Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
TREATMENT - Procedures Assessment
Breath sounds 0 1 2
Peak flow rate 0 1 2
Pulmonary function testing 0 1 2
Rate & work of breathing 0 1 2
Transcutaneous monitoring 0 1 2
INTERPRETATION OF LAB RESULTS
Arterial blood gases 0 1 2
Basic EKG 0 1 2
Blood chemistry 0 1 2
Chest X-ray 0 1 2
EQUIPMENT & PROCEDURES
Airway management devices/suctioning 0 1 2
Check intracuff pressure 0 1 2
Endotracheal tube/suctioning 0 1 2
Nasal airway placement 0 1 2
Nasal airway suctioning 0 1 2
Oral airway placement 0 1 2
Oropharyngeal/suctioning 0 1 2
Sputum specimen collection 0 1 2
Tracheostomy/suctioning 0 1 2
Analyze oxygen 0 1 2
Arterial line insertion 0 1 2
Care of patient with a chest tube 0 1 2
Assessment of function/proper operation 0 1 2
Placement assistance 0 1 2
Chest physiotherapy 0 1 2
Drawing arterial blood gases 0 1 2
Arterial line 0 1 2
Brachial artery 0 1 2
Femoral artery 0 1 2
Radial artery/Allen test 0 1 2
Extubate 0 1 2
Extubation assistance 0 1 2
Hemodynamic assistance 0 1 2
Incentive spirometry 0 1 2
Infection control practices 0 1 2
Intubate 0 1 2
Intubation assistance 0 1 2
Medication delivery system 0 1 2
Aerosal heated/cooled 0 1 2
Aerosal set up mask 0 1 2
Aerosal set up trach 0 1 2
IPPB 0 1 2
Medihaler 0 1 2
Metered dose inhalers 0 1 2
EQUIPMENT & PROCEDURES (CONT)
Bag and mask 0 1 2
ET Tube 0 1 2
External CPAP 0 1 2
Face masks 0 1 2
Nasal cannula 0 1 2
Nebulizer 0 1 2
Cold 0 1 2
Head held 0 1 2
Heated 0 1 2
Ultrasonic 0 1 2
Oxygen 0 1 2
T-piece 0 1 2
Trach collar 0 1 2
Thoracentesis assistance 0 1 2
Ventilator set up and care 0 1 2
Assist/control 0 1 2
CPAP 0 1 2
Flow-by 0 1 2
High frequency jet ventilator 0 1 2
High frequency oscillator 0 1 2
IMV 0 1 2
Inverse ratio ventilator 0 1 2
Pressure support 0 1 2
Pressure vents 0 1 2
SIMV 0 1 2
Trouble shooting high presure alarms 0 1 2
Trouble shooting low pressure alarms 0 1 2
Volume vents 0 1 2
Weaning 0 1 2
Care of the Patient With:
Acute/chronic bronchitis 0 1 2
ARDS(adult respiratory distress syndrome) 0 1 2
Aspiration 0 1 2
Asthma 0 1 2
Bronchoscopy 0 1 2
Cardiac Surgery 0 1 2
CHF 0 1 2
COPD 0 1 2
Cystic fibrosis 0 1 2
Epiglottitis 0 1 2
Fresh tracheostomy 0 1 2
Guillain Barre 0 1 2
Hemophneumothorax 0 1 2
Laryngospasm 0 1 2
Care of the Patient With: (CONT)
Myasthenia 0 1 2
Pneumonia 0 1 2
Pulmonary edema 0 1 2
Pulmonary embolism 0 1 2
Smoke inhalation 0 1 2
Status asthmaticus 0 1 2
Tension pneumothorax 0 1 2
Thoracotomy 0 1 2
Tracheo-esophageal fistula 0 1 2
Tuberculosis 0 1 2
MEDICATIONS - Administration of:
Aerobid, Vanceril 0 1 2
Aminophylline (Theophylline) 0 1 2
Azmacort 0 1 2
Bicarbonate 0 1 2
Combivent 0 1 2
Cromolyn Sodium (Intal) 0 1 2
Decadron 0 1 2
Flonase 0 1 2
Flovent 0 1 2
Inhaled steriods 0 1 2
Ipratropium bromide (Atrovent) 0 1 2
Isoetharine (Bronkosol) 0 1 2
Isoproterenol (Isuprel) 0 1 2
Metaproterenol (Alupent)Mucomyst 0 1 2
Nasalcort 0 1 2
Racemic epinephrine 0 1 2
Salbutamol (Albuterol, Proventil, Ventolin) 0 1 2
Terbutaline sulfate (Bricanyl) 0 1 2
FAMILIAR WITH EFFECTS OF:
Anectine 0 1 2
Atropine 0 1 2
Corticosteroids 0 1 2
Digitalis 0 1 2
Digoxin 0 1 2
FAMILIAR WITH EFFECTS OF: (CONT)
Dopamine 0 1 2
Duramorph 0 1 2
Heli-ox therapy 0 1 2
Ketamine 0 1 2
Lidocaine 0 1 2
Morphine sulfate 0 1 2
Nipride 0 1 2
Nitric oxide therapy 0 1 2
Pavulon 0 1 2
Pentamide isethionate 0 1 2
Porpofol 0 1 2
Theo-dur 0 1 2
Valium 0 1 2
Versed 0 1 2
PHLEBOTOMY - Equipment & Procedures
Drawing blood from central line 0 1 2
Drawing blood from peripheral line 0 1 2
Drawing venous blood 0 1 2
NEONATAL/PEDIATRICS - Equipment & Procedures
Assist in high risk delivery 0 1 2
Capillary blood gases 0 1 2
ECMO 0 1 2
Oxygen 0 1 2
Umbilical blood gases 0 1 2
Bronchopulmonary dysplasia (BPD) 0 1 2
Croup 0 1 2
Epiglottitis 0 1 2
Meconium aspiration 0 1 2
Near drowning 0 1 2
Persistent pulmonary hypertension (PPHN) 0 1 2
Pulmonary interstitial emphysema (PIE) 0 1 2
Respiratory distress syndrome (RDS) 0 1 2
Respiratory syncytial virus 0 1 2
Transient tachypnea of the newborn 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.
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