Geriatric & Long Term Care

Please rate your experience / frequency within the last year
0 = No Experience / Observed Only
1 = Limited Experience / Rarely Done (<6 times/year)
2 = May Need Some Review / Occasionally Done (1-2 times/month)
3 = Experienced / Frequently Done (daily or weekly)

Please rate your experience / frequency within the last year

0 = No Experience / Observed Only

1 = Limited Experience / Rarely Done (<6 times/year)

2 = May Need Some Review / Occasionally Done (1-2 times/month)

3 = Experienced / Frequently Done (daily or weekly)

Please rate your experience / frequency within the last year
0 = No Experience / Observed Only
1 = Limited Experience / Rarely Done (<6 times/year)
2 = May Need Some Review / Occasionally Done (1-2 times/month)
3 = Experienced / Frequently Done (daily or weekly)

MM slash DD slash YYYY

Type Of Facility Experience

Type of Facility Experience

Age Of Patients Cared For

Newborn/Neonate (birth to 30 days)
Infant (31 days to 12 months)
Toddler/Preschool (13 months to 5 years)
School Age Child/adolescent (6 years to 18 years)
Young Adults/Middle Adult (19 years to 64 years)
Older Adults/Elderly (65+ years)

General Skills

Standard Precautions
Isolation Precautions
Pain Management
Care of Patient in Restraints
Automated Med Dispensing Systems
Electronic Documentation
Peripheral IV Insertion, Care and Maintenance
Access/Management of Implanted Ports
Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
Patient/Family Education
Knowledge of "Do Not Use Abbreviations"
Do you have charge/supervisor experience?
Knowledge of current Joint Commission National Patient Safety Goals
Knowledge/familiarity with HCAHPS scores

Medications-knowledge And Use Of

Pouring From Stock Medications
Narcotic Administration
IV Push/Drip Medications
Antibiotics
Oral
Topical
Otic
Rectal
Vaginal
Ophthalmic
Continuous Subcutaneous Infusion Pumps
Total Parenteral Nutrition (TPN)
Peripheral Parenteral Nutrition
Patient Controlled Analgesia (PCA)

Phlebotomy / Iv Therapy

Blood Draw-Peripheral
Mixing IVs
Regulating IVs
IV Infusion Pumps
Blood/Blood Product Administration
IV Pumps

Cardiac General

Recognizing Basic & Life-Threatening Dysrhythmias
Congestive Heart Failure

Cardiac-care Of Patient With:

Pulse Checks
Use of Doppler
Cardiac Monitors
Obtaining EKGs - 12 Lead
Use of Automatic BP Cuff (ie Dinamap)

Knowledge And Use Of

Nitrates (Oral, Topical)
Antiarrythmics (Oral)
Antihypertensives (Oral)

Respiratory General

Emphysema
COPD
Asthma Exacerbation
Tracheostomy
Pneumonia
Pre/Post Thoracic Surgery
Chest Tubes

Respiratory-care Of Patient With:

Collection of Sputum Specimen
O2 Cannulas/Masks
Non-rebreather Mask
Nebulizer Set-up/Use
Incentive Spirometry
Chest PT
Suctioning (Oral/Nasotracheal)
Suctioning (Tracheostomy Tube)
Ventilator Patient (Mouth Care, Suctioning, Ambu bag)

Knowledge And Use Of

Bronchodilators (Oral, IV, Inhaler)
Steroids

Neuro General

Spinal Cord Injury - Acute
Spinal Cord Injury - Long Term
CVA Stroke
Neuromuscular Disease
Alzheimer Disease
Wandering
Hallucinations
Anxiousness
Agitation
Reality Orientation

Neuro-care Of Patient With:

Assessing Levels of Consciousness
Pupil Checks
Seizure Precautions
Stroke Precautions
Swallow Precautions
Assisting with Lumbar Puncture
Use of Hyper/Hypothermia Blanket

Sensory Deficits-care Of Patient With:

Dentures
Hearing Aid Devices
Care of Patients with Hearing Loss
Prosthetic Eye
Contact Lens Care
Cataracts
Blindness
Macular Degeneration

Knowledge And Use Of

Anticonvulsant
Sedative

Gi General

Nasogastric Tubes (i.e. Salem Sump, Levine)
Nasointestinal Tubes (i.e. Cantor, Miller-Abbot)
Jejunostomy, Gastrostomy, Cecostomy Tubes
Colostomy, Ileostomy
Administration of Tube Feedings via Flexible Tubes
By Gravity Infusion
By Feeding Pump

Gastrointestinal-care Of Patient With:

Collection of Stool Specimens
Bowel Preparation and Cleansing Procedures
Bowel Disimpaction
Bowel Retraining
Sitz Bath Treatments
Inserting and Checking Placement/Patency NG Tubes

Endocrine General

Diabetes
Hyper/hypoglycemia

Endocrine-care Of Patient With:

Blood Glucose Monitoring
Performing Fingersticks
Use of Blood Glucose Meter Device
Use of Visual Blood Glucose Strips

Knowledge And Use Of

Insulin
Single Type
Mixed Insulins
Insulin Infusion

Renal/gu General

Incontinence
Urinary Retention
UTI

Renal/gu-care Of Patient With:

Insertion of Catheter-Female
Insertion of Catheter - Male
Insertion of Suprapubic Catheter
Applications of Condom Catheter
Bladder Retraining
Urinary Diversion
Bladder Irrigation (Continuous and Intermittent)
Peritoneal Dialysis
Manual
Automatic Cycler Machine

Orthopedic General

Total Joint Replacement
Rheumatic/Arthritic Disease
Amputation
Fracture

Orthopedic-care Of Patient With:

Cast Care
CMS Checks
Traction - Skin
Traction - Skeletal
Range of Motion
Use of Assistive Devices
Applications of Splints of Extremities
Continuous Passive Motion Machine (CPM)
Transfer Techniques
Use of a Sliding Board
Gait Training/Retraining
Application of Prosthetic Devices
Application of Orthotic Devices

Wound/skin-care Of Patient With:

Pressure Sores
Leg Ulcers
Burns

Wound/skin General

Acute Dressing Changes
Wound Care
Irrigations
Identifying Common Skin Problems
Recognizing Normal Skin Changes
Use of Special Pressure Relief Devices
Pressure Relief Mattress/Seat Cushion

Additional Skills-care Of Patient With:

Hemovacs
Jackson-Pratt Tubes
enrose Drains
T-Tubes