Nurse Application Forms

Name:
Email:

Phone:

Service Description for Nurses

PHYSICAL REQUIREMENTS (F) – Frequently (O) - Occasionally

* Please look over this to make sure you are able to fulfill all requirements before submitting this application.

REQUIREMENT

USED

COMMENTS

SIT, STAND, WALK, BEND, SQUAT

(F)

CHARTING, FEEDING AND TALKING TO PATIENTS,

ALL INVOLVED IN PT. CARE

CRAWL, CLIMB

(O)

IN CASE OF FIRE

REACH ABOVE HEAD

(F)

HANGING IVs, FEEDING TUBES, REACHING MEDICINE CABINET, ETC.

LIFT UNASSISTED – UP TO 20 LBS

(F)

WORKING WITH EQUIPMENT

21 – 50 LBS

(O)

OVER 50 LBS ASSISTANCE NECESSARY

GRASPING USING BOTH HANDS

(F)

DAILY PT. CARE – GIVE MEDICATIONS, BLOOD PRESSURES OPEN BOTTLES, AND WORKING WITH EQUIPMENT

PUSHING/PULLING

(F)

WHEELCHAIRS, CARTS, BEDS

FINE MANIPULATING USING BOTH HANDS

(F)

TREATMENTS, GIVE MEDS, USING EQUIPMENT,

DAILY PT. CARE AND WRITING

MOVE AROUND MACHINES

(O)

MACHINES IN PT’s ROOMS

MANIPULATING FEET AND USING BOTH FEET

(F)

USING FOOT LOCKS AND PEDALS ON BEDS, HOPPERS

AND HAMPERS

EXPOSURE TO DUST, FUMES AND SHARP OBJECTS

(O)

DUST, CHEMICALS, SAFETY PINS, RAZORS, ETC

SENSORY REQUIREMENTS

REQUIREMENT

COMMENTS/RELATED JOB DUTY

CAN DISTINGUISH SMELLS

FOUL ODORS ARE OFTEN SYMPTOMATIC OF THE DISEASE PROCESS OR INFECTION

CAN HEAR NORMAL TONES AND SOFT TONES

TELEPHONE ORDERS FROM DOCTORS, PT. CALLS & CALL BELLS MUST BE HEARD FROM NEAR AND FAR DISTANCES BLOOD PRESSURES, PULSES, ETC.

CAN DISTINGUISH TEMPERATURES

TEMPERATURE OF EQUIPMENT, PT. TEMPS, BATHS, HEATING PADS, ICE PACKS, ETC.

EYESIGHT NORMAL OR CORRECTED AND ABLE TO DO CLOSE EYE WORK

OBSERVING PATIENTS, GIVING PATIENT CARE, CHARTS, TESTS, B/P READINGS, GIVING MEDS, ETC.

MENTAL REQUIREMENTS

REQUIREMENT

COMMENTS/RELATED JOB DUTIES

READ, WRITE AND SPEAK

NECESSARY – MUST READ MEDICAL INFO., COMMUNICATE TO STAFF, PT’s, AND DOCTORS

IS COHERENT

NECESSARY

MEMORY AND RECALL

NECESSARY

CAN CONTROL EMOTIONS & HANDLE STRESS

NECESSARY

HAS POSITIVE ATTITUDE TOWARD THE ILL, ELDERLY, & THE HANDICAPPED

NECESSARY

ABLE TO WORK WITH CONTROLLED SUBSTANCES

NECESSARY – MUST DISPENSE CONTROLLED SUBSTANCES

I have read and understand that the physical, sensory, and mental requirements outlined below are necessary of the services to be performed. I affirm I am able to perform the service without limitation and have not knowingly withheld any information relating to these requirements.


Clinical Skills Checklist for LPNs and RNs

Please put a number indicating your level of experience in each area:

0=No Experience

1=Limited Experience

2=Experienced

3=Proficient

Cardiac:

Obtain 12 lead EKG: Interpreting 12 lead EKG

Arrhythmia Interpretation: Assisting W/ Cardio version:

Defibrillation: Arrest/Resuscitation Management:

Interpreting Heart Sounds: Care, maintenance and monitoring of Swan Ganz Catheters:

Care of Post Open Heart Surgery Patients: Care and Monitoring of Balloon Pump Patients:

Assist and Care of Temporary Pacemaker Recipients: Setup and assist for Swan Ganz Catheter Insertion:

Setup and Assist for Arterial Line Catheter Insertion: Care of Patient in Shock:

Care of Patient with Fresh or Extending MI:

Titration of Medicine:

Dopamine: Isuprel:

Digitalis: Bretyllium:

Nipride: Dobutrex:

Lidocaine: Epinephrine:

Respiratory:

Endotracheal Intubation: Endotracheal Extubation:

Care/Maintain Tracheal Tubes: Care of Ventilator Patients:

Care of Patients Weaning from Ventilator: Care of patients with Pulmonary Edema:

Care of Patients with Adult Respiratory Distress Syndrome: Suctioning of Tracheal and Endotracheal Tubes:

Chest Tubes Insertion: Care of Patients with Chest Tubes:

Drawing ABG's: Interpreting ABG's

Neuro:

Neuro Vital Sign: ICP Monitors:

Care and Asses Fresh CVA Patients: Care of Patients W/ Closed Head Injuries:

Post Op care of Patients with Craniotomy: Care of Patients with Seizures:

Care of patients with Spinal Trauma: Care of Patients with Halo Transaction:

Care of patients with Crutchfield Tongs:

Gastro:

Care/Maintain/Insertion NG Tubes: Care/Maintain/Insertion G Tubes:

Care of patients with Duodenal Tubes: Care of patients with Blakemore Tubes:

Care of patients with Miller Abbot Tube: Care of patients with GI Bleed:

Renal:

Care of Hemodialysis patients: Care of Peritonealdyalisis patients:

Care of CAVH patients: CAre of Supra Pubic Catheters:

Care of patients with Renal Failure: Care of patients with Nephrectomy:

Phlebotomy:

Starting IV's Using Heplocks/Salinelock:

Using Infusion Pumps: Administering Blood Products:

Administering Hyperal/TPN:



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