LTC RN Skills Checklist

LTC RN Skills Checklist

First Name*

Last Name*

Years of Experience*

E-mail*

example@example.com

ANSWER KEY

PROFICIENCY

1=Not Applicable 2=No Experience 3=Some Experience

4=Experienced 5=Very Experienced

FREQUENCY

1=Never Performed 2=Assisted Only 3=Rarely Performed

4=Occasionally Performed 5=Regularly Performed

General Skills*

Rows	Proficiency	Frequency
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

Knowledge & Use of*

Rows	Proficiency	Frequency
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*

Rows	Proficiency	Frequency
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 Portacath
Mixing IVs
Regulating IVs
IV Infusion Pumps
Blood / Blood Product Administration

Care of Patients With*

Rows	Proficiency	Frequency
Recognizing Basic & Life- Threatening Dysrhythmia
Congestive Heart Failure
Cardiac General
Pulse Checks
Use of Doppler Cardiac Monitors
Taking EKGs- 12 Lead
Use of Automatic BP Cuff (i.e. Dinamap)

Knowledge and Use of*

Rows	Proficiency	Frequency
Nitrates (Oral, Topical)
Antiarrhythmics (Oral)
Antihypertensives (Oral)
Emphysema
COPD
Asthma Exacerbation
Tracheostomy
Pneumonia
Pre / Post Thoracic Surgery
Chest Tubes

Respiratory General*

Rows	Proficiency	Frequency
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*

Rows	Proficiency	Frequency
Developmentally Appropriate Assessment
Parental / Sibling Support
Pediatric Support Team Collaboration

Care of Patients With*

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

General*

Rows	Proficiency	Frequency
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*

Rows	Proficiency	Frequency
Anticonvulsant
Sedative

Care of Patients With*

Rows	Proficiency	Frequency
Dentures
Hearing Aids
Care of Patients With Hearing Loss
Prosthetic Eye
Contact Lens Care
Blindness
Macular Degeneration

Care of Patients With*

Rows	Proficiency	Frequency
Nasogastric Tubes ( i.e. Salem Sumo, Levine)
Nasointestinal Tubes (i.e. Cantor, Miller- Abbott)
Jejunostomy, Gastrostomy, Cecostomy Tubes
Colostomy, Ileostomy

Gastrointestinal*

Rows	Proficiency	Frequency
Administration of Tube Feedings Via Flexible Tubes
Bronchoscopy Lung / Wedge Resection
Collection of Stool Specimens
Bowel Preparation and Cleansing Procedures
Bowel Disimpaction
Bowel Retraining
Sitz Bath Treatments
Insertion and Checking Placement / Patency NG Tubes

Care of Patients With*

Rows	Proficiency	Frequency
Diabetes
Hyper / Hypoglycemia

General*

Rows	Proficiency	Frequency
Blood Glucose Monitoring
Performing Fingersticks
Use of Blood Glucose Meter Device
Use of Visual Blood Glucose Strips

Knowledge and Use of*

Rows	Proficiency	Frequency
Insulin
Single Type
Mixed Insulins
Insulin Infusion

Care of Patients With*

Rows	Proficiency	Frequency
Incontinence
Urinary Retention
UTI
RENAL / GU General
Insertion of Catheter- Female
Insertion of Catherer- Male
Insertion of Suprapubic Catheter
Application of Condom Catheter
Bladder Retraining
Urinary Diversion
Bladder Irrigation (Continuous and Intermittent)

Dialysis*

Rows	Proficiency	Frequency
Peritoneal Dialysis
Manual
Automatic Cycler Machine

Care of Patients With*

Rows	Proficiency	Frequency
Total Joint Replacement
Rheumatic / Arthritic Disease
Amputation
Fracture

General*

Rows	Proficiency	Frequency
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

Care of Patients With*

Rows	Proficiency	Frequency
Pressure Sores
Leg Ulcers
Burns

General*

Rows	Proficiency	Frequency
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

Care of Patients With*

Rows	Proficiency	Frequency
Hemovac Drains
Jackson-Pratt Tubes
Penrose Drains
T-Tubes

Age Specific Criteria*

Rows	Proficiency	Frequency
Newborn / Neonatal (up to 30 days)
Infant (30 days to 1 year)
Toddler (1 to 3 years)
Preschooler (3 to 5 years)
School Age (5 to 12 years)
Adolescents (12 to 18 years)
Young Adults (18 to 39 years)
Middle Adults (40 to 64 years)
Older Adults (65 & up)

Background Experience*

Rows	Proficiency	Frequency
Small Hospital
Large Hospital
Outpatient
Acute Care / Hospital
Cancer Center
Clinic
Managed Care
SNF / Long Term Care
Home Health

The information provided is true and to the best of my knowledge. I hereby authorize Summit Medical Staffing to present my Skills Checklist to facilities for the purpose of employment. Please Type Your Name in This Box to Electronically Sign this Form.*

First NameLast Name

Date*

MonthDayYear

Hour MinutesAM/PM Option

Form Reply Email Address

Salesforce Check

Medication

Cardiac

Neuro

Sensory Deficits

Gastrointestinal

Endocrine

Renal / GU

Orthopedic

Wound / Skin

Additional Skills