GENERAL INFORMATION

Note: * Denotes a required field.

Please enter your full name as it appears on your Social Security Card: First Name   Middle Name   Last Name  * Please enter the Last Four digits of your Social Security Number:  -   -   *       Please check here if you do not hold a valid social security card. Please provide your contact information: Phone Number  * E-mail Address  * Confirm E-mail Address  * Type your e-mail address again above.

This profile is for use by healthcare professionals in the PICU discipline and specialty. It will not be a determining factor for the program.

CHECKLIST INSTRUCTIONS

Please mark your level of experience      1. No theory and/or experience      2. Limited experience/need supervision and/or support      3. Experienced/minimal support needed to perform      4. Proficient/can perform independently

WORK SETTINGS

1

2

3

4

PICU

Pediatric CVICU

Pediatric Step Down

Pediatric PACU

CARDIOVASCULAR

1

2

3

4

Congenital Heart Disease/Repair

Post Cardiac Surgery (Directly from OR)

Post Cardiac Surgery (NOT Directly from OR)

Post Diagnostic/Interventional Cardiac Cath

Heart Failure/Cardiogenic Shock

Cardiac Transplant

Hemodynamic Monitoring

Arrhythmia Interpretation

Pacemaker - Temporary/Permanent

SVO2 Monitoring

Intra-Aortic Balloon Pump

Ventricular Assist Device

ECMO

PULMONARY

1

2

3

4

Respiratory Distress Syndrome/Resp. Failure

Reactive Airway Disease

ENT Surgery

Epiglottis

Cystic Fibrosis

Tuberculosis

Intubation/Extubation

Endotracheal Tube Management

Tracheostomy Management

Modes of Ventilation: AC/PC/SIMV/CPAP

Modes of Ventilation: Jet/Oscillator

Nitric Oxide

Hemo/Pneumothorax

NEUROLOGIC/ORTHOPEDIC

1

2

3

4

Brain Injury

Craniotomy

Spinal Cord Injury

Seizure Disorders

ICP Monitoring

VP Shunt

Meningitis

Neuromuscular Disease

Post Vertebral Surgery

Traction - General

Traction - Halo

GASTROINTESTINAL

1

2

3

4

Acute Surgical Abdomen

GI Bleeding

Pancreatitis

Hepatic Failure

Ostomy Management

Management of Gastric Tubes

Breast Milk Handling/Storage

RENAL/GENITOURINARY

1

2

3

4

Nephrotic Syndrome

Renal Transplant

Renal Replacement Therapy

Peritoneal Dialysis

ENDOCRINE/METABOLIC

1

2

3

4

Diabetes - Hypo/Hyperglycemic Crisis

Diabetic Ketoacidosis

IV Insulin Pumps

Indwelling Insulin Pumps

TRAUMA/OTHER

1

2

3

4

Blunt/Penetrating Trauma

Burns

Craniofacial Reconstruction

Near Drowning

Poison Ingestion/Overdose

Bites-Animal/Snake/Human

Suicide Precautions

Wound Management/VAC

Specialty Beds

ONCOLOGY

1

2

3

4

Bone Marrow Transplant

Immunosuppressive Disorder

Hemophilia Crisis

Sickle Cell Crisis

MEDICATIONS

1

2

3

4

Pediatric Dosage Calculations

Anti-Arrhythmics

Anticoagulants (IV, Oral & Injection)

Anti-Hypertensives

Anti-Seizure Medications

Benzodiazepines

Continuous IV Paralytics

Continuous IV Sedation

Procedural Sedation - Administration

Diuretics

Emergency Medication

Inhaled Medications

Insulin

IV Vasopressors

Narcotics/Opioid Analgesics (IV, Oral & Injection)

Non-Opioid Analgesics (IV, Oral & Injection)

Reversal Agents

Steroids (IV, Oral, Inhaled)

Automated Medication Dispensing (i.e. Pyxis, Omnicell)

IV THERAPY

1

2

3

4

Starting IVs

Central Line Blood Draw

Central Line/Implanted Line Care

TPN/Lipids

Blood Product Administration

Administration of Chemotherapy

CARDIAC MONITORING & EMERG. RESPONSE

1

2

3

4

Dysrhythmia Interpretation

Dysrhythmia Management

Management of Cardiac Arrest

Shock Management

Malignant Hyperthermia

Multisystem Organ Failure

PROFESSIONAL KNOWLEDGE AND SKILLS

1

2

3

4

National Patient Safety Goals/Core Measures

Recognize/Report Signs of Abuse

EMTALA

Fall Risk Assessment/Prevention

Pressure Ulcer Risk Assessment/Prevention

Restraints/Use of Least Restrictive Device

Normal Growth and Development

Age Specific/Population Based Care

Patient Family Teaching

Isolation Precautions

Infection Prevention

Reporting Communicable Diseases

Pain Assessment & Management

Charge Experience

Interpretation and Communication of Lab Values

EMR

1

2

3

4

EPIC

Cerner

Eclipsys

McKesson

Meditech

Other Computerized System

Computerized Physician Order Entry

Bar Coding for Medication Administration

EMR Conversion

Yes

No

Certifications

1

2

3

4

BLS

PALS

ACLS

PEARS

ENPC

CEN

TNCC

Please read and agree to the statements below by marking the checkbox. You will not be able to submit until you have marked the checkbox. * I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize Hudson Staffing to release this PICU Skills Checklist to the client facilities in relation to consideration of employment as a healthcare professional with those facilities.

Privacy Note: Hudson Staffing will record anonymous electronic information about your connection when you click on the submit button. This information is used for security purposes only. This information will include your IP Address (44.192.65.228) which will be used as a digital signature.