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Skills Assessment - Interventional Radiology RN Skills Checklist
 
The following checklist will be used to match your skills and interests with available assignments. Please enter your information, and we will store this information with your application/profile. Please indicate your level of proficiency by marking the appropriate number.
 
First Name:
Middle Initial:
Last Name:
SSN: - -
E-mail Address:
Home Phone: - -
Work Phone: - -
Cell Phone: - -
City:
State:
 
 
0. Theory, no practice   1. Limited   2. Confident   3. Very Confident
 
General: Experience:
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  
 
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  
 
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  
 
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  
 
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  
 
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  
 
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, Per Close success 0   1   2   3  
 
Age-Specific Practice Criteria:
Please check the box corresponding to each age group for which you have expertise in providing age-appropriate nursing care. Pediatrics (1 - 12 years)  
Adolescents (12 - 18 years)  
Adult (19 - 65 years)  
Older Adult (older than 65 years)  
 
Experience With Age Groups:
Calculate body weight to verify correct dosing of medication 0   1   2   3  
Assess immunization status for pediatrics and adolescents 0   1   2   3  
Set age-appropriate short-term and long-term goals in care planning 0   1   2   3  
Provide age-appropriate education, considering possible vision and hearing impairment for older than 65 years 0   1   2   3  
 
Certification:
ACLS Completion Date
BCLS Completion Date
Other (specify)
Completion Date
 
 
 
 


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