SKILLS CHECKLIST CRITICAL CARE NURSING

NAME OF APPLICANT: ____________________________________DATE: __________________

HOW TO COMPLETE THIS FORM: LEVELS OF PROFICIENCY:

A thorough evaluation of your skill level in various specialty areas will
enable us to locate assignments that are suitable to your skills and the
needs of our patients. Please identify your experience by placing an
“X” in the box that most accurately describes your level of expertise
for the skills listed. Complete the assessment for both the ADULT and
PEDIATRIC columns.
A= Perform Well (at least one year of current experience, very
comfortable performing without supervision).
B= Limited Experience (six months to one year of experience, would
require some assistance).
C= Perform infrequently (less than three months of experience, need
more experience and practice, assistance required).
D= No Experience (have never performed this task, willing to learn).

ADULT PEDIATRIC

COMPETENCIES A B C D A B C D
Critical Care Skills Utilized in ALL or MOST AREAS including Step-Down Areas
Airway Management
BiPAP and CPAP
Blood & Blood Products Transfusion
Blood Cultures, Obtain Peripheral
Blood Gas, Obtain via Arterial Line
Blood Sample, Obtain by Line Draw
Blood Sample, Obtain by Venipuncture
Cardiac Cath Lab Skills
Cardiac Output Monitoring with PiCCO
Cardiac Output Monitoring with Pulmonary
Artery Catheter
Capillary Blood Glucose Monitoring
Cardiac Rhythm Interpretation
Cardioversion, Assist with
Care of the Patient with Spinal Cord Injury
Care of the Patient with Head Injury
Continuous Renal Replacement Therapy
(CRRT with Prisma, Prismaflex or Fresenius)
Chest Tubes and Drainage System
Defibrillation, Independent
EKG, Obtaining 12 Lead
Endotracheal Tubes
EtCO2 Monitoring
Glasgow Coma Scale Calculation
High Frequency Oscillatory Ventilator
Hyperalimination & Lipids (TPN)
Intra-Aortic Balloon Pump, Care of Patient
With and Assist on Insertion
Intubation, Assist with
Intracranial Pressure Monitoring and
Ventricular Drains
Intravenous Insertion

June 2010 Page 1 of 3

 ADULT PEDIATRIC

COMPETENCIES A B C D A B C D
Critical Care Skills Utilized in ALL or MOST AREAS including Step-Down Areas
Pacemakers: Permanent/Transvenous
Patient Control Analgesia
PCA/Epidural Pain Control
Peritoneal Dialysis
Peripheral Nerve Stimulator
Physical Assessment, Head to Toe –
Basic/Advanced
Pneumatic Compression Devices for DVT
Prophylaxis
Pressure Lines – Arterial, Assist with
Insertion and Maintenance
Pressure Lines – Central Venous, Assist with
Insertion and Maintenance
Pressure Lines – Pulmonary Artery Catheter,
Assist with Insertion and Maintenance
Cardiaco pulmonary measurements via
PICCO
PTCA, Stent, Femoral Sheath Care
Sedation Monitoring/Scoring
Tracheostomy Tubes, New and Old
Transcutaneous Pacing
Ventilator Management
Pharmacology: Including Drug Calculation &Titration
Adenosine
Alteplase
Amiodarone, Bolus and Infusions
Diltiazem
Dobutamine/Dopamine
Epidural Anesthesia
Epinephrine Infusion
Enoxaparin
Esmolol
Etomidate
Fentanyl Infusion
Furosemide Infusion
Heparin Infusion
Insulin Infusion
Labetolol
Magnesium Sulfate
Midazalom
Milrinone
Morphine Infusion
Nitroglycerin Infusion
Nitroprusside Infusion

June 2010 Page 2 of 3

Norepinephrine

ADULT PEDIATRIC

COMPETENCIES A B C D A B C D
Pharmacology: Including Drug Calculation &Titration
Omeprazole
Pancuronium
Phenylephrine
Procainamide
Propofol
Prostaglandin
Rocuronium
Streptokinase
TPA – Tissue Plasminogen Activator
Vasopressin
Verapamil

CERTIFICATIONS:
Advanced Cardiac Life Support (ACLS) Yes No Date Attained: __________________
Pediatric Advanced Life support (PALS) Yes No Date Attained: __________________

CRITICAL CARE CERTIFICATION:

CCRN Yes No Date Attained: __________________
ENB-100 (UK) Yes No Date Attained: __________________
OTHER (please specify) ___________________________ Date Attained: __________________

How many beds are in your most recent ICU? ________________________________________________

What is your current nurse/patient ratio? ____________________________________________________

Please check the areas where you have clinical experience and feel you could comfortably work after
an orientation.
_____ Intubated and Ventilated patient
_____ Ventilated patient with single inotropic support and sedation
_____ ventilated patient with multiple inotropic support and sedated and chemically paralyzed
_____ Patient with an EVD and ICP monitoring
_____ Patient weaning from Inotropic support
_____ Patient with a tracheotomy.

--------Care of a patient on continuous renal replacement therapy.

Signature of the Applicant: ________________________________ Date: ___________________

June 2010 Page 3 of 3