* = Required Information

Name * 
            (Last,Middle,First)

The following checklist is used to assess your experience and skills and help your Nurse Advisor place you in the proper assignment. Please provide a self-assessment of your skills using the following guidelines:

  • 1 - No experience
  • 2 - Require training
  • 3 - Have performed this task and able to perform without supervision
  • 4 - Most experienced and able to perform independently
  • 5 - Able to teach and supervise

* I understand that the information provided in this application is true to the best of my knowledge. I authorize the release of the information in this document to LJD Healthcare Staffing and facilities where I may be employed.

Cardiac 1 2 3 4 5
Apical Pulse Rate Rhythm
Assessment Skills
Cardiac Arrest
CPR
Holter Monitor
Diuretics
Pacemaker
Care of Patient With 1 2 3 4 5
Acute MI
Aneurysm
CHF
Fluid Retention
Hypertension
Pre / Post Cardiac Surgery
Use and Administration of the Following: 1 2 3 4 5
Antihypertensive Meds
Cardizem
Coumadin
Digoxin
Diuretics
Inderal
Lasix
Potassium Supplements
Gastrointestinal 1 2 3 4 5
Colostomy Care
Dehiscence
G.I. Bleed
Gastrostomy Tube
NG Tube
T-Tube
Tube Feedings
Genitourinary / Renal 1 2 3 4 5
Foley Catheter Insertion
GU Irrigations
Ileostomy
Nephrostomy Tube
Suprapubic Catheter
Care of Patient With 1 2 3 4 5
Incontinence
Shunts and Fistulas
Straight Catheterization
Gynecology 1 2 3 4 5
Endometriosis
Hysterectomy
Mastectomy
Self Breast Exam
Maternal-Child Care 1 2 3 4 5
Assessment and Care of Complicated Pregnancy
Healthy Baby
Home Care of Postpartum Mother
Neonate Care 1 2 3 4 5
Collect Cord Blood Samples
Eye Prophylaxis
Suction
Newborn Care 1 2 3 4 5
Administer Blood and Blood Products
Cord and Circumcision Care
Draw Blood from U-line
Neonatal Level I
Neonatal Level II
Neonatal Level III
NG Feedings
Phototherapy
Suction with Catheter
Use of Equipment 1 2 3 4 5
Apnea Monitors
Cardiac Monitors
Oxyhood
Ventilators
Neurology 1 2 3 4 5
Assessment of Neuro Signs
Seizure Precautions
Traction
Care of Patient With 1 2 3 4 5
Neuro Trauma
Overdose
Seizure Activity
Stroke (CVA)
Trauma Spinal Cord Injury
Use and Administration of the Following: 1 2 3 4 5
Decadron
Dilantin
Phenobarbital
Valium
Orthopedic 1 2 3 4 5
Arthroscopy / Arthrotomy
Assistive Devices
Bucks Extension
Crutch Walking
Total Hip Replacement
Total Knee Replacement
Care of Patient With 1 2 3 4 5
Amputation
Skeletal Traction
Trauma
Pediatrics 1 2 3 4 5
Apnea Monitor
Assist with Lumbar Puncture
Calculation of Pedi Dosages
Cardiac Monitor
CPR ? Infant / Child
Valium
Preparation of Emergency Drugs
Scalp Veins
Starting IV Therapy
Tracheostomy Care and Suctioning
Use of Croup Tent
Use of Oxygen
Use of Ventilators
Care of Patient With 1 2 3 4 5
Asthma
Bone Marrow Transplant
Broncho - Pulmonary Dysplasia
Cardiac Surgery
CHF_
Cystic Fibrosis
Diabetes Mellitus
Epiglottis
Failure to Thrive
Leukemia
Meningitis
Near Drowning
Overdose / Poison Ingestion
PDA Ligation
Post Harrington Rod Insertion
RDS
Reye's Syndrome
Sickle Cell Disease
Spina Bifida
Tracheoesophageal
Respiratory 1 2 3 4 5
Assessment / Auscultation of Lung Sounds
Care of Home Ventilator Patients
Establishing an Airway
Home Administration of O2 via:          
Nasal Cannula
Face Mask
Identifying Rales, Rhonchi
Principals of Chest Percussion
Ultrasonic Nebulizer
Care of Patient With 1 2 3 4 5
COPD
Lung Cancer
Pulmonary Emboli
Tracheostomy
Use and Administration of the Following: 1 2 3 4 5
Aminophylline
Brethine
Bronkosol
Skin 1 2 3 4 5
Assessment Skills
Decubitus Care
Irrigation of Wounds
Patient Teaching Skills of Wound Care
Wound Care (Aseptic)
Wound Care (Sterile)
Vascular 1 2 3 4 5
Administration of Blood & Blood Products
Assessment of Vascular System
Dialysis
Fluid Overload
Heparin Locks
Hickman / Broviac Catheters
Infusion Pumps
Knowledge of Normal Serum Lab Values
Obtaining Venous Blood Samples
Peripheral Pulses
Port-a-caths
Starting IV's
TPN / Hyperalimentation
Use and Administration of the Following: 1 2 3 4 5
Heparin
I.V Infusions
Other 1 2 3 4 5
Burn Patients
Chemotherapy
Documentation of Skilled Care
Isolation Techniques
Medicare 485 / 486 Forms
Oncology
Use and Administration of the Following: 1 2 3 4 5
Diabetic Teaching
Glucometers
Insulins
 
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