ICU Skills Assessment

Name*
First NameLast Name
Date*
MonthDayYear
RN/LPN SKILLS ASSESSMENT
Complete the following questions about your experience as a practicing Nurse.
Critical Care SKILLS SELF EVALUATION
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Critical Care / ICU / Telemetry / PCU Experience?*
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Patient Care
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Acute MI*

1 2 3 4
1 is Never Performed, 4 is Expert
Cardiopulmonary Arrest*

1 2 3 4
1 is Never Performed, 4 is Expert
Angina*

1 2 3 4
1 is Never Performed, 4 is Expert
Chest Trauma*

1 2 3 4
1 is Never Performed, 4 is Expert
Stab Wounds*

1 2 3 4
1 is Never Performed, 4 is Expert
Congestive Heart Failure*

1 2 3 4
1 is Never Performed, 4 is Expert
Cardiogenic Shock*

1 2 3 4
1 is Never Performed, 4 is Expert
Cardiac Tamponade*

1 2 3 4
1 is Never Performed, 4 is Expert
Pre and Post open heart surgery*

1 2 3 4
1 is Never Performed, 4 is Expert
Pre and Post heart transplant*

1 2 3 4
1 is Never Performed, 4 is Expert
Triple A repair*

1 2 3 4
1 is Never Performed, 4 is Expert
Endarterectomy*

1 2 3 4
1 is Never Performed, 4 is Expert
Post op vascular surgery*

1 2 3 4
1 is Never Performed, 4 is Expert
Valve replacement*

1 2 3 4
1 is Never Performed, 4 is Expert
Head Trauma*

1 2 3 4
1 is Never Performed, 4 is Expert
Subarachnoid Hemorrhage*

1 2 3 4
1 is Never Performed, 4 is Expert
Subdural Hematoma*

1 2 3 4
1 is Never Performed, 4 is Expert
Drug Overdose*

1 2 3 4
1 is Never Performed, 4 is Expert
Alcohol overdose*

1 2 3 4
1 is Never Performed, 4 is Expert
Seizures*

1 2 3 4
1 is Never Performed, 4 is Expert
Degenerative Neurological Disease*

1 2 3 4
1 is Never Performed, 4 is Expert
Airway obstruction*

1 2 3 4
1 is Never Performed, 4 is Expert
TB*

1 2 3 4
1 is Never Performed, 4 is Expert
Asthma*

1 2 3 4
1 is Never Performed, 4 is Expert
Resp Failure*

1 2 3 4
1 is Never Performed, 4 is Expert
Pulmonary Edema*

1 2 3 4
1 is Never Performed, 4 is Expert
ARDS*

1 2 3 4
1 is Never Performed, 4 is Expert
Pulmonary Embolus*

1 2 3 4
1 is Never Performed, 4 is Expert
Lung Transplant*

1 2 3 4
1 is Never Performed, 4 is Expert
Gun Shot Wound*

1 2 3 4
1 is Never Performed, 4 is Expert
Liver Failure*

1 2 3 4
1 is Never Performed, 4 is Expert
Subtotal Gastrectomy*

1 2 3 4
1 is Never Performed, 4 is Expert
Cancer*

1 2 3 4
1 is Never Performed, 4 is Expert
AIDS*

1 2 3 4
1 is Never Performed, 4 is Expert
Diabetes*

1 2 3 4
1 is Never Performed, 4 is Expert
Burns*

1 2 3 4
1 is Never Performed, 4 is Expert
Epidural Analgesic/anasthesia*

1 2 3 4
1 is Never Performed, 4 is Expert
IV conscious sedation*

1 2 3 4
1 is Never Performed, 4 is Expert
PCA*

1 2 3 4
1 is Never Performed, 4 is Expert
Narcotic administration*

1 2 3 4
1 is Never Performed, 4 is Expert
Cardiovascular care:
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Abnormal heart sounds / murmurs*

1 2 3 4
1 is Never Performed, 4 is Expert
Doppler use*

1 2 3 4
1 is Never Performed, 4 is Expert
Pulse / circulation checks*

1 2 3 4
1 is Never Performed, 4 is Expert
Interpret Cardiac Enzyme results*

1 2 3 4
1 is Never Performed, 4 is Expert
Interpret coagulation results*

1 2 3 4
1 is Never Performed, 4 is Expert
Assist w/ Central Line Insertion*

1 2 3 4
1 is Never Performed, 4 is Expert
Assist w/ Arterial Line Insertion*

1 2 3 4
1 is Never Performed, 4 is Expert
Assist w/ PA catheter / Swan-Ganz*

1 2 3 4
1 is Never Performed, 4 is Expert
Assist w/ pericardiocentesis*

1 2 3 4
1 is Never Performed, 4 is Expert
Cardioversion*

1 2 3 4
1 is Never Performed, 4 is Expert
Hemodynamic monitoring*

1 2 3 4
1 is Never Performed, 4 is Expert
Cardiac Output*

1 2 3 4
1 is Never Performed, 4 is Expert
CVP monitoring*

1 2 3 4
1 is Never Performed, 4 is Expert
MAP*

1 2 3 4
1 is Never Performed, 4 is Expert
PA / Swan-Ganz*

1 2 3 4
1 is Never Performed, 4 is Expert
PCW pressure*

1 2 3 4
1 is Never Performed, 4 is Expert
Radial art-line*

1 2 3 4
1 is Never Performed, 4 is Expert
Record 12 Lead EKG *

1 2 3 4
1 is Never Performed, 4 is Expert
Interpret 12 Lead EKG*

1 2 3 4
1 is Never Performed, 4 is Expert
Arrhthmia interpretation*

1 2 3 4
1 is Never Performed, 4 is Expert
Lead placement*

1 2 3 4
1 is Never Performed, 4 is Expert
Assess rhythm strips*

1 2 3 4
1 is Never Performed, 4 is Expert
External Pacemaker*

1 2 3 4
1 is Never Performed, 4 is Expert
Permanent Pacemaker*

1 2 3 4
1 is Never Performed, 4 is Expert
Temporary Pacemaker*

1 2 3 4
1 is Never Performed, 4 is Expert
Transthoracic Pacemaker*

1 2 3 4
1 is Never Performed, 4 is Expert
Ventricular Assistive Device*

1 2 3 4
1 is Never Performed, 4 is Expert
Pre / Post cardiac cath*

1 2 3 4
1 is Never Performed, 4 is Expert
Pre / Post angioplasty*

1 2 3 4
1 is Never Performed, 4 is Expert
Cardiovascular Meds
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Cardarone*

1 2 3 4
1 is Never Performed, 4 is Expert
Atropine*

1 2 3 4
1 is Never Performed, 4 is Expert
Bicarbonate*

1 2 3 4
1 is Never Performed, 4 is Expert
Digoxin*

1 2 3 4
1 is Never Performed, 4 is Expert
Bretylol*

1 2 3 4
1 is Never Performed, 4 is Expert
Cardizem*

1 2 3 4
1 is Never Performed, 4 is Expert
Dobutamine*

1 2 3 4
1 is Never Performed, 4 is Expert
Epinephrine*

1 2 3 4
1 is Never Performed, 4 is Expert
Esmolol*

1 2 3 4
1 is Never Performed, 4 is Expert
Inocor*

1 2 3 4
1 is Never Performed, 4 is Expert
Lidocaine*

1 2 3 4
1 is Never Performed, 4 is Expert
Nipride*

1 2 3 4
1 is Never Performed, 4 is Expert
Procainamide*

1 2 3 4
1 is Never Performed, 4 is Expert
Retavase*

1 2 3 4
1 is Never Performed, 4 is Expert
Streptokinase*

1 2 3 4
1 is Never Performed, 4 is Expert
TPA*

1 2 3 4
1 is Never Performed, 4 is Expert
Verapamil*

1 2 3 4
1 is Never Performed, 4 is Expert
Pulmonary Care
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Breath Sounds*

1 2 3 4
1 is Never Performed, 4 is Expert
Sputum Collection*

1 2 3 4
1 is Never Performed, 4 is Expert
Resp Isolation*

1 2 3 4
1 is Never Performed, 4 is Expert
Nasotracheal Suction*

1 2 3 4
1 is Never Performed, 4 is Expert
Endotracheal Suction*

1 2 3 4
1 is Never Performed, 4 is Expert
Obtaining ABGs*

1 2 3 4
1 is Never Performed, 4 is Expert
Pleural Tubes*

1 2 3 4
1 is Never Performed, 4 is Expert
Trach Care*

1 2 3 4
1 is Never Performed, 4 is Expert
Vent Settings*

1 2 3 4
1 is Never Performed, 4 is Expert
IMV*

1 2 3 4
1 is Never Performed, 4 is Expert
SIMV*

1 2 3 4
1 is Never Performed, 4 is Expert
PEEP*

1 2 3 4
1 is Never Performed, 4 is Expert
Pressure Support*

1 2 3 4
1 is Never Performed, 4 is Expert
CPAP*

1 2 3 4
1 is Never Performed, 4 is Expert
Vent Weaning*

1 2 3 4
1 is Never Performed, 4 is Expert
Bipap*

1 2 3 4
1 is Never Performed, 4 is Expert
02 therapy*

1 2 3 4
1 is Never Performed, 4 is Expert
Nasal Cannula*

1 2 3 4
1 is Never Performed, 4 is Expert
Face Mask*

1 2 3 4
1 is Never Performed, 4 is Expert
ET tube 02*

1 2 3 4
1 is Never Performed, 4 is Expert
Wall 02*

1 2 3 4
1 is Never Performed, 4 is Expert
Portable 02*

1 2 3 4
1 is Never Performed, 4 is Expert
Venti-mask*

1 2 3 4
1 is Never Performed, 4 is Expert
Non-Rebreather*

1 2 3 4
1 is Never Performed, 4 is Expert
Pulse Ox*

1 2 3 4
1 is Never Performed, 4 is Expert
Ambu Bag*

1 2 3 4
1 is Never Performed, 4 is Expert
Laryngospasm*

1 2 3 4
1 is Never Performed, 4 is Expert
Tension Pneumothorax*

1 2 3 4
1 is Never Performed, 4 is Expert
Aspiration*

1 2 3 4
1 is Never Performed, 4 is Expert
Pulmonary Meds
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Theophyline*

1 2 3 4
1 is Never Performed, 4 is Expert
Alupent*

1 2 3 4
1 is Never Performed, 4 is Expert
Ventolin*

1 2 3 4
1 is Never Performed, 4 is Expert
Xopenex*

1 2 3 4
1 is Never Performed, 4 is Expert
DuoNeb*

1 2 3 4
1 is Never Performed, 4 is Expert
MucoMyst*

1 2 3 4
1 is Never Performed, 4 is Expert
Neuro:
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Lumbar Puncture*

1 2 3 4
1 is Never Performed, 4 is Expert
Glascow coma scale*

1 2 3 4
1 is Never Performed, 4 is Expert
Neuro Assessment*

1 2 3 4
1 is Never Performed, 4 is Expert
ICP/ventriculostomy insertion*

1 2 3 4
1 is Never Performed, 4 is Expert
Halo traction*

1 2 3 4
1 is Never Performed, 4 is Expert
Stryker Frame*

1 2 3 4
1 is Never Performed, 4 is Expert
Epidural admin*

1 2 3 4
1 is Never Performed, 4 is Expert
Intracranial pressure monitoring*

1 2 3 4
1 is Never Performed, 4 is Expert
Nerve Stimulation*

1 2 3 4
1 is Never Performed, 4 is Expert
Rotating Bed*

1 2 3 4
1 is Never Performed, 4 is Expert
Pathologic reflexes*

1 2 3 4
1 is Never Performed, 4 is Expert
Reflex/motor deficits*

1 2 3 4
1 is Never Performed, 4 is Expert
Visual / Communication deficits*

1 2 3 4
1 is Never Performed, 4 is Expert
Neuro Meds:
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Barbituate induced coma*

1 2 3 4
1 is Never Performed, 4 is Expert
decadron*

1 2 3 4
1 is Never Performed, 4 is Expert
dilantin*

1 2 3 4
1 is Never Performed, 4 is Expert
phenobarbital*

1 2 3 4
1 is Never Performed, 4 is Expert
mannitol*

1 2 3 4
1 is Never Performed, 4 is Expert
valium*

1 2 3 4
1 is Never Performed, 4 is Expert
ativan*

1 2 3 4
1 is Never Performed, 4 is Expert
TPA*

1 2 3 4
1 is Never Performed, 4 is Expert
Gastrointestinal
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Bowel Sounds*

1 2 3 4
1 is Never Performed, 4 is Expert
Abd palpitation*

1 2 3 4
1 is Never Performed, 4 is Expert
NG insertion/removal/care*

1 2 3 4
1 is Never Performed, 4 is Expert
Pericentesis*

1 2 3 4
1 is Never Performed, 4 is Expert
Gastrostomy*

1 2 3 4
1 is Never Performed, 4 is Expert
Jejunostomy*

1 2 3 4
1 is Never Performed, 4 is Expert
Balloon Tamponade*

1 2 3 4
1 is Never Performed, 4 is Expert
Intepret serum lab values*

1 2 3 4
1 is Never Performed, 4 is Expert
Intepret LFTs*

1 2 3 4
1 is Never Performed, 4 is Expert
GI Medications
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
AquaMephyton*

1 2 3 4
1 is Never Performed, 4 is Expert
H2 blockers / Proton Pump Inihibitors*

1 2 3 4
1 is Never Performed, 4 is Expert
Ipecac*

1 2 3 4
1 is Never Performed, 4 is Expert
Antiemetics*

1 2 3 4
1 is Never Performed, 4 is Expert
Renal / GU
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Insertion/care/removal of foley cath*

1 2 3 4
1 is Never Performed, 4 is Expert
Continuous bladder irrigation*

1 2 3 4
1 is Never Performed, 4 is Expert
Suprapubic Catheter care*

1 2 3 4
1 is Never Performed, 4 is Expert
Electrolyte fluid balance*

1 2 3 4
1 is Never Performed, 4 is Expert
Hemodialysis*

1 2 3 4
1 is Never Performed, 4 is Expert
Peritoneal Dialysis*

1 2 3 4
1 is Never Performed, 4 is Expert
AV fistula/shunt*

1 2 3 4
1 is Never Performed, 4 is Expert
Interpret BUN / Creatinine*

1 2 3 4
1 is Never Performed, 4 is Expert
Endocrinology
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Lab results*

1 2 3 4
1 is Never Performed, 4 is Expert
Bair Hugger*

1 2 3 4
1 is Never Performed, 4 is Expert
Blood glucoses*

1 2 3 4
1 is Never Performed, 4 is Expert
Thyroid Studies*

1 2 3 4
1 is Never Performed, 4 is Expert
Misc ICU experience
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Anaphylaxis*

1 2 3 4
1 is Never Performed, 4 is Expert
DIC*

1 2 3 4
1 is Never Performed, 4 is Expert
Hypovolemic shock*

1 2 3 4
1 is Never Performed, 4 is Expert
Septic Shock*

1 2 3 4
1 is Never Performed, 4 is Expert
Organ / Tissue Donation*

1 2 3 4
1 is Never Performed, 4 is Expert
Place check mark in box to continue:*
I hereby verify that all of the above information is correct, true, and valid. If any information were to be found false, it may be grounds for immediate termination.
Should be Empty:

RN/LPN SKILLS ASSESSMENT

Patient Care

Cardiovascular care:

Cardiovascular Meds

Pulmonary Care

Pulmonary Meds

Neuro:

Neuro Meds:

Gastrointestinal

GI Medications

Renal / GU

Endocrinology

Misc ICU experience