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Long Term Care RN

This self evaluation is for assessing your experience in specific clinical areas. This self evaluation will not be a determining factor in accepting your application to become an employee of Fusion Medical Staffing.

  • 0 = Not Applicable
  • 1 = No Experience
  • 2 = Some Experience
  • 3 = Intermittent Experience
  • 4 = Experienced
  • 5 = Very Experienced
*Required
n/a
1
2
3
4
5

* Required

Age of Patients Cared For

Newborn/ Neonate (birth to 30 days)*

Infant (1 month to 1 year)*

Toddler (1 year to 3 years)*

Preschooler (3 years to 5 years)*

School Age Child (5 years to 12 years)*

Adolescents (12 years to 18 years)*

Young Adults (18 years to 39 years)*

Middle Adults (39 years to 64 years)*

Older Adults (64 years to 79 years)*

Elderly Adults (over 79+ years)*

General Skills

Standard Precautions*

Isolation Precautions*

Pediatric Respiratory/ Cardiac Arrest*

Adult Respiratory/ Cardiac Arrest*

Crash Carts*

Defibrillators*

Care of Patients in Restraints*

Pain Management*

Automated Med Dispensing System*

Care Planning & Discharge Planning*

Patient/ Family Education*

Electronic Documentation*

Patient Head to Toe Assessment*

Medication-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*

Blood Draw- Central Line/ Port*

Insertion, Care and Maintenance of Peripheral IV*

Care and Maintenance of Central Lines*

Care and Maintenance of Implanted Port- A- Cath*

Mixing IVs*

Regulating IVs*

IV Infusion Pumps*

Blood/ Blood Product Administration*

Cardiac

Recognizing Basic & Life- Threatening Dysrhythmia*

Congestive Heart Failure*

Pulse Checks*

Use of Doppler Cardiac Monitors*

Taking EKGs- 12 Lead*

Use of Automatic BP Cuff (ie Dinamap)*

Care of Patient With:

Heart Failure*

CHF*

MI*

Arrhythmias*

Hypertension*

Hypotension*

CAD*

Knowledge and Use of:

Anticoagulants*

Nitrates (Oral, Topical)*

Antiarrhythmics (Oral)*

Antihypertensives (Oral)*

Respiratory

COPD*

Asthma Exacerbation*

Tracheostomy*

Pneumonia*

Emphysema*

Pre/ Post Thoracic Surgery*

Chest Tubes*

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

Spinal Cord Injury- Acute*

Spinal Cord Injury- Long Term*

CVA/Stroke*

Neuromuscular Disease*

Alzheimer's Disease*

Wandering*

Hallucinations*

Anxiety*

Agitation*

Reality Orientation*

Assessing Levels of Consciousness*

Pupil Checks*

Seizure Precautions*

Stroke Precautions*

Swallow Precautions*

Assisting with Lumbar Puncture*

Use of Hyper/ Hypothermia Blanket*

Knowledge and Use of:

Anticonvulsant*

Sedative*

Sensory Deficits - Care of Patients With

Dentures*

Hearing Aids*

Hearing Loss*

Prosthetic eye*

Contact Lens Care*

Blindness*

Macular Degeneration*

Gastrointestinal - Care of Patients With

Nasogastric tubes (i.e. Salem Sump, Levine)*

Nasointestinal Tubes (i.e. Cantor, Miller- Abbott)*

Jejunostomy, Gastrostomy, Cecostomy Tubes*

Colostomy, Ileostomy*

Bronchoscopy Lung/ Wedge Resection*

GI General

Collection of Stool Specimens*

Bowel Preparation and Cleansing Procedures*

Administration of Tube Feedings via Flexible Tubes*

Bowel Disimpaction*

Bowel Retraining*

Sitz Bath Treatments*

Insertion and Checking Placement/ Patency NG Tubes*

Endocrine - Care of Patients With

Diabetes*

Hyper/ hypoglycemia*

Endocrine General

Blood Glucose Monitoring*

Performing Fingersticks*

Use of Blood Glucose Meter Device*

Use of Visual Blood Glucose Strips*

Knowledge and Use of:

Single Type Insulin*

Mixed Insulins*

Insulin Infusion*

RENAL/GU - Care of Patients With

Incontinence*

Urinary Retention*

UTI*

Insertion of Foley Catheter- Female*

Insertion of Foley Catheter- Male*

Straight Catheterization- Male*

Straight Catheterization- Female*

Insertion of Suprapubic Catheter*

Application of Condom Catheter*

Bladder Retraining*

Urinary Diversion*

Bladder Irrigation (Continuous and Intermittent)*

Peritoneal Dialysis

Manual*

Automatic Cycler Machine*

Orthopedic - Care of Patients With

Total Joint Replacement*

Rheumatic/ Arthritic Disease*

Amputation*

Fracture*

Orthopedic General

Cast Care*

CMS Checks*

Traction- Skin*

Traction- Skeletal*

Range of Motion*

Use of Assistive Devices*

Application of Splints of Extremities*

Continuous Passive Motion Machine (CPM)*

Transfer Techniques*

Use of Sliding Board*

Gait Training/ Retraining*

Application of Prosthetic Devices*

Application of Orthotic Devices*

Wound/Skin - Care of Patients 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 Patients With

Hemovacs*

Jackson-Pratt Tubes*

Penrose Drains*

T-Tubes*

Wound Vac

Application Agreement

The information I have given is true and accurate to the best of my knowledge, and I hereby authorize Fusion Medical Staffing to release this Skills Checklist to staffing clients of Fusion Medical Staffing. Submit this skills evaluation with your initial application. To be updated annually.

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