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 Critical Care / ICU 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

Cardiac

1

2

3

4

Acute Coronary Syndrome

Congestive Heart Failure

Cardiogenic Shock

Cardiac Tamponade

Heart Sounds

Immediate Post-Op Open Heart (directly from OR)

Immediate Post-Op Open Heart (NOT directly from OR)

Heart Transplant

Open Chest Emergency

Sheath Removal

Pacemaker - Temporary/Permanent

Pacemaker - Epicardial

Hemodynamic Monitoring

SVO2 Monitoring

Intra-Aortic Balloon Pump

Ventricular Assist Device

ECMO

PULMONARY

1

2

3

4

Respiratory Failure

ARDS

Pneumothorax

Pulmonary Embolism

Pulmonary Edema

Fresh Tracheostomy

Chest Trauma

Post Thoracic Surgery

Lung Transplant

Intubation/Extubation

Modes of Ventilation (AC/PC/SIMV/CPAP)

Nitric Oxide

Interpretation of Arterial Blood Gases

Chest Tube Placement & Management

Neurological & Psychiatric

1

2

3

4

Stroke Scale Assessment

CVA

Brain Injury

Post Craniotomy

Spinal Cord Injury

Seizure Disorders

ICP Monitoring

Hypothermia Protocol

Substance Withdrawal

Suicide Precautions

GASTROINTESTINAL

1

2

3

4

GI Bleeding

GI Surgery

Liver Failure

Pancreatitis

Liver Transplant

Pancreas Transplant

RENAL/GENITOURINARY

1

2

3

4

Renal Failure

Renal Surgery

TURP

Renal Transplant

Arteriovenous Fistula/Shunt

Nephrostomy Tubes

Peritoneal Dialysis

Continuous Renal Replacement Therapy

Endocrine Metabolic

1

2

3

4

Diabetes - Hypo/Hyperglycemic Crisis

Diabetic Ketoacidosis

Pituitary Disorders

IV Insulin Protocols

Indwelling Insulin Pumps

MEDICATIONS

1

2

3

4

Anti-Arrhythmics

Anticoagulants (IV, oral, & injection)

Anti-Hypertensives

Anti-Psychotics

Anti-Seizure Medications

Benzodiazepines

Continuous IV Paralytics

Continuous IV Sedation

Procedural Sedation – Administration

Diuretics

Emergency Medications

Inhaled Medications

Insulin

IV Vasopressors

Narcotics/Opioid Analgesics (IV, oral, & injection)

Nitrates (Oral & Topical)

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 Draws

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

Obtain 12 Lead EKG

Interpret 12 Lead EKG

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

Fall Risk Assessment/Prevention

Pressure Ulcer Risk Assessment/Prevention

Restraints/Use of Least Restrictive Device

Patient/Family Teaching

Age Specific/Population-Based Care

Isolation Precautions

Infection Prevention

Pain Assessment & Management

Charge Experience

Interpretation and Communication of Lab Values

Specialty Beds

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

BLS

ACLS

PALS

TNCC

CCRN

Telemetry Certificate/Course

Critical Care Course

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 Critical Care / ICU 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 (3.87.250.158) which will be used as a digital signature.