* = 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
A - Line (Transducer set-up, D/C)
Cardiac Arrest/ CPR
Interpretation of Arrhythmias
Interpretation of Hemodynamic Monitoring
Pacemakers - Permanent
Sheath Removal - Femoral
Swan Ganz (Transducer set-up, D/C)
Telemetry
Care of Patient With 1 2 3 4 5
Aneurysm
Angina
CHF
Open Sternal Wound
Post MI
Pre/Post Cardiac Cath
Pre/ Post Cardiac Surgery
Use and Administration of the Following: 1 2 3 4 5
Atropine
Digoxin
Dopamine
Inderal
Lidocaine
Neosynephrine/ Nipride
NTG
Prep. / Titration of Emergency Drugs
Pronestyl
Quinidine
Thrombolytic
Thrombolytic Agents
Titrate Morphine
Verapamil
Gastrointestinal 1 2 3 4 5
Enterostomal Care
Gastrostomy Tube
Jejunostomy Tube
NG Tube Insertion
Care of Patient With 1 2 3 4 5
Bowel Obstruction
ERCP
Esophageal Bleeding
G.I. Bleed
Liver Transplant
Pancreatitis
Paralytic Ileus
Whipple Procedure
Genitourinary / Renal 1 2 3 4 5
Electrolyte Imbalance / Replacement
Foley Catheter Insertion
GU Irrigations
Nephrostomy Tube
Suprapubic Tube
Care of Patient With 1 2 3 4 5
Chronic/Acute Renal Failure
Nephrectomy
Renal Transplant
Renal Trauma
Shunts and Fistulas
T.U.R.P.
Gynecology 1 2 3 4 5
Ectopic Pregnancy
Endometriosis
Gyn Exam / Pap
Hysterectomy
Mastectomy
Repair of Cystocele / Rectocele
Self Breast Exam
Tubal Ligation
Neurology 1 2 3 4 5
Assessment of Neuro Signs
Assist with Lumbar Puncture
Glascow Coma Scale
Halo Traction
Seizure Precautions
Care of Patient With 1 2 3 4 5
Cranial Hemorrhage
CVA
Head Injury/ Trauma
Multiple Sclerosis
Neuro Injury/ Trauma
Overdose
Post-Op AV-Shunts
Pre/ Post Neuro Surgery
Seizure Activity
Use and Administration of the Following: 1 2 3 4 5
Decadron
Dilantin
Magnesium Sulfate
Phenobarbital
Steroids
Valium
Orthopedic 1 2 3 4 5
Amputation
Arthroscopic Surgery
Bucks Extension
K-Wires/ Steinman Pins
Laminectomy
Otho Trauma
Removal of Hardware
Skeletal Traction
Spika Cast/ Body Cast
Total Joint Replacement
Care of Patient With 1 2 3 4 5
AIDS
Delirium Tremens
HIV Infection
Respiratory 1 2 3 4 5
Ambuing Techniques
Chest Tubes (Emerson/Pleuravac)
Establishing an Airway
Incentive Spirometer
Interpretation of ABG
Nasotracheal Suctioning
Oral Suctioning
Pulse Oximetry
Use of IPPB
Care of Patient With 1 2 3 4 5
ARDS
Asthma
COPD
Emphysema
Inhalation Injuries
Pneumonia
Pneumothorax
Pre/ Post Thoracic Surgery
Pulmonary Edema
Pulmonary Embolism
Use and Administration of the Following:          
Alupent
Aminophylline
Bronkosol
Corticosteroids
Ventolin
Vascular 1 2 3 4 5
Administration of Blood & Blood Products
Air Occlusive Dressing
Assist with IV Cutdown
Fluid Overload
Hemodialysis
Heparin Drip (Precautions & Maintenance)
Hickman / Broviac / Groshong Catheters
Infusion Pumps
Knowledge of Normal Serum Lab Values
Maintenance of Heparin Lock
Peripheral Pulses
Peritoneal Dialysis
Sickle Cell Disease
Starting IV's
Subcutaneous Central Line
Thrombophlebitis
TPN/Hyperalimentation
Other 1 2 3 4 5
Accucheck
Burn Patients
Chemotherapy
Diabetic Teaching
Isolation Techniques
Oncology
Patient Teaching
 
* Security Code