Respiratory Therapy Skills Checklist  

* Denotes required field
This profile is for use by Respiratory Therapists with more than one year experience in their discipline and specialty. It will not be a determining factor for employment but it may aid in promoting yourself at the Interview.

Please enter your full legal name as it appears on your Social Security Card.

First name*

_______________________________


Last name*

______________________________

Social Security number

_____ - _____ - _____ 

Date

_____ /_____ /_____ 

 

Email: ______________________________________


Please indicate your level of experience by checking the applicable box below.
A. Theory, no practice C. One - two years experience
B. Intermittent experience D. Two plus years experience
 

A. TREATMENTS/PROCEDURES
  1. Assessment
    a. Breath sounds | A |    | B |    | C |    | D |
    b. Peak flow rate | A |    | B |    | C |    | D |
    c. Pulmonary function testing | A |    | B |    | C |    | D |
    d. Rate and work of breathing | A |    | B |    | C |    | D |
    e. Transcutaneous monitoring | A |    | B |    | C |    | D |
  2. Interpretation of lab results  
    a. Arterial blood gases | A |    | B |    | C |    | D |
    b. Basic EKG | A |    | B |    | C |    | D |
    c. Blood chemistry | A |    | B |    | C |    | D |
    d. Chest x-ray | A |    | B |    | C |    | D |
  3. Equipment & procedures  
    a. Airway management devices/suctioning  
      (1) Check intracuff pressure | A |    | B |    | C |    | D |
      (2) Endotracheal tube/suctioning | A |    | B |    | C |    | D |
      (3) Nasal airway placement | A |    | B |    | C |    | D |
      (4) Nasal airway/suctioning | A |    | B |    | C |    | D |
      (5) Oral airway placement | A |    | B |    | C |    | D |
      (6) Oropharyngeal/suctioning | A |    | B |    | C |    | D |
      (7) Sputum specimen collection | A |    | B |    | C |    | D |
      (8) Tracheostomy/suctioning | A |    | B |    | C |    | D |
    b. Analyze oxygen | A |    | B |    | C |    | D |
    c. Arterial line insertion | A |    | B |    | C |    | D |
    d. Care of the patient with a chest tube  
      (1) Assessment of function/proper operation | A |    | B |    | C |    | D |
      (2) Placement assistance | A |    | B |    | C |    | D |
    e. Chest physiotherapy | A |    | B |    | C |    | D |
    f. Drawing arterial blood gases  
      (1) Arterial line | A |    | B |    | C |    | D |
      (2) Brachial artery | A |    | B |    | C |    | D |
      (3) Femoral artery | A |    | B |    | C |    | D |
      (4) Radial artery/Allen tests | A |    | B |    | C |    | D |
    g. Extubate | A |    | B |    | C |    | D |
    h. Extubation assistance | A |    | B |    | C |    | D |
    i. Hemodynamic monitoring | A |    | B |    | C |    | D |
    j. Incentive spirometry | A |    | B |    | C |    | D |
    k. Infection control practices | A |    | B |    | C |    | D |
    l. Intubate | A |    | B |    | C |    | D |
    m. Intubation assistance | A |    | B |    | C |    | D |
    n. Medication delivery systems  
      (1) Aerosol heated/cool | A |    | B |    | C |    | D |
      (2) Aerosol set up-mask | A |    | B |    | C |    | D |
      (3) Aerosol set up-trach | A |    | B |    | C |    | D |
      (4) IPPB | A |    | B |    | C |    | D |
      (5) Medihaler | A |    | B |    | C |    | D |
      (6) Metered dose inhalers | A |    | B |    | C |    | D |
    o. O2  
      (1) Bag and mask | A |    | B |    | C |    | D |
      (2) ET tube | A |    | B |    | C |    | D |
      (3) External CPAP | A |    | B |    | C |    | D |
      (4) Face masks | A |    | B |    | C |    | D |
      (5) Nasal cannula | A |    | B |    | C |    | D |
      (6) Nebulizer  
        a. Cold | A |    | B |    | C |    | D |
        b. Hand held | A |    | B |    | C |    | D |
        c. Heated | A |    | B |    | C |    | D |
        d. Ultrasonic | A |    | B |    | C |    | D |
      (7) O2 | A |    | B |    | C |    | D |
      (8) T-piece | A |    | B |    | C |    | D |
      (9) Trach collar | A |    | B |    | C |    | D |
    p. Thoracentesis assistance | A |    | B |    | C |    | D |
    q. Ventilator set up and care
      (1) Assist/control | A |    | B |    | C |    | D |
      (2) CPAP | A |    | B |    | C |    | D |
      (3) Flow-by | A |    | B |    | C |    | D |
      (4) High frequency jet ventilator | A |    | B |    | C |    | D |
      (5) High frequency oscillator | A |    | B |    | C |    | D |
      (6) IMV | A |    | B |    | C |    | D |
      (7) Inverse ratio ventilator | A |    | B |    | C |    | D |
      (8) Pressure support | A |    | B |    | C |    | D |
      (9) Pressure vents | A |    | B |    | C |    | D |
      (10) SIMV | A |    | B |    | C |    | D |
      (11) Trouble shooting high pressure alarms | A |    | B |    | C |    | D |
      (12) Trouble shooting low pressure alarms | A |    | B |    | C |    | D |
      (13) Volume vents | A |    | B |    | C |    | D |
      (14) Weaning | A |    | B |    | C |    | D |

B. CARE OF THE PATIENT WITH:
  a. Acute/chronic bronchitis | A |    | B |    | C |    | D |
  b. ARDS (adult respiratory distress syndrome) | A |    | B |    | C |    | D |
  c. Aspiration | A |    | B |    | C |    | D |
  d. Asthma | A |    | B |    | C |    | D |
  e. Bronchoscopy | A |    | B |    | C |    | D |
  f. Cardiac surgery | A |    | B |    | C |    | D |
  g. CHF | A |    | B |    | C |    | D |
  h. COPD | A |    | B |    | C |    | D |
  i. Cystic fibrosis | A |    | B |    | C |    | D |
  j. Epiglottitis | A |    | B |    | C |    | D |
  k. Fresh tracheostomy | A |    | B |    | C |    | D |
  l. Gullian Barre | A |    | B |    | C |    | D |
  m. Hemopneumothorax | A |    | B |    | C |    | D |
  n. Laryngospasm | A |    | B |    | C |    | D |
  o. Myasthenia | A |    | B |    | C |    | D |
  p. Pneumonia | A |    | B |    | C |    | D |
  q. Pulmonary edema | A |    | B |    | C |    | D |
  r. Pulmonary embolism | A |    | B |    | C |    | D |
  s. Smoke inhalation | A |    | B |    | C |    | D |
  t. Status asthmaticus | A |    | B |    | C |    | D |
  u. Tension pneumothorax | A |    | B |    | C |    | D |
  v. Thoracotomy | A |    | B |    | C |    | D |
  w. Tracheo-esophageal fistula | A |    | B |    | C |    | D |
  x. Tuberculosis | A |    | B |    | C |    | D |

C. MEDICATIONS
  1. Administration of:
  a. Aerobid, Vanceril | A |    | B |    | C |    | D |
  b. Aminophylline (Theophylline) | A |    | B |    | C |    | D |
  c. Azmacort | A |    | B |    | C |    | D |
  d. Bicarbonate | A |    | B |    | C |    | D |
  e. Combivent | A |    | B |    | C |    | D |
  f. Cromolyn Sodium (Intal) | A |    | B |    | C |    | D |
  g. Decadron | A |    | B |    | C |    | D |
  h. Flonase | A |    | B |    | C |    | D |
  i. Flovent | A |    | B |    | C |    | D |
  j. Inhaled steroids | A |    | B |    | C |    | D |
  k. Ipratropium bromide (Atrovent) | A |    | B |    | C |    | D |
  l. Isoetharine (Bronkosol) | A |    | B |    | C |    | D |
  m. Isoproterenol (Isuprel) | A |    | B |    | C |    | D |
  n. Metaproterenol (Alupent) | A |    | B |    | C |    | D |
  o. Mucomyst | A |    | B |    | C |    | D |
  p. Nasalcort | A |    | B |    | C |    | D |
  q. Racemic epinephrine | A |    | B |    | C |    | D |
  r. Salbutamol (Albuterol, Proventil, Ventolin) | A |    | B |    | C |    | D |
  s. Terbutaline sulfate (Bricanyl) | A |    | B |    | C |    | D |
  2. Familiar with effects of:
  a. Anectine | A |    | B |    | C |    | D |
  b. Atropine | A |    | B |    | C |    | D |
  c. Corticosteroids | A |    | B |    | C |    | D |
  d. Digitalis | A |    | B |    | C |    | D |
  e. Digoxin | A |    | B |    | C |    | D |
  f. Dopamine | A |    | B |    | C |    | D |
  g. Duramorph | A |    | B |    | C |    | D |
  h. Heli/ox therapy | A |    | B |    | C |    | D |
  i. Ketamine | A |    | B |    | C |    | D |
  j. Lidocaine | A |    | B |    | C |    | D |
  k. Morphine sulfate | A |    | B |    | C |    | D |
  l. Nipride | A |    | B |    | C |    | D |
  m. Nitric oxide therapy | A |    | B |    | C |    | D |
  n. Pavulon | A |    | B |    | C |    | D |
  o. Pentamidine isethionate | A |    | B |    | C |    | D |
  p. Propofol | A |    | B |    | C |    | D |
  q. Theo-dur | A |    | B |    | C |    | D |
  r. Valium | A |    | B |    | C |    | D |
  s. Versed | A |    | B |    | C |    | D |

D. PHLEBOTOMY
  1. Equipment & procedures
  a. Drawing blood from central line | A |    | B |    | C |    | D |
  b. Drawing blood from peripheral line | A |    | B |    | C |    | D |
  c. Drawing venous blood | A |    | B |    | C |    | D |

E. NEONATAL/PEDIATRICS
  1. Equipment & procedures
  a. Assist in high risk delivery | A |    | B |    | C |    | D |
  b. Capillary blood gases | A |    | B |    | C |    | D |
  c. ECMO | A |    | B |    | C |    | D |
  d. O2 | A |    | B |    | C |    | D |
  e. Umbilical blood gases | A |    | B |    | C |    | D |
  2. Care of the infant or child with:
  a. Bronchopulmonary dysplasia (BPD) | A |    | B |    | C |    | D |
  b. Croup | A |    | B |    | C |    | D |
  c. Epiglottitis | A |    | B |    | C |    | D |
  d. Meconium aspiration | A |    | B |    | C |    | D |
  e. Near drowning | A |    | B |    | C |    | D |
  f. Persistent pulmonary hypertension(PPHN) | A |    | B |    | C |    | D |
  g. Pulmonary interstitial emphysema (PIE) | A |    | B |    | C |    | D |
  h. Respiratory distress syndrome (RDS) | A |    | B |    | C |    | D |
  i. Respiratory syncytial virus | A |    | B |    | C |    | D |
  j. Transient tachypnea of the newborn | A |    | B |    | C |    | D |

AGE SPECIFIC PRACTICE CRITERIA
Please check the boxes below for each age group for which you have expertise in providing age-appropriate nursing care.

A. Newborn/Neonate (birth - 30 days)
F. Adolescents (12 - 18 years)
B. Infant (30 days - 1 year) G. Young adults (18 - 39 years)
C. Toddler (1 - 3 years) H. Middle adults (39 - 64 years)
D. Preschooler (3 - 5 years) I. Older adults (64+)
E. School age children (5 - 12 years)  

EXPERIENCE WITH AGE GROUPS: A B C D E F G H I
Able to adapt care to incorporate normal growth and development.
Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.
Can ensure a safe environment reflecting specific needs of various age groups.

Experience with the following ventilators:
Bear _________________ Series (name or number)
Bird _________________ Series (name or number)
BP _________________ Series (name or number)
Hamilton Amadeus, Veolar _________________ Series (name or number)
MA _________________ Series (name or number)
Newport _________________ Series (name or number)
Sechrist _________________ Series (name or number)
Servo _________________ Series (name or number)
Drager Infant    
Emerson    
Engstrom    
Puritian Bennett 7200    
Others, List _________________  

My experience is primarily in: (Please indicate number of years.)
General adult inpatient
___ year(s) Pediatrics ___ year(s)
Home care ___ year(s) Pulmonary rehab ___ year(s)
Intensive care unit ___ year(s) Sleep lab ___ year(s)
Long term care ___ year(s) Subacute ___ year(s)
Neonatal ICU ___ year(s) Level   ___    

Certification:
Please check the boxes below and indicate the expiration date for each certificate that you have. If you do not know the exact date, please use the last date of the specific month (e.g., 08/31/2003).

BCLS
Exp. date:
________  (mm/dd/yyyy)
PALS
Exp. date:
________  (mm/dd/yyyy)
EKG technician
Date:
________  (mm/dd/yyyy)
EEG technician
Date:
________  (mm/dd/yyyy)
ACLS
Exp. date:
________  (mm/dd/yyyy)
NRP
Exp. date:
________  (mm/dd/yyyy)
RRT
Date:
________  (mm/dd/yyyy)
CRTT
Date:
________  (mm/dd/yyyy)
Arterial blood gas technician
Exp.date:
__________ (mm/dd/yyyy)
Other (type): ________________
Exp.date:
________   (mm/dd/yyyy)
Computerized charting system: ________________
Exp.date:
________ (mm/dd/yyyy)

The information I have given is true and accurate to the best of my knowledge.

Signature: ____________________________ Date:_____________