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 Respiratory Therapist 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

Treatment/ Procedures

1. Assessment

1

2

3

4

Breath Sounds

Peak Flow Rate

Pulmonary Function Testing

Rate and Work of Breathing

Transcutaneous Monitoring

2. Interpretation of Lab Results

1

2

3

4

Arterial Blood Gases

Basic EKG

Blood Chemistry

Chest X-Ray

3. Equipment and Procedures

1

2

3

4

Airway Management Devices/ Suctioning

Check Intracuff Pressure

Endotracheal Tube/ Suctioning

Nasal Airway Placement

Nasal Airway/ Suctioning

Oral Airway/ Placement

Oropharyngeal/ Suctioning

Sputum Specimen Collection

Tracheostomy/ Suctioning

Analyze Oxygen

Arterial Line Insertion

Care of the Patient With a Chest Tube:

1

2

3

4

Assessment of Function/ Proper

Placement Assistance

Chest Physiotherapy

Drawing Arterial Blood Gasses:

1

2

3

4

Arterial Line

Brachial Artery

Femoral Artery

Radial Artery; Allen Tests

Extubate

Extubation Assistance

Hemodynamic Monitoring

Incentive Spirometry

Infection Control Procedures

Intubate

Intubation Assistance

Medication Delivery Systems:

1

2

3

4

Aerosol Heated/cool

Aerosol Setup-Mask

Aerosol Set up-Trach

IPPB

Medihaler

Metered Dose Inhaler

02 Therapy:

1

2

3

4

Bag and Mask

ET Tube

External CPAP

Face Masks

Nasal Cannula

Nebulizer:

1

2

3

4

Cold

Hand Held

Heated

Ultrasonic

Portable 02 Tank

T-Piece

Trach Collar

Thoracentesis Assistance

Cardiac Surgery

1

2

3

4

CHF

COPD

Cystic Fibrosis

Epiglottitis

Fresh Tracheostomy

Gullian-Barre

Hemo pneumothorax

Laryngospasm

Myasthenia Gravis

Pneumonia

Pulmonary Edema

Pulmonary Embolism

Smoke Inhalation

Status Asthmaticus

Tension Pneumothorax

Thoracotomy

Tracheo-Esophageal Fistula

Tuberculosis

5. Medications

1

2

3

4

Administration of:

Aerobid, Vanceril

Aminophyline (Theophyline)

Azmacort

Bicarbonate

Combivent

Cromolyn Sodium (Intal)

Decadron

Flonase

Flovent

Inhaled Steroids

Ipratropium Bromade

(Atrovent)

Isoetharine (Bronkosol)

Isoproterenol (Isuprel)

Metaproterenol

Mucomyst

Nasacort

Racemic Epinephrine

Salbutamol (Albuterol,

Proventil, Ventolin)

Terbutaline Sulfate (Bricanyl)

Familiar with the Effects Of:

1

2

3

4

Anectine

Atropine

Ventilator Set Up and Care:

1

2

3

4

Assist/ Control

CPAP

Flow-by

High Frequency Jet Ventilator

High Frequency Oscillator

IMV

Inverse Ratio Ventilator

Pressure Support

Pressure Vents

SIMV

Trouble Shooting High

Pressure Alarms

Trouble Shooting Low

Pressure Alarms

Volume Vents

Weaning

4. Care of the Patient With:

1

2

3

4

Acute/ Chronic Bronchitis

ARDS (Adult Respiratory

Distress Syndrome)

Aspiration

Asthma

Bronchoscopy

Cardiac Surgery

CHF

COPD

Cystic Fibrosis

Epiglottitis

Fresh Tracheostomy

Gullian-Barre

Hemo pneumothorax

Laryngospasm

Myasthenia Gravis

Pneumonia

Pulmonary Edema

Pulmonary Embolism

Smoke Inhalation

Status Asthmaticus

Tension Pneumothorax

Thoracotomy

Tracheo-Esophageal Fistula

Tuberculosis

5. Medications

1

2

3

4

Administration of:

Aerobid, Vanceril

Aminophyline (Theophyline)

Azmacort

Bicarbonate

Combivent

Cromolyn Sodium (Intal)

Decadron

Flonase

Flovent

Inhaled Steroids

Ipratropium Bromade

(Atrovent)

Isoetharine (Bronkosol)

Isoproterenol (Isuprel)

Metaproterenol

Mucomyst

Nasacort

Racemic Epinephrine

Salbutamol (Albuterol,

Proventil, Ventolin)

Terbutaline Sulfate (Bricanyl)

Familiar with the Effects Of:

1

2

3

4

Anectine

Atropine

Corticosteroids

Digitalis

Digoxin

Dopamine

Duramorph

Heli/ox Therapy

Ketamine

Lidocaine

Morphine Sulphate

Nipride

Nitric Oxide Therapy

Pavulon

Pentamidine Isethionate

Propofol

Theo-dur

Valium

Versed

6. Phlebotomy

1

2

3

4

Equipment & Procedures:

Drawing Blood From Central

Line

Drawing Blood From

Peripheral Line

Drawing Venous Blood

7. Neonatal/ Pediatrics

1

2

3

4

Equipment & Procedures:

Assist In High Risk Delivery

Capillary Blood Gasses

ECMO

02 To Tent

Umbilical Blood Gasses

Care of the Infant or Child With:

1

2

3

4

Bronchopulmonary Dysplasia

(BPD)

Croup

Epiglottis

Meconium Aspiration

Near Drowning

Persistent Pulmonary

Hypertension (PPHN)

Pulmonary Interstitial

Emphysema (PIE)

Respiratory Distress Syndrome

(RDS)

Respiratory Synical Virus

Transient Tachypnea of the

Newborn

Age Specific Practice Criteria

1

2

3

4

Newborn/Neonate (birth – 30 days)

Infant (30 days – 1 year)

Toddler (1 – 3 years)

Preschooler (3 – 5 yrs)

School age children (5 – 12 years)

Adolescents (12 – 18 years)

Young Adults (18 – 39 years)

Middle Adults (39 – 64 years)

Older Adults (64+ years)

Care of Patient with:

Able to adapt care to incorporate normal growth and

development

Able to adapt method and terminology of

patient instructions to their age,

comprehension, and maturity level.

Can ensure a safe environment, reflecting

specific needs of various groups.

Experience With the Following Ventilators:

1

2

3

4

Ventilator:

Bear

Bird

BP

Hamilton Amedeus,

Veolar

MA

Newport

Sechrist

Servo

Drager Infant

Emerson

Engstrom

Putitan Bennett 7200 Series

Primary Experience:

1

2

3

4

General Adult

Home Care

Intensive Care Unit

Long Term Care

Neonatal ICU

Pediatrics

Pulmonary Rehab

Sleep Lab

Subacute

Certification:

BCLS

PALS

ACLS

NRP

EKG Technician

EEG Technician

RRT

CRTT

Arterial Blood Gas Technician

Computerized charting system

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 Respiratory Therapist 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 (18.210.22.132) which will be used as a digital signature.