CRITICAL CARE EXPERIENCE PROFILE

First Name: Last Name:Grad from nursing school:

Degree: CCRN N/A ACLS N/A

CNS N/A

State of original License:

State of current License:

Phone Number:

Please indicate your level of experience with the following patient groups and clinical skills category according to the number of years of experience indicated below:

CATEGORIES 0, 1, 2, 3

0=No experience
1=limited experience
2=perform with review
3=perform independently

	PATIENT GROUPS	0	1	2	3
	Neonate
	Infant
	Children
	Adolescent
	Adult
	Geriatric
CRITICAL CARE ASSESSMENT
Abnormal heart sounds
Vascular bruits
Doppler pulses
Peripheral pulses
Arrythmia identification
EKG interpretation
Glasgow coma scale
Burn assessment
Code Blue team leader
CRITICAL CARE SKILLS
CHF
Acute MI
Acute MI with thrombolytics
Inbound transfer facility
Outbound transfer facility
Pre/post CABG
Pre/post aneurysm repair
Pre/post angioplasty
Pre/post gastrectomy
Pre/post thoracotomy
Pre/post transplant
Pre/post radical neck
Pre/post organ donation
Pre/post craniotomy
EKG, set up & initiate
Atrial Fib
1st & 2nd degree AV blocks
Cardioversion
Temporary pacemaker
Permanent pacemaker
Balloon pump
Swan-Ganz, set up & assist with insertion
Interpretation of PA readings
Cardiac output, calculating
Undiagnosed chest pain
Cardiomyopathy
Peripheral vascular insufficiency
Electrophysiology studies
Cardiac rehab
Starting IV's
Cardizem
Dobutamine
Dopamine
Isuprel
Nitroglycerine
Lidocaine
Insulin infusion
KPO4 infusion
Paralytics (Diprivan)
Heating/cooling blankets
Spinal cord injury
Septic shock
Hypovolemic shock
Drug overdose
Alcohol intoxication
Burns
Gunshot/stab wound
ABD aortic aneurysm repair
ICP monitoring (Camino)
Acute CVA
Acute CVA with thrombolytics
Hyperglycemic crisis
Multiple trauma
ABG's drawing from A-line
ABG's, arterial stick
ABG's interpretation
Ventilators, set up & adjustments
Oxygen masks
Ambu bags
Non rebreather
Oximetry
Skin care/wound prevention

CRITICAL CARE NURSING WORK HISTORY
TO NAME OF HOSPITAL:
SUPERVISOR NAME:
NUMBER OF HOSPITAL BEDS:
NUMBER OF BEDS ON UNIT:
PATIENT TYPES		LDRP
TRAVEL ASSIGNMENT?
DESCRIPTION OF DUTIES:


TO NAME OF HOSPITAL:
SUPERVISOR NAME:
NUMBER OF HOSPITAL BEDS:
NUMBER OF BEDS ON UNIT:
PATIENT TYPES		LDRP
TRAVEL ASSIGNMENT?
DESCRIPTION OF DUTIES:


TO NAME OF HOSPITAL:
SUPERVISOR NAME:
NUMBER OF HOSPITAL BEDS:
NUMBER OF BEDS ON UNIT:
PATIENT TYPES		LDRP
TRAVEL ASSIGNMENT?
DESCRIPTION OF DUTIES:

Authorization (Please type your name and the date.)

By submitting this application, I hereby certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.

Signature Date

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