perioperative - tlcnursing.com · colostomy/ileostomy esophogeal resection exploratory laparotomy...
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Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 1 of 14
TLC R N APP
IV Therapy
Scrub Circulate
0 1 2 0 1 2
Start peripheral IV - angio cath
IV Therapy - Assist with:
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0 1 2 0 1 2
Insertion of A-lines
Insertion of CVP - jugular
Insertion of CVP - sublavian
Insertion of Swan-Ganz
Drawing blood from central line
Drawing venous blood
Administration of blood and products
Scrub Circulate
0 1 2 0 1 2
Packed red blood cells
Plasma/Albumin
Whole blood
General Surgery
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0 1 2 0 1 2
Abdominal perineal resection
Adrenalectomy
Anal fissurectomy
Appendectomy
Bowel resection
Breast biopsy
Cholecystectomy (open)
Colectomy
Colostomy/ileostomy
Esophogeal resection
Exploratory laparotomy
Gastrectomy
Gastroplasty
Hemorrhoidectomy
Hemicolectomy
Hepatic resection
Herniorrhaphy - femoral
Herniorrhaphy - inguinal
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]
Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 2 of 14
TLC R N APP
Scrub Circulate
0 1 2 0 1 2
Herniorrhaphy - umbilical
Herniorrhaphyhiatal transabdominal/transthoracic
Hiatal hernia repair
Hepatic resection
Insertion - Hickman
Insertion - Groshong
Insertion - Portacath
Hydroceletomy
Imperforate anus reconstruction
Lumbar sympathectomy
Omphalocele repair
Pancreatectomy / pancreatogram
Pilonidal cystectomy
Portal caval shunt
Pyloric stenosis
Radical mastectomy
Saphenous vein ligation and stripping
Sentinel node biopsy
Splenectomy
Tenchknoff duct cyst excision
Thyroglossal duct cyst excision
Thryoidectomy
Vagotomy
Thoracic and Open Heart
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0 1 2 0 1 2
Cervical rib excision
Chamberlain procedure
Closed thoracotomy
Correction pectus excavatum
Esophagectomy
Heller procedure
Mitral commissurotomy
Mitral or aortic valve replacement
IAPB insertion
CABG
Cardiac valve replacement
Patent ductus arteriosus repair
Septal defect repairs
Pacemaker implanation - endocardial
Pacemaker implanation - myocardial
Pacemaker - temporary
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]
Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 3 of 14
TLC R N APP
Scrub Circulate
0 1 2 0 1 2
Pericardiectomy
Pericardial window
Resection coarctation aorta
Portocaval shunt
Tetrology of fallot
Thoracoplasty
Tracheal resection
Transthoracic diaphragmatic heniorrhaphy
Vascular
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0 1 2 0 1 2
A-V access graft
Aortic aneurysm with graft replacement
Endarterectomy/carotid - femoral
Fem-pop bypass
Peripheral vascular bypass procedures
Resection carotid aneurysm with graft
Thrombectomy/embolectomy
Vena cava filter/umbrella
Vena cava ligation
Neurology
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0 1 2 0 1 2
A-V malformation
Anterior cervical fusion
Anterior laparoscopic spine procedures
Anterior lumbar interbody fusion (ALIF)
Burr holes for subdural hematoma
Carotid ligation
Cervical sympathectomy
Craniectomy for decompression fracture
Discetomy
Hypophysectomy
Insertion nerve stimulators
Insertion medication pumps
Laminectomy
Myelomeningocele repair
Pedicle screw insertion
Posterior lumbar interbody fusion (PLIF)
Shunt procedure/VP, VA/LP
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]
Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 4 of 14
TLC R N APP
Scrub Circulate
0 1 2 0 1 2
Spine fusion
Ulnar nerve transfer
Ventriculography / ventriculoscopy
Ventriculostomy
Neurology - Cranioplasty/craniotomy
Scrub Circulate
0 1 2 0 1 2
Clipping of aneurysm
Tumor excision
Stealth crainiotomy
Urology
Scrub Circulate
0 1 2 0 1 2
Adult circumcision
Cystectomy
Cystoscopy/ureteroscopy
Hypospadias repair
Ileal loop
Implants - penile and testicular
Lithotripsy
Nephrectomy
Nephrolithotomy
Orchiopexy
Prostatectomy - perineal
Prostatectomy - supra-pubic
Pyleoplasty
Radical node dissection
Scott incontinence device
TURP
Ureterolithotomy
Vasectomy
Vasovasostomy
Waterhouse procedure
Gynecology
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0 1 2 0 1 2
Cesarean section
Colpotomy
Dilation and curettage (DandC)
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]
Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 5 of 14
TLC R N APP
Scrub Circulate
0 1 2 0 1 2
Hysterectomy - abdominal
Hysterectomy - vaginal
Marshall - Marchetti
Marsupialization, Bartholin cyst
Ovarian cystectomy
Radium insertion
Salpingo-oophorectomy
Sacral spinus fixation
Shirodkar procedure
Suction curettage
Termination of pregnancy
Tubal ligation
Vaginal recontruction
Vaginectomy/vulvectomy
Orthopedics
Scrub Circulate
0 1 2 0 1 2
Acetabular/pelvic ORIF
Achilles tendon repair
Amputation- leg, arm
Anterior cruciate ligament repair
Application of external fixators - extremeties
Application of external fixators - pelvis
Application of halo traction
Arthrotomy
Bipolar/unipolar hips
Bunionectomy
Calcanel reconstruction
Capsulorrhaphy
Carpal tunnel release
Closed reduction fracture
Hand surgery with implants
Harrington rod instrumentation and / or Dwyer procedure
Heel cord lengthening
Laminectomy
Olecranon bursa, excision of
ORIF, internal fixation with compression set
Patellectomy
PuttiPlatt/Bankart procedure/rotator cuff repair
Reduction with compression sets
Reimplanation of digits
Repair hammer toes
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]
Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 6 of 14
TLC R N APP
Scrub Circulate
0 1 2 0 1 2
Sacro-iliac (SI) joint screws
Sharrard procedure
Spica cast, application
Spinal fusion
Tendon transplants (hand and foot)
Orthopedics - Arthroscopy
Scrub Circulate
0 1 2 0 1 2
Ankle
Elbow
Knee
Shoulder
Orthopedics - Hip compression nails and lag screws
Scrub Circulate
0 1 2 0 1 2
Jewett
Kuntscher rod
Lottes
Rush
Schneider
Zimmer
Iliac crest bone graft
Insertion Austin Moore hip prosthesis
Orthopedics - Intramedullary rods
Scrub Circulate
0 1 2 0 1 2
Extraction
Femoral
Humeral
Insertion
Supracondylar
Tibal
Orthopedics - Total joint replacements/revisions
Scrub Circulate
0 1 2 0 1 2
Hip
Knee
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]
Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 7 of 14
TLC R N APP
Scrub Circulate
0 1 2 0 1 2
Shoulder
Plastics
Scrub Circulate
0 1 2 0 1 2
Abdominal lipectomy
Abdominalplasty
Blepharoplasty
Cleft lip repair
Dermabrasion
Face lift
Mentoplasty
Otoplasty
Pedicle grafts
Rhytidectomy
Scar revisions
Split thickness skin grafting
Tissue expanders
Plastics - Mammoplasty
Scrub Circulate
0 1 2 0 1 2
Augmentation
Reduction
Tramflaps with reconstructive mammoplasty
Ear, Nose and Throat
Scrub Circulate
0 1 2 0 1 2
Adenoidectomy
Caldwell - Luc
Cleft lip/palate repair
Closed reduction nasal fx
Ethmoidectomy
Excision of salivary gland tumor
Fenestration procedure
Frontal flap sinus procedure
Glossectomy
Laryngectomy
Mandibulectomy
Mastoidectomy
Maxillary advancement with graft
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]
Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 8 of 14
TLC R N APP
Scrub Circulate
0 1 2 0 1 2
Maxillectomy
Myringoplasty
Myringotomy with PE tube insertion
Nasal polypectomy
Open reducation facial fx
Open reducation nasal fx
Parotidectomy
Pharyngeal flap procedure
Radical neck dissection
Ranulectomy
Rhinoplasty/septoplasty
Selective osteotomy of maxilla/mandible
Sinus endoscopy
Sinusotomy
Stapedectomy
Submucous resection
Tonsillectomy
Tracheostomy
Tympanoplasty
Oral
Scrub Circulate
0 1 2 0 1 2
Closed reducation facial fractures/wiring
Excision odontoma
Excision of deciduous teeth
Extraction of impacted molars
Fractured jaws, mandibular and zagomatic
Ginivectomy
LeFort osteotomies
Maxillary procedure with graft
Pediatric dentistry
Sagittal osteotomy
Temporomandibular (TMJ) with arthroplasty
TMJ exploration
Ophthalmology
Scrub Circulate
0 1 2 0 1 2
Cataract extraction with IOL
Corneal transplant
Dacryocystectomy
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]
Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 9 of 14
TLC R N APP
Scrub Circulate
0 1 2 0 1 2
Eye enucleation
Exicison of chalazion
Canthotomy
Correction of ectropian/entropian
Enucleation
Eye transplant
Iridectomy
Lacrimal duct probing
Lid and muscle procedures
Orbital implant
Phaco emulsification
Ptergium repair
Recession resection
Refractive keratoplasty
Repair orbital blowout fracture
Repair of retinal detachment
Scleral buckle
Vitrectomy
Endoscopic Procedures
Scrub Circulate
0 1 2 0 1 2
Bronchoscopy
Colonscopy
Culdoscopy
Esophagoscopy
Gastroscopy
Hysteroscopy
Laparoscopic procedures
Scrub Circulate
0 1 2 0 1 2
Appendectomy
Cholecystectomy / cholangiogram
Colon resection
Diagnostic
Hernia repair
Nissen fundoplication
Salpingo-oophorectomy
Tubal ligation
Vaginal hysterectomy
Larynoscpy and microlaryngoscopy
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]
Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 10 of 14
TLC R N APP
Scrub Circulate
0 1 2 0 1 2
Mediastinoscopy
Pelviscopy
Sigmoidoscopy
Thoracoscopy
Transplant
Scrub Circulate
0 1 2 0 1 2
Bone
Bone marrow
Corneal transplant
Harvesting
Heart
Kidney
Liver
Lung
Multi-organ
Pancreas
Skin
Trauma
Scrub Circulate
0 1 2 0 1 2
Burns
Motor vehile accidents (multiple injuries)
Traumatic amputations
Trauma - Gunshot/stab wounds
Scrub Circulate
0 1 2 0 1 2
Abdomen
Chest
Head
Equipment
Scrub Circulate
0 1 2 0 1 2
Argon beam coagulator
Bair hugger
Blood/fluid warmer
Cardiac monitor and pacemaker
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]
Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 11 of 14
TLC R N APP
Scrub Circulate
0 1 2 0 1 2
Cell saver
Cidex soak
Cry-opthalmic unit
Defibrillator/pacer
Electrosurgical unit
Emerson thoracic pump
ETO sterilizer
Eye magnet
Fiber optic luminator
Flash autoclave
Hypo/hyperthemia units
Kreiselman resuscitor
Mesh graft
MicroscopesNerve stimulatorNitrous oxide bank
Nitrous oxide bank
Ohio suction units
Orthopedic arm board with drain
Pleurevac disp. chest drainage
Pneumatic tourniquet
Sterad machine
Steri-vac aeratopm cabinet
Steris unit
Tele therometer
Ultrasonic cleaner
Vac-pac positioner
Vacuum curettage
Washer sanitizer
Washer sterilizer
Equipment - Fracture tables
Scrub Circulate
0 1 2 0 1 2
Chick/Marquet tables
Jackson table
Rush/Skytron tables
Equipment - Intestinal stapling devices
Scrub Circulate
0 1 2 0 1 2
EEA
GIA
LDS
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]
Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 12 of 14
TLC R N APP
Scrub Circulate
0 1 2 0 1 2
TA
Equipment - Laser
Scrub Circulate
0 1 2 0 1 2
CO2
Eye magnet
Yag
Other
Camera/video systems
Scrub Circulate
0 1 2 0 1 2
Camera controller
Light source
Printers
VCRs
Dermatome
Scrub Circulate
0 1 2 0 1 2
Brown
Padgett
Zimmer
Disposable grounding pads
Drills
Scrub Circulate
0 1 2 0 1 2
3-M maxi driver
Codman craniotome
Hall air-driver
Hall dental
Hall neurotome
Midax Rex/Anspach
Minidriver
Stryker drills - large battery
Stryker drills - small battery
Surgairtome
Synthes A-O drill
Electrosurgical unit
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]
Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 13 of 14
TLC R N APP
Miscellaneous
Scrub Circulate
0 1 2 0 1 2
Assist with intubation
Conscious sediation administration
Conscious sediation monitoring
Management of malignant hypertensive crisis
Able to assure a safe environment for the specific needs of various age groups
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0 1 2 0 1 2
A.Newborn/Neonate (birth - 30 days)
B.Infant (30 days - 1 year)
C.Toddler (1 - 3 years)
D.Preschooler (3 - 5 years)
E.School age children (5 - 12 years)
F.Adolescents (12 - 18 years)
G.Young adults (18 - 39 years)
H.Middle adults (39 - 64 years)
I.Older adults (64+)
Able to communicate and/or instruct patients according to their age, maturity, comprehension
Scrub Circulate
0 1 2 0 1 2
A.Newborn/Neonate (birth - 30 days)
B.Infant (30 days - 1 year)
C.Toddler (1 - 3 years)
D.Preschooler (3 - 5 years)
E.School age children (5 - 12 years)
F.Adolescents (12 - 18 years)
G.Young adults (18 - 39 years)
H.Middle adults (39 - 64 years)
I.Older adults (64+)
Evaluate age-appropriate behavior, motor skills and physiological norms
Scrub Circulate
0 1 2 0 1 2
A.Newborn/Neonate (birth - 30 days)
B.Infant (30 days - 1 year)
C.Toddler (1 - 3 years)
D.Preschooler (3 - 5 years)
E.School age children (5 - 12 years)
F.Adolescents (12 - 18 years)
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]
Completed Date:
da_initialsInitials:
Signed Date: da_date
Last Name First Name Social Security Number Discipline
Perioperative 0 = No Knowledge / 1 = Limited Knowledge / 2 = Proficient
TRAVELER SKILLS CHECKLIST
Traveler Skills ChecklistPage 14 of 14
TLC R N APP
Scrub Circulate
0 1 2 0 1 2
G.Young adults (18 - 39 years)
H.Middle adults (39 - 64 years)
I.Older adults (64+)
56 W Twin Oaks Terrace Suite 1 So. Burlington, VT 05403 Phone: (802) 735 1123 Fax: (877) 867 9432 www.vtnursing.com Email: [email protected]