Telemetry/Progressive Care Self Assessment

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Transcription:

Telemetry/Progressive Care Self Assessment Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional. 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Print Name Last 4 Digits of SS# Date General Skills Advanced directives 0 1 2 3 4 5 Awareness of HCAHPS 0 1 2 3 4 5 Patient/family teaching 0 1 2 3 4 5 Restrictive devices (restraints) 0 1 2 3 4 5 Lift/transfer devices 0 1 2 3 4 5 Specialty beds 0 1 2 3 4 5 End of life care/palliative care 0 1 2 3 4 5 Automated Medication Dispensing System, Pyxis, Omnicell, or other 0 1 2 3 4 5 Bar coding for medication administration 0 1 2 3 4 5 National Patient Safety Goals 0 1 2 3 4 5 Accurate patient identification 0 1 2 3 4 5 Effective communication 0 1 2 3 4 5 Interpretation & communication of lab values 0 1 2 3 4 5 Medication administration 0 1 2 3 4 5 Labeling 0 1 2 3 4 5 Anticoagulation therapy 0 1 2 3 4 5 Medication reconciliation 0 1 2 3 4 5 Monitoring conscious sedation 0 1 2 3 4 5 Pain assessment & management 0 1 2 3 4 5 Use of PCA (IV, intrathecal, epidural) 0 1 2 3 4 5 Infection control 0 1 2 3 4 5 Universal precautions 0 1 2 3 4 5 Isolation 0 1 2 3 4 5 Minimize risk for falls 0 1 2 3 4 5 Prevention of pressure ulcers 0 1 2 3 4 5 Wound care 0 1 2 3 4 5 Wound vac 0 1 2 3 4 5 Cardiac Monitoring & Emergency Care Obtains 12 lead EKG 0 1 2 3 4 5 Interpretation of rhythm strips 0 1 2 3 4 5 Treatment of dysrythmias 0 1 2 3 4 5 2012 MedStaff Healthcare Solutions Rev. 09/12 F0377 Tele/Prog 1 of 6

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) General Skills - cont. Use of rapid response teams 0 1 2 3 4 5 Cardiac arrest/cpr 0 1 2 3 4 5 O2 therapy & delivery 0 1 2 3 4 5 Pulse oximetry 0 1 2 3 4 5 Use of doppler 0 1 2 3 4 5 IV Therapy Starting & maintaining peripheral IVs 0 1 2 3 4 5 Blood draw: venous 0 1 2 3 4 5 Central line care 0 1 2 3 4 5 Blood draw: central line 0 1 2 3 4 5 Care & management of ports 0 1 2 3 4 5 Care & management of PICC/Groshong/Hickman 0 1 2 3 4 5 TPN & lipids 0 1 2 3 4 5 Administration of blood/blood products 0 1 2 3 4 5 Administration of chemotherapy 0 1 2 3 4 5 Monitoring chemotherapy (does not initiate) 0 1 2 3 4 5 Other Care of patient with sepsis 0 1 2 3 4 5 Diabetes mellitus 0 1 2 3 4 5 Blood Glucose Monitoring (BGM) 0 1 2 3 4 5 Insulin administration 0 1 2 3 4 5 Cardiovascular Assessment of heart sounds 0 1 2 3 4 5 External & temporary pacemakers 0 1 2 3 4 5 Management of permanent pacemaker/aicd 0 1 2 3 4 5 Angina 0 1 2 3 4 5 CHF 0 1 2 3 4 5 Acute MI 0 1 2 3 4 5 Pre/post cardiac surgery (CABG & valves) 0 1 2 3 4 5 Pre/post vascular surgery (abdominal or thoracic AA, fem-pop, carotid) 0 1 2 3 4 5 Cardiogenic shock 0 1 2 3 4 5 Preparation & administration of emergency (ACLS) meds 0 1 2 3 4 5 Inotropics (i.e. digoxin, dopamine, epinephrine) 0 1 2 3 4 5 Antiarrythmics (beta blockers/ca+ channel blockers) 0 1 2 3 4 5 Antianginals (isordil/nitrates) 0 1 2 3 4 5 Antihypertensives 0 1 2 3 4 5 2012 MedStaff Healthcare Solutions Rev. 09/12 F0377 Tele/Prog 2 of 6

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Cardiovascular - cont. Antilipemics ( statins ) 0 1 2 3 4 5 Diuretics 0 1 2 3 4 5 Pulmonary Assessment of breath sounds 0 1 2 3 4 5 Airway management/suctioning (ETT, oral, trach) 0 1 2 3 4 5 Incentive spirometer 0 1 2 3 4 5 Recognition & treatment of abnormal ABGS s 0 1 2 3 4 5 Management of chest tubes 0 1 2 3 4 5 Heimlich valve 0 1 2 3 4 5 COPD/emphysema 0 1 2 3 4 5 Asthma 0 1 2 3 4 5 Tuberculosis 0 1 2 3 4 5 Pulmonary embolism 0 1 2 3 4 5 Pulmonary edema 0 1 2 3 4 5 Pneumothorax 0 1 2 3 4 5 Tracheostomy 0 1 2 3 4 5 Pneumonia 0 1 2 3 4 5 Thoracentesis/paracentesis 0 1 2 3 4 5 Antihistamines 0 1 2 3 4 5 Bronchodilators 0 1 2 3 4 5 Expectorants & antitussives 0 1 2 3 4 5 Use of inhalers 0 1 2 3 4 5 Use of nebulizer treatments 0 1 2 3 4 5 Neurology Comprehensive neuro assessment 0 1 2 3 4 5 Glasgow coma scale 0 1 2 3 4 5 Utilize seizure precautions/seizures 0 1 2 3 4 5 Assist with lumbar puncture 0 1 2 3 4 5 TIA/CVA 0 1 2 3 4 5 Cranial hemorrhage & hematoma 0 1 2 3 4 5 Aspiration precautions 0 1 2 3 4 5 Overdose/DT s 0 1 2 3 4 5 Spinal cord injury/trauma 0 1 2 3 4 5 TBI (Traumatic Brain Injury) 0 1 2 3 4 5 2012 MedStaff Healthcare Solutions Rev. 09/12 F0377 Tele/Prog 3 of 6

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Neurology - cont. Pre/post neuro surgery 0 1 2 3 4 5 Degenerative neurological disorders 0 1 2 3 4 5 Halo traction/vest 0 1 2 3 4 5 Anticonvulsants (Dilantin/Neurontin/phenobarbitol) 0 1 2 3 4 5 Antidepressants 0 1 2 3 4 5 Antiparkinsons (Cogentin/levodopa/Sinemet) 0 1 2 3 4 5 Gastrointestinal Insertion & management of NG tube 0 1 2 3 4 5 Insertion & management of small bore feeding tubes (Dobhoff, Keofeed) 0 1 2 3 4 5 Management of gastrostomy/jejunostomy tube 0 1 2 3 4 5 Management of post surgical drains 0 1 2 3 4 5 GI bleed (upper/lower) 0 1 2 3 4 5 Hepatitis 0 1 2 3 4 5 Pre/post open abdominal surgery 0 1 2 3 4 5 Colostomy/ileostomy 0 1 2 3 4 5 IBS 0 1 2 3 4 5 ERCP 0 1 2 3 4 5 Paralytic ileus 0 1 2 3 4 5 Gastric bypass 0 1 2 3 4 5 Gastric banding 0 1 2 3 4 5 Peritonitis 0 1 2 3 4 5 Antiulcer drugs 0 1 2 3 4 5 Antiemetics 0 1 2 3 4 5 Antacids 0 1 2 3 4 5 Digestive enzymes 0 1 2 3 4 5 Genitourinary/Renal Insertion & maintenance of foley catheter 0 1 2 3 4 5 Care of nephrostomy tube 0 1 2 3 4 5 Care of suprapubic tube 0 1 2 3 4 5 Fluid & electrolyte disturbance 0 1 2 3 4 5 UTI 0 1 2 3 4 5 2012 MedStaff Healthcare Solutions Rev. 09/12 F0377 Tele/Prog 4 of 6

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Genitourinary/Renal - cont. BPH 0 1 2 3 4 5 TURP 0 1 2 3 4 5 Prostate cancer 0 1 2 3 4 5 Nephrectomy 0 1 2 3 4 5 Ilioconduit 0 1 2 3 4 5 Renal Surgery 0 1 2 3 4 5 Chronic/acute renal failure 0 1 2 3 4 5 Hemodialysis 0 1 2 3 4 5 Peritoneal dialysis 0 1 2 3 4 5 Gynecology Assist with GYN exam/pap 0 1 2 3 4 5 GYN surgeries 0 1 2 3 4 5 GYN malignancies 0 1 2 3 4 5 Progressive Care Nursing Requirements Basic & advanced life support protocols 0 1 2 3 4 5 Adenosine administration 0 1 2 3 4 5 Chest tube insertion & management 0 1 2 3 4 5 Insertion & management of arterial line 0 1 2 3 4 5 Management & D/C of arterial & venous sheaths 0 1 2 3 4 5 Femoral hemostasis devices (femstop/vasoseal) 0 1 2 3 4 5 Ventilator management 0 1 2 3 4 5 Interpretation of weaning parameters 0 1 2 3 4 5 Drug dose calculation for: Non-titrated IV vasoactive agents (Dobutrex/dopamine) 0 1 2 3 4 5 Nitrates (IV nitroglycerine) 0 1 2 3 4 5 Platelet inhibitors (reopro) 0 1 2 3 4 5 Fibrinolytics/IIb IIIa inhibitors 0 1 2 3 4 5 Anti-arrhythmic agents (amiodarone/cardizem/lidocaine) 0 1 2 3 4 5 Patient Monitoring (Pre/Post Procedure) Cardioversion 0 1 2 3 4 5 TEE 0 1 2 3 4 5 Cardiac catheterization 0 1 2 3 4 5 Bronchoscopy 0 1 2 3 4 5 EGD 0 1 2 3 4 5 PEG placement 0 1 2 3 4 5 2012 MedStaff Healthcare Solutions Rev. 09/12 F0377 Tele/Prog 5 of 6

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Progressive Care Nursing Requirements - cont. Patient Monitoring (During/Intra Procedure) Cardioversion 0 1 2 3 4 5 TEE 0 1 2 3 4 5 Bronchoscopy 0 1 2 3 4 5 EGD 0 1 2 3 4 5 PEG placement 0 1 2 3 4 5 Age Specific Competencies Newborn/neonate (birth-30 days) 0 1 2 3 4 5 Infant (31 days-1 year) 0 1 2 3 4 5 Toddler (ages 2-3 years) 0 1 2 3 4 5 Preschool (ages 4-5 years) 0 1 2 3 4 5 School age (ages 6-12 years) 0 1 2 3 4 5 Adolescent (ages 13-21 years) 0 1 2 3 4 5 Young adult (ages 22-39 years) 0 1 2 3 4 5 Adult (ages 40-64 years) 0 1 2 3 4 5 Older adult (ages 65-79 years) 0 1 2 3 4 5 Elderly (ages 80+ years) 0 1 2 3 4 5 Please list any Additional Skills: 1. 2. 3. 4. Additional training: 1. 2. 3. 4. Additional equipment: 1. 2. 3. 4. Fax to: 1-888-298-3146 The information on this and all preceding pages is true and correct. Signature Date 2012 MedStaff Healthcare Solutions Rev. 09/12 F0377 Tele/Prog 6 of 6

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