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Print this form and fax or mail:
Fax to: (505) 797-3822
Mail to: 5150 San Francisco RD NE Albuquerque, NM 87109
NAME: ___________________________________
Last First M.I.
|
- CRTT Years Experience: _____ - RRT Years Experience: _____ |
DIRECTIONS: Place an x in the box that best describes your level of proficiency for each of the skills presented.
LEVELS OF PROFICIENCY KEY:
HP
= Highly Proficient; Extensively experienced; able to supervise and/or train others.VE = Very Experienced; can perform well, without assistance or supervision.
EX = Experienced; competent; can perform independently; may need initial review or supervision.
SE
= Some Experience; need review and assistance or supervision.NE = No Experience.
| PROFICIENCY LEVEL | PROFICIENCY LEVEL | |||||||||||
| WORK SUMMARY: | HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | ||
| Intensive Care Unit | Neonatal ICU Level III | |||||||||||
| Coronary Care Unit | Emergency Room | |||||||||||
| Burn ICU | Pulmonary Rehabilitation | |||||||||||
| Transplant | Sleep Lab | |||||||||||
| Pediatrics | Home Care | |||||||||||
| Pediatric ICU | Transports | |||||||||||
| Neonatal ICU Level II | Other: __________ | |||||||||||
| CARE OF PATIENTS WITH: | HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | ||
| Asthma | Meconium Aspiration | |||||||||||
| Status Asthmaticus | Neonatal Pneumonia | |||||||||||
| Acute/Chronic Bronchitis | Persistent Fetal Circulation | |||||||||||
| Broncho-Pulmonary Dysplasia (BPD) | Pulmonary Interstitial Emphysema (PIE) | |||||||||||
| Cardiac Surgery | Transient Tachypnea | |||||||||||
| Cystic Fibrosis | Croup | |||||||||||
| Epiglottitis | Myesthenia Gravis | |||||||||||
| Failure to Thrive | Guillian Barre | |||||||||||
| Respiratory Distress Syndrome | Open Hearts | |||||||||||
| Tracheo-Esophageal Fistula | Thoracotomies | |||||||||||
| Hyaline Membrane Disease | Fem-pop Bypass | |||||||||||
| (HMD/IRDS) | Pacer |
| BASIC TREATMENTS: | HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | ||
| Incentive Spirometry | Chest Physical Therapy Postural Drainage | |||||||||||
| IPPB Treatments | Medihalers | |||||||||||
| Hand Held Nebulizers | Other: __________ | |||||||||||
| Ultrasound Nebulizers |
| BASIC RESPIRATORY THERAPY: | HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | ||
| Patient Assessment and Monitoring | Know Difference in Various O2 Masks | |||||||||||
| O2 Set-up | Analyze Oxygen - FiO2 | |||||||||||
| * Nasal Canula | Interpretation of ABG's | |||||||||||
| * Mask | Determination of Acid-Base States | |||||||||||
| * Trach | Placement of Oral Airway | |||||||||||
| * Aerosol | Placement of Nasal Airway | |||||||||||
| Change O2 Tank | Nasotracheal Suctioning | |||||||||||
| Calculate Time Left in O2 Tank | Endotracheal Suctioning | |||||||||||
| Change Regulator, Empty to Full Tank | Check Intracuff Pressure | |||||||||||
| Differentiate Hi Flow - Low Flow O2 Delivery | Ventilate Patient with Manual Resuscitator | |||||||||||
| Determine Proper FiO2 On Flow Rates | Heated and Cool Nebulizers | |||||||||||
| Other: __________ | ||||||||||||
| Other: __________ |
| SPECIFIC SKILLS: | HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | ||
| Pulse Oximetry | Operate and Maintain Blood Gas Machine | |||||||||||
| Drawing ABG's | Carboxy-Hemoglobin Determination | |||||||||||
| * Allen's Test | Interpretation of Radiographic Finding | |||||||||||
| * Radial Artery | Stress Testing | |||||||||||
| * Brachial Artery | Cardiac Output Monitoring | |||||||||||
| * Femoral Artery | Balloon Pumps | |||||||||||
| * Arterial Line | Hemodynamic Monitoring | |||||||||||
| Pulmonary Function Testing Complete Lab Work-up | ECMO | |||||||||||
| Bedside PFT's | Perfusionist | |||||||||||
| Measure Peak Flow Rate | Other: ______________ | |||||||||||
| Change and Clean Trach Tubes | Other: ______________ | |||||||||||
| Knowledge of Chest Tubes | ||||||||||||
| Assist with Bronchoscopies |
| MEDICATIONS: | HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | ||
| Racemic Epinephrine (Vaponefrin) | Atropine Sulfate | |||||||||||
| Isoproteronol (Isuprel) | Mucomyst | |||||||||||
| Isoetharine (Bronkosol) | Cromolyn Sodium (Intal) | |||||||||||
| Metaproterenal (Alupent) | Gentamycin | |||||||||||
| Albuterol (Proventil, Ventolin) | Tobramycin | |||||||||||
| Terbutaline Sulfate (Bricanyl) | Decadron |
| VENTILATORS: | HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | ||
| Pressure Pre-set | Bear II | |||||||||||
| Volume Pre-set | Monaghan 225 | |||||||||||
| Bird | Angstrom | |||||||||||
| PR II | Siemens Servo 900B or 900C | |||||||||||
| Emerson (Post-op) | Ohio 560 | |||||||||||
| Emerson (Silver Streak) | Bear 5 | |||||||||||
| MA - 1 | Hamilton Veolar | |||||||||||
| MA - 2+2 | Hamilton Amadaus | |||||||||||
| Bear I | Puritan Bennett 7200 |
| VENTILATOR PROCEDURES: | HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | ||
| IMV | Inverse Ratio Ventilation | |||||||||||
| CPAP | Assist with Intubation | |||||||||||
| PEEP | Intubate | |||||||||||
| Assist Control | Assist with Extubation | |||||||||||
| Blowby | Extubate | |||||||||||
| Flowby | Troubleshoot Ventilators | |||||||||||
| Pressure Support | Other: | |||||||||||
| Weaning | (1) _______________ | |||||||||||
| * Negative Inspiratory Force | (2) _______________ | |||||||||||
| * Vital Capacity | (3) _______________ | |||||||||||
| * Tidal Volume | (4) _______________ | |||||||||||
| (5) _______________ |
| NEONATAL/ PEDIATRIC ICU: | HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | ||
| Baby Bird | IMV | |||||||||||
| Bear Cub | ECMO | |||||||||||
| Sechrist | Umbilical Artery Catheters | |||||||||||
| Healthdyne | Neonatal Resuscitation | |||||||||||
| Infant Star | Neonatal Advanced Life Support | |||||||||||
| Jet Ventilation | Pediatric Resuscitation | |||||||||||
| PEEP | Pediatric Advanced Life Support | |||||||||||
| CPAP | Ambulance Transport | |||||||||||
| Natal CPAP | Intubation | |||||||||||
| Transcutaneous Monitoring | Extubation | |||||||||||
| Blenders | Assist in High Risk Delivery | |||||||||||
| Pressure Manometer | Other: ______________ |
Signature: ___________________________ Date: _________________
