Interventional Radiology Skills Checklist

Interventional Radiology

Name*

Telephone*

Who is your recruiter?*

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Please indicate your level of experience (0, 1, 2, or 3)

0 = Theory, no practice

1 = Limited

2 = Confident

3 = Very Confident

A. GENERAL

Admit patient to pre-procedure holding

0

1

2

3

Complete assessments, obtain family history & risk factors

0

1

2

3

Start peripheral IV

0

1

2

3

Complete pre-procedure checklist

0

1

2

3

Transport pre-procedure patient to the Lab.

0

1

2

3

Transport post-procedure patient to in-hospital units

0

1

2

3

B. PROCEDURES

Cerebral Angiogram – Prepare

0

1

2

3

Cerebral Angiogram – Assist

0

1

2

3

Lower Extremity Angiogram – Prepare

0

1

2

3

Lower Extremity Angiogram – Assist

0

1

2

3

Upper Extremity Angiogram – Prepare

0

1

2

3

Upper Extremity Angiogram – Assist

0

1

2

3

Ultrasound Guided Biopsy – Prepare

0

1

2

3

Ultrasound Guided Biopsy – Assist

0

1

2

3

CT Scan Guided Biopsy – Prepare

0

1

2

3

CT Scan Guided Biopsy – Assist

0

1

2

3

Liver Biopsy and Embolization – Prepare

0

1

2

3

Liver Biopsy and Embolization – Assist

0

1

2

3

Prepare and Assist with Line Placement – Broviac

0

1

2

3

Prepare and Assist with Line Placement – Groshong

0

1

2

3

Prepare and Assist with Line Placement – Hickman

0

1

2

3

Prepare and Assist with Line Placement – PICC

0

1

2

3

Prepare and Assist with Line Placement – PortaCath

0

1

2

3

Uterine Fibroid Embolization – Prepare

0

1

2

3

Uterine Fibroid Embolization – Assist

0

1

2

3

Temporary Hemodialysis Shunt Placement– Prepare

0

1

2

3

Temporary Hemodialysis Shunt Placement– Assist

0

1

2

3

Permanent Hemodialysis Shunt Placement– Prepare

0

1

2

3

Permanent Hemodialysis Shunt Placement– Assist

0

1

2

3

AV Fistula/Shunt Declotting – Prepare

0

1

2

3

AV Fistula/Shunt Declotting – Assist

0

1

2

3

Vertebroplasty – Prepare

0

1

2

3

Vertebroplasty – Assist

0

1

2

3

Lumbar Puncture – Prepare

0

1

2

3

Lumbar Puncture – Assist

0

1

2

3

Myelogram – Prepare

0

1

2

3

Myelogram – Assist

0

1

2

3

Other Procedures (please list):

0

1

2

3

0

1

2

3

0

1

2

3

Provide care for the post-procedure patient

0

1

2

3

C. CARDIOVASCULAR

Assess heart sounds and peripheral pulses

0

1

2

3

Interpret arrhythmias

0

1

2

3

Perform CPR

0

1

2

3

Perform defibrillation

0

1

2

3

Participate as a team member in resuscitation

0

1

2

3

D. PULMONARY

Assess lung sounds

0

1

2

3

Set up oxygen devices

0

1

2

3

Obtain pulse oximetry reading

0

1

2

3

Interpret ABG

0

1

2

3

Use Ambu bag

0

1

2

3

Assist with intubation

0

1

2

3

Assist with chest tube insertion

0

1

2

3

Provide care for the patient with mechanical ventilation

0

1

2

3

E. NEUROLOGICAL

Identify sudden change in level of consciousness

0

1

2

3

Assess sensory, motor, speech

0

1

2

3

Assess reflexes (Babinski, gag)

0

1

2

3

F. MEDICATIONS

Titrate vasoactive drugs

0

1

2

3

Calculate mcg/min and mcg/kg/min

0

1

2

3

Use IV infusion pump to calculate drug doses

0

1

2

3

Administer IV dopamine

0

1

2

3

Administer IV nitroglycerine

0

1

2

3

Administer IV dobutamine (Dobutrex)

0

1

2

3

Administer IV lidocaine

0

1

2

3

Administer IV diltiazem (Cardizem)

0

1

2

3

Administer IV epinephrine

0

1

2

3

Administer IV atropine

0

1

2

3

Administer IV heparin

0

1

2

3

Administer IV benzodiazepines (Valium, Versed, Ativan)

0

1

2

3

Administer IV propofol (Diprivan)

0

1

2

3

Administer IV neuromuscular blocking agents (Pavulon, Norcuron)

0

1

2

3

Administer IV narcotics (morphine, fentanyl)

0

1

2

3

G. PAIN/WOUND MANAGEMENT

Assess pain level/tolerance

0

1

2

3

Care of patient with anesthesia/analgesia

0

1

2

3

Care of patient with IV conscious sedation

0

1

2

3

Care of patient with narcotic analgesia

0

1

2

3

Care of patient with patient controlled analgesia (PCA pump)

0

1

2

3

Assess surgical wound status with/without drain(s)

0

1

2

3

Care of patient with sterile dressing changes

0

1

2

3

Care of patient with FemoStop device

0

1

2

3

Assessment of VasoSeal, AngioSeal, PerClose success

0

1

2

3

H. AGE SPECIFIC PRACTICE CRITERIA

Please check the box corresponding to each age group for which you have expertise in providing age-appropriate nursing care.

Pediatric (1-18years)

Adolescents (12 - 18 years)

Adult (19 - 65 years)

Older adults (Older than 65years)

I. EXPERIENCE WITH AGE GROUPS

1. Calculate body weight to verify correct dosing of medication

0

1

2

3

2. Assess immunization status for pediatric, and adolescent

0

1

2

3

3. Set age-appropriate short-term and long-term goals in care planning

0

1

2

3

4. Provide age-appropriate education, considering possible vision and hearing impairment for Older than 65years.

0

1

2

3

Certification: (mm/dd/yyyy)

ACLS Completion Date:

BCLS Completion Date:

Other (specify):

Completion Date:

Do you speak any languages other than English?

Yes

No

If yes, which language(s)?

*

I hereby certify that ALL information I have provided to Clover Health Services, on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.