy | ||||||
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Sinusotomy | ||||||
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Stapedectomy | ||||||
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Submucous resection | ||||||
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Tonsillectomy | ||||||
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Tracheostomy | ||||||
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Tympanoplasty | ||||||
| Rating Stars (Click) | Oral | 1 | 2 | 3 | 4 | ||
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Closed reducation facial fractures/wiring | ||||||
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Excision odontoma | ||||||
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Excision of deciduous teeth | ||||||
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Extraction of impacted molars | ||||||
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Fractured jaws, mandibular and zagomatic | ||||||
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Ginivectomy | ||||||
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LeFort osteotomies | ||||||
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Maxillary procedure with graft | ||||||
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Pediatric dentistry | ||||||
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Sagittal osteotomy | ||||||
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Temporomandibular (TMJ) with arthroplasty | ||||||
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TMJ exploration | ||||||
| Rating Stars (Click) | Ophthalmology | 1 | 2 | 3 | 4 | ||
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Cataract extraction with IOL | ||||||
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Corneal transplant | ||||||
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Dacryocystectomy | ||||||
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Eye enucleation | ||||||
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Exicison of chalazion | ||||||
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Canthotomy | ||||||
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Correction of ectropian/entropian | ||||||
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Enucleation | ||||||
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Eye transplant | ||||||
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Iridectomy | ||||||
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Lacrimal duct probing | ||||||
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Lid and muscle procedures | ||||||
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Orbital implant | ||||||
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Phaco emulsification | ||||||
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Ptergium repair | ||||||
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Recession resection | ||||||
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Refractive keratoplasty | ||||||
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Repair orbital blowout fracture | ||||||
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Repair of retinal detachment | ||||||
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Scleral buckle | ||||||
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Vitrectomy | ||||||
| Rating Stars (Click) | Endoscopic Procedures | 1 | 2 | 3 | 4 | ||
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Bronchoscopy | ||||||
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Colonscopy | ||||||
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Culdoscopy | ||||||
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Esophagoscopy | ||||||
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Gastroscopy | ||||||
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Hysteroscopy | ||||||
| Rating Stars (Click) | Laparoscopic procedures | 1 | 2 | 3 | 4 | ||
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Appendectomy | ||||||
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Cholecystectomy / cholangiogram | ||||||
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Colon resection | ||||||
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Diagnostic | ||||||
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Hernia repair | ||||||
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Nissen fundoplication | ||||||
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Salpingo-oophorectomy | ||||||
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Tubal ligation | ||||||
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Vaginal hysterectomy | ||||||
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Larynoscpy and microlaryngoscopy | ||||||
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Mediastinoscopy | ||||||
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Pelviscopy | ||||||
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Sigmoidoscopy | ||||||
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Thoracoscopy | ||||||
| Rating Stars (Click) | Transplant | 1 | 2 | 3 | 4 | ||
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Bone | ||||||
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Bone marrow | ||||||
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Corneal transplant | ||||||
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Harvesting | ||||||
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Heart | ||||||
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Kidney | ||||||
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Liver | ||||||
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Lung | ||||||
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Multi-organ | ||||||
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Pancreas | ||||||
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Skin | ||||||
| Rating Stars (Click) | Trauma | 1 | 2 | 3 | 4 | ||
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Burns | ||||||
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Motor vehile accidents (multiple injuries) | ||||||
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Traumatic amputations | ||||||
| Rating Stars (Click) | Trauma - Gunshot/stab wounds | 1 | 2 | 3 | 4 | ||
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Abdomen | ||||||
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Chest | ||||||
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Head | ||||||
| Rating Stars (Click) | Equipment | 1 | 2 | 3 | 4 | ||
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Argon beam coagulator | ||||||
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Bair hugger | ||||||
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Blood/fluid warmer | ||||||
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Cardiac monitor and pacemaker | ||||||
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Cell saver | ||||||
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Cidex soak | ||||||
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Cry-opthalmic unit | ||||||
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Defibrillator/pacer | ||||||
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Electrosurgical unit | ||||||
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Emerson thoracic pump | ||||||
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ETO sterilizer | ||||||
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Eye magnet | ||||||
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Fiber optic luminator | ||||||
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Flash autoclave | ||||||
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Hypo/hyperthemia units | ||||||
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Kreiselman resuscitor | ||||||
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Mesh graft | ||||||
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MicroscopesNerve stimulatorNitrous oxide bank | ||||||
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Nitrous oxide bank | ||||||
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Ohio suction units | ||||||
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Orthopedic arm board with drain | ||||||
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Pleurevac disp. chest drainage | ||||||
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Pneumatic tourniquet | ||||||
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Sterad machine | ||||||
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Steri-vac aeratopm cabinet | ||||||
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Steris unit | ||||||
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Tele therometer | ||||||
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Ultrasonic cleaner | ||||||
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Vac-pac positioner | ||||||
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Vacuum curettage | ||||||
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Washer sanitizer | ||||||
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Washer sterilizer | ||||||
| Rating Stars (Click) | Equipment - Fracture tables | 1 | 2 | 3 | 4 | ||
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Chick/Marquet tables | ||||||
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Jackson table | ||||||
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Rush/Skytron tables | ||||||
| Rating Stars (Click) | Equipment - Intestinal stapling devices | 1 | 2 | 3 | 4 | ||
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EEA | ||||||
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GIA | ||||||
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LDS | ||||||
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TA | ||||||
| Rating Stars (Click) | Equipment - Laser | 1 | 2 | 3 | 4 | ||
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CO2 | ||||||
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Eye magnet | ||||||
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Yag | ||||||
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Other | ||||||
| Rating Stars (Click) | Camera/video systems | 1 | 2 | 3 | 4 | ||
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Camera controller | ||||||
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Light source | ||||||
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Printers | ||||||
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VCRs | ||||||
| Rating Stars (Click) | Dermatome | 1 | 2 | 3 | 4 | ||
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Brown | ||||||
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Padgett | ||||||
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Zimmer | ||||||
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Disposable grounding pads | ||||||
| Rating Stars (Click) | Drills | 1 | 2 | 3 | 4 | ||
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3-M maxi driver | ||||||
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Codman craniotome | ||||||
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Hall air-driver | ||||||
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Hall dental | ||||||
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Hall neurotome | ||||||
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Midax Rex/Anspach | ||||||
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Minidriver | ||||||
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Stryker drills - large battery | ||||||
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Stryker drills - small battery | ||||||
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Surgairtome | ||||||
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Synthes A-O drill | ||||||
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Electrosurgical unit | ||||||
| Rating Stars (Click) | Miscellaneous | 1 | 2 | 3 | 4 | ||
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Assist with intubation | ||||||
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Conscious sediation administration | ||||||
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Conscious sediation monitoring | ||||||
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Management of malignant hypertensive crisis | ||||||
| Rating Stars (Click) | Able to assure a safe environment for the specific needs of various age groups | 1 | 2 | 3 | 4 | ||
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A.Newborn/Neonate (birth - 30 days) | ||||||
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B.Infant (30 days - 1 year) | ||||||
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C.Toddler (1 - 3 years) | ||||||
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D.Preschooler (3 - 5 years) | ||||||
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E.School age children (5 - 12 years) | ||||||
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F.Adolescents (12 - 18 years) | ||||||
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G.Young adults (18 - 39 years) | ||||||
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H.Middle adults (39 - 64 years) | ||||||
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I.Older adults (64+) | ||||||
| Rating Stars (Click) | Able to communicate and/or instruct patients according to their age, maturity, comprehension | 1 | 2 | 3 | 4 | ||
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A.Newborn/Neonate (birth - 30 days) | ||||||
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B.Infant (30 days - 1 year) | ||||||
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C.Toddler (1 - 3 years) | ||||||
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D.Preschooler (3 - 5 years) | ||||||
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E.School age children (5 - 12 years) | ||||||
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F.Adolescents (12 - 18 years) | ||||||
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G.Young adults (18 - 39 years) | ||||||
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H.Middle adults (39 - 64 years) | ||||||
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I.Older adults (64+) | ||||||
| Rating Stars (Click) | Evaluate age-appropriate behavior, motor skills and physiological norms | 1 | 2 | 3 | 4 | ||
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A.Newborn/Neonate (birth - 30 days) | ||||||
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B.Infant (30 days - 1 year) | ||||||
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C.Toddler (1 - 3 years) | ||||||
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D.Preschooler (3 - 5 years) | ||||||
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E.School age children (5 - 12 years) | ||||||
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F.Adolescents (12 - 18 years) | ||||||
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G.Young adults (18 - 39 years) | ||||||
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H.Middle adults (39 - 64 years | ||||||
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I.Older adults (64+) | ||||||