Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
Pulmonary embolism 0 1 2
Hemostatic devices 0 1 2
MEDICATIONS ADMINISTRATION SIDE EFFECTS
AND DESIRED OUTCOME
Digoxin (Lanoxin) 0 1 2
Isuprel (isoproterenol) 0 1 2
Insulin (all types) 0 1 2
Versed 0 1 2
Phenergan 0 1 2
Amiodarone 0 1 2
Diltiazem (Cardizem) 0 1 2
Lidocaine (Xylocaine) 0 1 2
Nitroglycerine (Tridil) 0 1 2
Streptokinase 0 1 2
AquaMephyton (vitamin K) 0 1 2
Epinephrine (Adrenalin) 0 1 2
Phenobarbital 0 1 2
Tegretol (Carbamazepine) 0 1 2
Decadron (Dexamethasone) 0 1 2
Sodium Bicarbonate 0 1 2
Thorazine 0 1 2
Atropine 0 1 2
Dobutamine (Dobutrex) 0 1 2
Metoprolol (Lopressor) 0 1 2
Procainamide (Pronestyl) 0 1 2
TPA (Alteplase) 0 1 2
Inderal (Propranolol) 0 1 2
Pitressin (Vasopressin) 0 1 2
Aminophylline (Theophylline) 0 1 2
Dilantin (Phenytoin) 0 1 2
Valium (Diazepam) 0 1 2
Demerol 0 1 2
Morphine 0 1 2
Inocor (Amrinone) 0 1 2
Verapamil (calan, isoptin, verelan) 0 1 2
Kayexelate 0 1 2
Lasix (furosemide) 0 1 2
BASIC NURSING CARE SKILLS & KNOWLEDGE OF
PATIENTS NEEDING OR WITH:
Oxygen therapy 0 1 2
ET Tube 0 1 2
Oximetry reading 0 1 2
Oral airway inserting 0 1 2
Aspiration 0 1 2
Internal cardioverter defibrillator 0 1 2
PARTICIPATION AND OR ASSISTING PHYSICAN
WITH PATIENTS THAT REQUIRE:
Arterial line insertion 0 1 2
Central line insertion 0 1 2
Cardioversion 0 1 2
Intubation 0 1 2
Open chest emergency 0 1 2
Intra aortic balloon pump 0 1 2
Swaz-Ganz/PA Catheter insertion 0 1 2
Emergency tracheostomy 0 1 2
Femoral artery sheath removal 0 1 2
Blood sampling during catheterization 0 1 2
Blood pressure measurement interop 0 1 2
HEMODYNAMIC MONITORING
Cardiac index 0 1 2
MAP 0 1 2
Radial A-line 0 1 2
Cardiac output 0 1 2
PCW Pressure 0 1 2
SVO2 0 1 2
CVP monitoring 0 1 2
PVR 0 1 2
SVR 0 1 2

Age Specific Practice Criteria
Please check the appropriate boxes below for each group for which you have experience in providing age-appropriate nursing care.
A=Newborn/Infant(Birth - 1 Year) B= Pediatric/Adolescent(1-18 Yrs) C=Adultt(19-64 Yrs) D=Geriatric(65 + Yrs)
A
B
C
D
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.
Able to ensure a safe environment to reflect needs and alter environment accordingly.
Able to administer medications appropriately and understand different meds, dosages, and possible side effects.
Send Email to:  
By checking this box I understand that this is my electronic signature and all the information is correct and true.