Telemetry Skills Checklist

FREEDOM MEDSTAFF INC.

Name: Date:

Years of Experience :

Directions for completing skills checklist:

The following is a list of equipment and/or procedures performed in rendering care to patients. Please indicate your level of expereince/proficiency with each area and, where applicable, the types of equipment and/or systems you are familiar with. Use the following key as a guideline:

A) Theory Only/No Expereince--Didactic instruction only, no hands on experience B) Limited Experience--Knows procedure/has used equipment, but has done so

infrequently or not within the last six months C) Moderate Experience--Able to demonstrate equipment/procedure, performs the

task/skill independently with only resource assistance needed. D) Proficient/Competent--Able to demonstrate/perform the task/skill proficiently

without any assistance and can instruct/teach.

A. CARDIOVASCULAR

1. Assessment a. Auscultation (rate, rhythm)

b. Doppler

c. Heart sounds/murmurs

d. Pulses/Circulation checks 2. Interpretation of Lab Results

a . Cardiac Enzymes/lsoenzymes

b. Coagulation studies 3. Equipment & procedures

a. Monltotrlng/Telemetry

(1) Arrhythmia Interpretation

(2) Basic 12 lead interpretation

(3) Lead placement: 5 electrode telemetry

(4) Lead placement: I, III, V-leads (5) Lead placement: Lead II and MCLl

b. Pacemaker

(1) Permanent

(2) Temporary epocardial wires (3) Temporary external placement

( 4) Temporary transvenous

c. Assist with:

(1) Arterial line insertion (2) Central line insertion

d . Hemodynamlc monitoring

(1) A-line (radial)

A

0

0 0

0

0 0

0

0 0 0 0

0 0 0

0

0 0

0

B

0

0 0

0

0 0

0 0

0 0 0

0 0 0

0

0 0

0

C

0

0 0

0

0 0

0 0 0 0 0

0 0 0

0

0 0

0

D

0

0 0

0

0 0

0 0 0 0 0

0 0 0

0

0 0

0

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(2) CVP monitoring 0 0 0 0

(3) Femoral artery sheath removal 0 0 0 0

(4) Swan-Ganz 0 0 0 0

e. Perform

( 1) Controlled cardioversion 0 0 0 0

(2) Emergency defibrillation 0 0 0 0

(3) Cardiopulmonary resuscitation (CPR) 0 0 0 0

4 . Care of the patient with:

a. Abdominal aortic bypass 0 0 0 0

b. Aneurysm 0 0 0 0

c. Angina 0 0 0 0

d. Cardiac arrest 0 0 0 0

e. Cardiomyopathy 0 0 0 0

f. Carot id endarterectomy 0 0 0 0

g. Congestive heart failure (CHF) 0 0 0 0

h. Femoral-popliteal bypass 0 0 0 0

I. Post acute MI (24-48 hours) 0 0 0 0 j . Post angioplasty 0 0 0 0

k. Post arthrectomy (DCA) 0 0 0 0

I. Post CABG (24 hours) 0 0 0 0

m. Post cardiac catheterization 0 0 0 0

n. Post stent placement 0 0 0 0

o. Cardiogenic shock 0 0 0 0

5. Medications

a. Atropine 0 0 0 0

b. Diuretics 0 0 0 0

c. Digoxin 0 0 0 0

d. Andrenergics 0 0 0 0

e. Beta blockers 0 0 0 0

f. Ca+ channel blockers 0 0 0 0

g. Lidocaine 0 0 0 0 h. Vasopressors 0 0 0 0

I. Nitrates 0 0 0 0

j . Antiarhythmics 0 0 0 0 k. Preparation of emergency medications 0 0 0 0

I. Oral, IV and subcutaneous anticoagulants 0 0 0 0

m. Thrombolyt ic agents 0 0 0 0

B. PULMONARY

1. Assessment

a. Breath sounds 0 0 0 0

b. Breathing patterns 0 0 0 0

2. I nterpretation of Lab Results

a. Arterial blood gases 0 0 0 0

b. Blood chemistry

3. Equipment and procedures 0 0 0 0

a. Assist with intubation 0 0 0 0

b. Assist with thoracentesis 0 0 0 0

c. Care of airway management devices/suctioning 0 0 0 0

( 1) Endotracheal tube/suctioning

(2) Nasal airway/suctioning 0 0 0 0

(3) Oropharyngeal/suctioning 0 0 0 0

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( 4) Oximetry 0 0 0 0

(5) Sputum specimen collection 0 0 0 0

( 6) Tracheostomy/suctioning 0 0 0 0

d. Care of patient on ventilator

(1) Extubation 0 0 0 0

(2) Weaning modes 0 0 0 0

e. Care of patient with chest tube:

(1) Assist with set-up & insertion 0 0 0 0

(2) Mediastinal tube removal 0 0 0 0

(3) Pleural tube removal 0 0 0 0

( 4) Use of Pleurevac or Thoraclex 0 0 0 0

(5) Use of water seal drainage system 0 0 0 0

f. Chest physiotherapy 0 0 0 0

g. Establishing an airway 0 0 0 0

h. Incentive spirometry 0 0 0 0

I. Oxygen therapy & medication delivery systems

(1) Ambu bag and mask (2) ET tube 0 0 0 0

(3) External CPAP

( 4) Face masks 0 0 0 0

(5) Inhalers 0 0 0 0

(6) Nasal cannula 0 0 0 0

(7) Portable oxygen tanks 0 0 0 0

(8) Tracheostomy 0 0 0 0

(9) Transtracheal cannulation 0 0 0 0

j. Oral airway insertion 0 0 0 0

k. Restraints 0 0 0 0

4. Care of the patient with:

a.ARDS 0 0 0 0

b. Bronchoscopy 0 0 0 0

c.COPD 0 0 0 0 d. Fresh trachostomy 0 0 0 0

e. Lobectomy 0 0 0 0

f . Pneumonectomy 0 0 0 0 g. Pneumonia 0 0 0 0

h. Pulmonary edema 0 0 0 0

I. Pulmonary embolism 0 0 0 0

j . Status asthmaticus 0 0 0 0

k. Thoracotomy 0 0 0 0

I. Tuberculosis 0 0 0 0

5. Medications

a. Aminophylline 0 0 0 0

b. Corticosteroids 0 0 0 0

c. Atrovent 0 0 0 0

d. Antibiotics 0 0 0 0

e. Albuterol 0 0 0 0

C. NEURO LOGI CAL

1. Assessment

a. Cerebellar function 0 0 0 0

b. Cranial nerves 0 0 0 0

c. Glasgow coma scale 0 0 0 0

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d. Level of consciousness 0 0 0 0

e. Pathologic reflexes 0 0 0 0

2. Equipment and procedures

a. Assist with lumbar puncture 0 0 0 0

b. Halo traction 0 0 0 0

c. Nerve stimulator 0 0 0 0

d. Rotation bed 0 0 0 0

e. Seizure precautions 0 0 0 0

f. Use of hyper/hypothermia blanket 0 0 0 0

g. Bed alarms 0 0 0 0

3. Care of the patient with :

a. Aneurysm precautions 0 0 0 0

b. Basal skull fracture 0 0 0 0

c. Closed head injury 0 0 0 0

d. Coma 0 0 0 0

e. TIA/CVA 0 0 0 0

f. DT's g. Encephalitis 0 0 0 0

h. Externalized VP shunts 0 0 0 0

I. Meningitis 0 0 0 0

j. Mulitple sclerosis 0 0 0 0

k. Neuromuscular disease 0 0 0 0

I. Post Craniotomy 0 0 0 0

m. Seizures 0 0 0 0

n. Spinal cord injury 0 0 0 0

4. Medications

a. Dilantin 0 0 0 0

b. Phenobarbitol 0 0 0 0

c. Versed 0 0 0 0

d. Lasix/Mannitol 0 0 0 0

e. Val ium 0 0 0 0 f. Morphine sulfate 0 0 0 0

g. Oral analgesics/narcotics 0 0 0 0

D. GASTROINTESTINAL 1. Assessment

a. Abdominal/bowel sounds 0 0 0 0

b. Fluid Balance 0 0 0 0

c. Nutritional 0 0 0 0

2. Interpretation of blood chemistry 0 0 0 0

3. Equipment and procedures

a. Administration of tube feeding (1) Feeding pump 0 0 0 0

(2) Gravity feeding 0 0 0 0

b. Flexible feeding tube (Corpak, Dobhoff, etc.) 0 0 0 0

c. Placement of nasogastric tube 0 0 0 0

d. Salem sump to suction 0 0 0 0

e. Saline lavage 0 0 0 0

4. Management of:

a. Gastronomy tube 0 0 0 0

b. Jejunostomy tube 0 0 0 0

c. PPN (peripheral parenteral nutrition) 0 0 0 0

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d. TPN and lipids administration 0 0 0 0

e. T-tube 0 0 0 0

5. Care of the patient with:

a. Bowel obstruction 0 0 0 0

b. Colostomy 0 0 0 0

c. ERCP 0 0 0 0

d. Esophageal bleeding 0 0 0 0

e. GI bleeding 0 0 0 0

f. GI surgery 0 0 0 0

g. Hepatitis 0 0 0 0

h. Ileostomy 0 0 0 0

I. Inflammatory bowel disease 0 0 0 0 j. Liver failure 0 0 0 0

k . Liver transplant 0 0 0 0

I. Pancreatitis 0 0 0 0

m. Paralytic ileus 0 0 0 0

n. Whipple procedure 0 0 0 0

o. Pre/post open abdominal surgery 0 0 0 0

E.RENAL/ GENITOURINARY 1. Assessment

a. A-V fistula/shunt 0 0 0 0

b. Fluid & elctrolyte imbalance 0 0 0 0

2. Interpretation of BUN & cretinlne 0 0 0 0

3. Equipment and procedures a. Foley catheter insertion

(1) Female 0 0 0 0

(2) Male 0 0 0 0

b. Supra-pubic

c. Bladder irrigation 0 0 0 0

(1) Continuous 0 0 0 0

(2) Intermittent d. Specimen collection

(1) Routine 0 0 0 0

(2) 24 hour 0 0 0 0

e. Nephrostomy tube ca re f . Manual CAPO administration 0 0 0 0

g. Peritoneal dialysis via automatic cycler

4. Care of the patient with: 0 0 0 0

a. Hemodialysis 0 0 0 0

b. Nephrectomy 0 0 0 0

c. Peritoneal dialysis 0 0 0 0

d. Renal failure 0 0 0 0

e. Renal transplant 0 0 0 0

f. TURP 0 0 0 0

F. GYNECOLOGY 1. Assessment

a. Assist with gynecological exam/PAP 0 0 0 0

b. Breast care/self-examination education 0 0 0 0

2. Interpretation of lab results 0 0 0 0

3. Care of the patient with :

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a. Gynecological surgery 0 0 0 0

b. Gynecological malignancy 0 0 0 0

c. Mastectomy 0 0 0 0

d. Hyserectomy 0 0 0 0

G. METABOLIC

1. Assessment

a. S/S diabetic ketoacidosis 0 0 0 0

b. S/S insulin shock 0 0 0 0

2. Interpretation of lab results

a. Blood glucose 0 0 0 0

b. Thyroid levels 0 0 0 0

3. Equipment and procedures

a . Blood glucose monitoring (1) Blood glucose measuring device type:

(2) Insulin administration-IV drip 0 0 0 0

(3) Visual blood glucose strips 0 0 0 0 4 . Care of the patient with:

a. Cushing's syndrome 0 0 0 0

b. Diabetes insipidus 0 0 0 0

c. Diabetes mellitus 0 0 0 0

d. Diabetic ketoacidosis 0 0 0 0

e. Disorders of adrenal gland (Addison's disease) 0 0 0 0

f. Drug overdose 0 0 0 0

g. Hyperthyroidism 0 0 0 0

h. Hypothyroidism 0 0 0 0

I. Pheochromocytoma 0 0 0 0

j . Post adrenalectomy 0 0 0 0

k. Post hypophysectomy 0 0 0 0

I. Post thyroidectomy 0 0 0 0

5. Medications

a. Hydrocortisone 0 0 0 0

b. IM vasopressin (Pitressin) 0 0 0 0

c. Insulin 0 0 0 0 d. Prednisone 0 0 0 0

e. Radioactive iodine 0 0 0 0

H. WOUND MANAGEMENT

1. Assessment

a. Skin for impending breakdown 0 0 0 0

b. Stasis ulcers 0 0 0 0

c. Surgical wound healing 0 0 0 0

2. Equipment and procedures a. Air flu idized, low airloss beds 0 0 0 0

b. Sterile dressing changes 0 0 0 0

c. Wound care/irrigations 0 0 0 0

d. Perform cast care 0 0 0 0

e. Maintain traction (skin/skeletal) 0 0 0 0

3. Care of the patient with:

a. Burns 0 0 0 0

b. Pressure sores 0 0 0 0

c. Staged decubitus ulders 0 0 0 0

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d. Surgical wounds with draln(s) 0 0 0 0

e. Traumatic wounds 0 0 0 0

I. PHLEBOTOMY / IV THERAPY 1. Equipment and procedures

a. Drawing blood from central line 0 0 0 0

b. Drawing venous blood 0 0 0 0

C. Starting IVs

(1) Angiocath 0 0 0 0

(2) Butterfly 0 0 0 0

(3) Heparin lock 0 0 0 0

d. Administration of blood/blood products

(1) Albumin/plasma 0 0 0 0

(2) Cryoprecipitate 0 0 0 0

(3) Packed red blood cells 0 0 0 0

( 4) Whole blood 0 0 0 0

2. Care of the patient with:

a. Peripheral line/dressing 0 0 0 0

b. Central line/catheter/dressing

(1) Broviac 0 0 0 0

(2) Groshong 0 0 0 0

(3) Hickman 0 0 0 0

( 4) Portacath 0 0 0 0

(5) Quinton 0 0 0 0

J. PAI N MANAGEMENT

1. Assessment

2. Care of the patient with:

a. Anesthesia/analgesia 0 0 0 0

b. IV conscious sedation 0 0 0 0

c. Narcotic Analgesia 0 0 0 0

d. Patient control led analgesia 0 0 0 0

K. MISCELLANEOUS 1. Infectious diseases (HIV/AIDS) 0 0 0 0

2. Anitbiotice Resistance Infections 0 0 0 0

3. Chemotherapy 0 0 0 0

4. Patient education 0 0 0 0

5. Informed Consent 0 0 0 0

6. Computerized charting 0 0 0 0

7. Automated medication dispensing systems 0 0 0 0

8. AMA procedures yes 0 no 0

9. Suicide precautions yes 0 no 0

AGE SPECIFIC PRACTICE

A. Newborn/Neonate (birth - 30 days) D.Preschooler (3 - 5 years) I G.Young adults (18 - 39 years)

B.Infant (30 days - 1 year) E.School age children (5 - 12 years) H.Middle adults (39 - 64 years)

C.Toddler ( 1 - 3 years) F.Adolescents (12 - 18 years) I.Older adults (64+)

EXPERIENCE WITH AGE GROUPS A B C D E G H

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Retyped name acts as signature, if submitting form by email.______________________________________________________________Signature:

Able to adapt care to incorporate normal growth 0 0 0 0 0 0 0 0

and development.

Able to adapt method and terminology of patient instructions to 0 0 0 0 0 0 0 0

their age, comprehension and maturity level.

Can ensure a safe environment reflecting specific needs of 0 0 0 0 0 0 0 0

various age groups.

My experience is primarily in: (Please Indicate number of years) O Medical year(s) 0 Cardiothoracic year(s) 0 Neuro year(s)

O Neurological year(s) O Cardiovascular year(s) 0 Burn year(s)

0 Trauma year(s) 0 Coronary care year(s) 0 PACC year(s)

0 Other (specify) year(s)

Signature Date