Intensive Care RN

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Name*

First Last

Phone*

Email*

Age Specific Care

Proficiency Rating

Frequency Rating

Newborn/Neonate (birth - 30 days) *

Newborn/Neonate (birth - 30 days) proficiency*

Newborn/Neonate (birth - 30 days) frequency*

Infant (30 days - 1 year) *

Infant (30 days - 1 year) proficiency*

Infant (30 days - 1 year) frequency*

Toddler (1 - 3 years) *

Toddler (1 - 3 years) proficiency*

Toddler (1 - 3 years) frequency*

Preschooler (3 - 5 years) *

Preschooler (3 - 5 years) proficiency*

Preschooler (3 - 5 years) frequency*

School Age Child (5 - 12 years) *

School Age Child (5 - 12 years) proficiency*

School Age Child (5 - 12 years) frequency*

Adolescents (12 - 18 years) *

Adolescents (12 - 18 years) proficiency*

Adolescents (12 - 18 years) frequency*

Young Adults (18 - 39 years) *

Young Adults (18 - 39 years) proficiency*

Young Adults (18 - 39 years) frequency*

Middle Adults (39 - 64 years) *

Middle Adults (39 - 64 years) proficiency*

Middle Adults (39 - 64 years) frequency*

Older Adults (64+ years) *

Older Adults (64+ years) proficiency*

Older Adults (64+ years) frequency*

Elderly Adults (over 79+ years) *

Elderly Adults (over 79+ years) proficiency*

Elderly Adults (over 79+ years) frequency*

General Skills

Proficiency Rating

Frequency Rating

Draw Blood Cultures *

Draw Blood Cultures proficiency*

Draw Blood Cultures frequency*

Perform Blood Draw *

Perform Blood Draw proficiency*

Perform Blood Draw frequency*

Discontinue ART Line *

Discontinue ART Line proficiency*

Discontinue ART Line frequency*

Discontinue PICC Line *

Discontinue PICC Line proficiency*

Discontinue PICC Line frequency*

Initiate IV Access *

Initiate IV Access proficiency*

Initiate IV Access frequency*

Standard Precautions *

Standard Precautions proficiency*

Standard Precautions frequency*

Isolation Precautions *

Isolation Precautions proficiency*

Isolation Precautions frequency*

Pediatric Respiratory / Cardiac Arrest *

Pediatric Respiratory / Cardiac Arrest proficiency*

Pediatric Respiratory / Cardiac Arrest frequency*

Adult Respiratory / Cardiac Arrest *

Adult Respiratory / Cardiac Arrest proficiency*

Adult Respiratory / Cardiac Arrest frequency*

Defibrillators *

Defibrillators proficiency*

Defibrillators frequency*

Care of Patient in Restraints *

Care of Patient in Restraints proficiency*

Care of Patient in Restraints frequency*

Pain Management *

Pain Management proficiency*

Pain Management frequency*

Automated Med Dispensing Systems *

Automated Med Dispensing Systems proficiency*

Automated Med Dispensing Systems frequency*

List Types:

Care Planning *

Care Planning proficiency*

Care Planning frequency*

Discharge Planning *

Discharge Planning proficiency*

Discharge Planning frequency*

Patient / Family Education *

Patient / Family Education proficiency*

Patient / Family Education frequency*

Electronic Documentation *

Electronic Documentation proficiency*

Electronic Documentation frequency*

List Types:

Patient Head to Toe Assessment *

Patient Head to Toe Assessment proficiency*

Patient Head to Toe Assessment frequency*

Dressing Changes *

Dressing Changes proficiency*

Dressing Changes frequency*

Knowledge of Normal Serum Lab Values *

Knowledge of Normal Serum Lab Values proficiency*

Knowledge of Normal Serum Lab Values frequency*

Obtaining Cultures (Blood, Sputum, Swab) *

Obtaining Cultures (Blood, Sputum, Swab) proficiency*

Obtaining Cultures (Blood, Sputum, Swab) frequency*

Administration of Blood & Blood Products *

Administration of Blood & Blood Products proficiency*

Administration of Blood & Blood Products frequency*

PCA Pumps *

PCA Pumps proficiency*

PCA Pumps frequency*

Infusion Pump:

Calculate mcg / min and mcg / kg / min *

Calculate mcg / min and mcg / kg / min proficiency*

Calculate mcg / min and mcg / kg / min frequency*

Titrating Medications *

Titrating Medications proficiency*

Titrating Medications frequency*

Neuro General Skills

Proficiency Rating

Frequency Rating

Cranial Nerve Assessment *

Cranial Nerve Assessment proficiency*

Cranial Nerve Assessment frequency*

ICP Monitoring *

ICP Monitoring proficiency*

ICP Monitoring frequency*

Assessment of Neuro Signs *

Assessment of Neuro Signs proficiency*

Assessment of Neuro Signs frequency*

Glasgow Coma Scale *

Glasgow Coma Scale proficiency*

Glasgow Coma Scale frequency*

Stroke Scale *

Stroke Scale proficiency*

Stroke Scale frequency*

Seizure Precautions *

Seizure Precautions proficiency*

Seizure Precautions frequency*

Assist with Lumbar Puncture *

Assist with Lumbar Puncture proficiency*

Assist with Lumbar Puncture frequency*

Crutchfield Tongs *

Crutchfield Tongs proficiency*

Crutchfield Tongs frequency*

Halo Traction *

Halo Traction proficiency*

Halo Traction frequency*

Stryker Frame *

Stryker Frame proficiency*

Stryker Frame frequency*

Hypo / Hyperthermia Blanket *

Hypo / Hyperthermia Blanket proficiency*

Hypo / Hyperthermia Blanket frequency*

Neuro - Care of Patient with:

Proficiency Rating

Frequency Rating

Meningitis *

Meningitis proficiency*

Meningitis frequency*

Coma *

Coma proficiency*

Coma frequency*

CVA / TIA *

CVA / TIA proficiency*

CVA / TIA frequency*

Seizure Activity *

Seizure Activity proficiency*

Seizure Activity frequency*

Overdose *

Overdose proficiency*

Overdose frequency*

Neuro Injury / Trauma *

Neuro Injury / Trauma proficiency*

Neuro Injury / Trauma frequency*

Pre / Post Neuro Surgery *

Pre / Post Neuro Surgery proficiency*

Pre / Post Neuro Surgery frequency*

Cranial Hemorrhage *

Cranial Hemorrhage proficiency*

Cranial Hemorrhage frequency*

Knowledge and Use of:

Proficiency Rating

Frequency Rating

Anti-seizure Meds *

Anti-seizure Meds proficiency*

Anti-seizure Meds frequency*

Sedatives *

Sedatives proficiency*

Sedatives frequency*

Analgesics *

Analgesics proficiency*

Analgesics frequency*

Cardiac General Skills

Proficiency Rating

Frequency Rating

Interpretation of 12 lead EKG *

Interpretation of 12 lead EKG proficiency*

Interpretation of 12 lead EKG frequency*

Interpretation of Arrhythmias *

Interpretation of Arrhythmias proficiency*

Interpretation of Arrhythmias frequency*

Defibrillation / Cardioversion *

Defibrillation / Cardioversion proficiency*

Defibrillation / Cardioversion frequency*

Permanent Pacemaker *

Permanent Pacemaker proficiency*

Permanent Pacemaker frequency*

Temporary Pacemaker *

Temporary Pacemaker proficiency*

Temporary Pacemaker frequency*

AICD *

AICD proficiency*

AICD frequency*

Interpretation of Hemodynamic Monitoring *

Interpretation of Hemodynamic Monitoring proficiency*

Interpretation of Hemodynamic Monitoring frequency*

Art-Line (Transducer set-up, D/C) *

Art-Line (Transducer set-up, D/C) proficiency*

Art-Line (Transducer set-up, D/C) frequency*

Swan-Ganz (Transducer set-up, D/C) *

Swan-Ganz (Transducer set-up, D/C) proficiency*

Swan-Ganz (Transducer set-up, D/C) frequency*

Balloon Pump (IABP) *

Balloon Pump (IABP) proficiency*

Balloon Pump (IABP) frequency*

SVO2 Monitoring *

SVO2 Monitoring proficiency*

SVO2 Monitoring frequency*

Sheath Removal *

Sheath Removal proficiency*

Sheath Removal frequency*

Interpretation of Cardiac Enzymes *

Interpretation of Cardiac Enzymes proficiency*

Interpretation of Cardiac Enzymes frequency*

Cardiac - Care of Patient with:

Proficiency Rating

Frequency Rating

Aneurysm *

Aneurysm proficiency*

Aneurysm frequency*

Acute MI / Unstable Angina *

Acute MI / Unstable Angina proficiency*

Acute MI / Unstable Angina frequency*

CHF *

CHF proficiency*

CHF frequency*

Cardiogenic / Hypovolemic Shock *

Cardiogenic / Hypovolemic Shock proficiency*

Cardiogenic / Hypovolemic Shock frequency*

Pre / Post Cardiac Surgery *

Pre / Post Cardiac Surgery proficiency*

Pre / Post Cardiac Surgery frequency*

Pre / Post Cardiac Cath *

Pre / Post Cardiac Cath proficiency*

Pre / Post Cardiac Cath frequency*

Percutaneous Transluminal Coronary Angioplasty *

Percutaneous Transluminal Coronary Angioplasty proficiency*

Percutaneous Transluminal Coronary Angioplasty frequency*

Heart Transplant *

Heart Transplant proficiency*

Heart Transplant frequency*

Knowledge and use of:

Proficiency Rating

Frequency Rating

Atropine *

Atropine proficiency*

Atropine frequency*

Bretylol *

Bretylol proficiency*

Bretylol frequency*

Bumex *

Bumex proficiency*

Bumex frequency*

Digoxin *

Digoxin proficiency*

Digoxin frequency*

Dopamine *

Dopamine proficiency*

Dopamine frequency*

Dobutrex *

Dobutrex proficiency*

Dobutrex frequency*

Heparin Drip (Precautions & Maintenance) *

Heparin Drip (Precautions & Maintenance) proficiency*

Heparin Drip (Precautions & Maintenance) frequency*

Inderal *

Inderal proficiency*

Inderal frequency*

Inocor *

Inocor proficiency*

Inocor frequency*

Isuprel *

Isuprel proficiency*

Isuprel frequency*

Lidocaine *

Lidocaine proficiency*

Lidocaine frequency*

Nipride *

Nipride proficiency*

Nipride frequency*

Nitroglycerin *

Nitroglycerin proficiency*

Nitroglycerin frequency*

Pronestyl *

Pronestyl proficiency*

Pronestyl frequency*

Titrate Morphine *

Titrate Morphine proficiency*

Titrate Morphine frequency*

Thrombolytic Agents *

Thrombolytic Agents proficiency*

Thrombolytic Agents frequency*

Magnesium Sulfate *

Magnesium Sulfate proficiency*

Magnesium Sulfate frequency*

Versed *

Versed proficiency*

Versed frequency*

Prep / Titration of Emergency Drugs *

Prep / Titration of Emergency Drugs proficiency*

Prep / Titration of Emergency Drugs frequency*

Respiratory General Skills:

Proficiency Rating

Frequency Rating

Establishing an Airway *

Establishing an Airway proficiency*

Establishing an Airway frequency*

Oxygen Delivery Systems *

Oxygen Delivery Systems proficiency*

Oxygen Delivery Systems frequency*

Chest Tubes (Emerson / Pleuravac) *

Chest Tubes (Emerson / Pleuravac) proficiency*

Chest Tubes (Emerson / Pleuravac) frequency*

Pulse Oximetry *

Pulse Oximetry proficiency*

Pulse Oximetry frequency*

Interpretation of ABG *

Interpretation of ABG proficiency*

Interpretation of ABG frequency*

Drawing ABG Blood Sample from Art - Line *

Drawing ABG Blood Sample from Art - Line proficiency*

Drawing ABG Blood Sample from Art - Line frequency*

Use of Intermittent Positive Pressure Breathing *

Use of Intermittent Positive Pressure Breathing proficiency*

Use of Intermittent Positive Pressure Breathing frequency*

Use of Pressure Support *

Use of Pressure Support proficiency*

Use of Pressure Support frequency*

Suctioning *

Suctioning proficiency*

Suctioning frequency*

Ventilators *

Ventilators proficiency*

Ventilators frequency*

List Types:

Respiratory - Care of Patient with:

Proficiency Rating

Frequency Rating

COPD *

COPD proficiency*

COPD frequency*

ARDS *

ARDS proficiency*

ARDS frequency*

Pre / Post Thoracic Surgery *

Pre / Post Thoracic Surgery proficiency*

Pre / Post Thoracic Surgery frequency*

Pulmonary Embolism *

Pulmonary Embolism proficiency*

Pulmonary Embolism frequency*

Pulmonary Edema *

Pulmonary Edema proficiency*

Pulmonary Edema frequency*

Pneumonia *

Pneumonia proficiency*

Pneumonia frequency*

Inhalation Injuries *

Inhalation Injuries proficiency*

Inhalation Injuries frequency*

Lung Transplant *

Lung Transplant proficiency*

Lung Transplant frequency*

Knowledge and use of:

Proficiency Rating

Frequency Rating

Bronchodilators *

Bronchodilators proficiency*

Bronchodilators frequency*

Corticosteroids *

Corticosteroids proficiency*

Corticosteroids frequency*

Gastrointestinal General Skills:

Proficiency Rating

Frequency Rating

NG Tube Insertion *

NG Tube Insertion proficiency*

NG Tube Insertion frequency*

Gastrostomy Tube *

Gastrostomy Tube proficiency*

Gastrostomy Tube frequency*

Jejunostomy Tube *

Jejunostomy Tube proficiency*

Jejunostomy Tube frequency*

Enterostomal Care *

Enterostomal Care proficiency*

Enterostomal Care frequency*

Gastrointestinal - Care of Patient with:

Proficiency Rating

Frequency Rating

PEG Tube *

PEG Tube proficiency*

PEG Tube frequency*

Pancreatitis *

Pancreatitis proficiency*

Pancreatitis frequency*

GI Bleed *

GI Bleed proficiency*

GI Bleed frequency*

Esophageal Bleeding *

Esophageal BleedingLithotripsy proficiency*

Esophageal Bleeding frequency*

Bowel Obstruction *

Bowel Obstruction proficiency*

Bowel Obstruction frequency*

Whipple Procedure *

Whipple Procedure proficiency*

Whipple Procedure frequency*

Liver Transplant *

Liver Transplant proficiency*

Liver Transplant frequency*

Hepatitis *

Hepatitis proficiency*

Hepatitis frequency*

Paralytic Ileus *

Paralytic Ileus proficiency*

Paralytic Ileus frequency*

Endoscopic Retrograde Cholangio - Pancreatography *

Endoscopic Retrograde Cholangio - Pancreatography proficiency*

Endoscopic Retrograde Cholangio - Pancreatography frequency*

Knowledge and use of:

Proficiency Rating

Frequency Rating

Antiemetics *

Antiemetics proficiency*

Antiemetics frequency*

Proton Pump Inhibitors *

Proton Pump Inhibitors proficiency*

Proton Pump Inhibitors frequency*

TPN / Hyperalimentation *

TPN / Hyperalimentation proficiency*

TPN / Hyperalimentation frequency*

Genitourinary / Renal General Skills

Proficiency Rating

Frequency Rating

Foley / Straight Catheter Insertion *

Foley / Straight Catheter Insertion proficiency*

Foley / Straight Catheter Insertion frequency*

GU Irrigations (Continuous and Intermittent) *

GU Irrigations (Continuous and Intermittent) proficiency*

GU Irrigations (Continuous and Intermittent) frequency*

Nephrostomy Tube *

Nephrostomy Tube proficiency*

Nephrostomy Tube frequency*

Suprapubic Tube *

Suprapubic Tube proficiency*

Suprapubic Tube frequency*

Electrolyte Imbalance / Replacement *

Electrolyte Imbalance / Replacement proficiency*

Electrolyte Imbalance / Replacement frequency*

Genitourinary / Renal - Care of Patient with:

Proficiency Rating

Frequency Rating

T.U.R.P. *

T.U.R.P. proficiency*

T.U.R.P. frequency*

Shunts & Fistulas *

Shunts & Fistulas proficiency*

Shunts & Fistulas frequency*

Nephrectomy *

Nephrectomy proficiency*

Nephrectomy frequency*

Renal Transplant *

Renal Transplant proficiency*

Renal Transplant frequency*

Renal Failure *

Renal Failure proficiency*

Renal Failure frequency*

Peritoneal Dialysis *

Peritoneal Dialysis proficiency*

Peritoneal Dialysis frequency*

Hemodialysis *

Hemodialysis proficiency*

Hemodialysis frequency*

Continuous Renal Replacement Therapy *

Continuous Renal Replacement Therapy proficiency*

Continuous Renal Replacement Therapy frequency*

Renal Trauma *

Renal Trauma proficiency*

Renal Trauma frequency*

Endocrine General Skills

Proficiency Rating

Frequency Rating

Diabetic Teaching *

Diabetic Teaching proficiency*

Diabetic Teaching frequency*

Endocrine - Care of Patient with:

Proficiency Rating

Frequency Rating

Hyper / Hypoglycemia *

Hyper / Hypoglycemia proficiency*

Hyper / Hypoglycemia frequency*

Diabetic Ketoacidosis *

Diabetic Ketoacidosis proficiency*

Diabetic Ketoacidosis frequency*

Knowledge and use of:

Proficiency Rating

Frequency Rating

Insulin (IV, SQ) *

Insulin (IV, SQ) proficiency*

Insulin (IV, SQ) frequency*

D50 *

D50 proficiency*

D50 frequency*

Vascular General Skills

Proficiency Rating

Frequency Rating

Peripheral Pulses *

Peripheral Pulses proficiency*

Peripheral Pulses frequency*

Dopplers *

Dopplers proficiency*

Dopplers frequency*

Peripheral IV Insertion, Care and Maintenance *

Peripheral IV Insertion, Care and Maintenance proficiency*

Peripheral IV Insertion, Care and Maintenance frequency*

Assisting with Insertion of Central Lines *

Assisting with Insertion of Central Lines proficiency*

Assisting with Insertion of Central Lines frequency*

Care and Maintenance of Central Lines *

Care and Maintenance of Central Lines proficiency*

Care and Maintenance of Central Lines frequency*

Assist with IV Cutdown *

Assist with IV Cutdown proficiency*

Assist with IV Cutdown frequency*

Other

Proficiency Rating

Frequency Rating

Lithotripsy *

Care of Patient with Trauma Wounds proficiency*

Care of Patient with Trauma Wounds frequency*

Care of Oncology Patient *

Care of Oncology Patient proficiency*

Care of Oncology Patient frequency*

Chemotherapy Administration *

Chemotherapy Administration proficiency*

Chemotherapy Administration frequency*

Care of Patient with Burns *

Care of Patient with Burns proficiency*

Care of Patient with Burns frequency*

Care of Patient with HIV / AIDS *

Care of Patient with HIV / AIDS proficiency*

Care of Patient with HIV / AIDS frequency*

Hyperbaric Oxygenation *

Hyperbaric Oxygenation proficiency*

Hyperbaric Oxygenation frequency*

Suicide Precautions *

Suicide Precautions proficiency*

Suicide Precautions frequency*

Post Mortem Care *

Post Mortem Care proficiency*

Post Mortem Care frequency*

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Date*

Skills/Competences

Proficiency

Frequency

INTENSIVE CARE RN

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