CNA Application Forms

Name:


Email:

Phone:

SERVICE DESCRIPTION FOR CERTIFIED NURSING ASSISTANT

CONTRACT LABOR – PHYSICAL, SENSORY, & MENTAL REQUIREMENTS

PHYSICAL REQUIREMNTS (F) – Frequently used (O) – Occasionally used

Please look over this description. Make sure you are able to complete all requirements before submitting this application.

REQUIREMENT

USED

COMMENTS

SIT

(O)

FEED, READ, AND TALK TO PTs.

STAND

(F)

INVOLVING PT. CARE

WALK, BEND, SQUAT

(F)

DAILY

LIFTING UNNASSISTED – UP TO 20 LBS

(F)

WORKING WITH EQUIPMENT

21-50 LBS

(O)

OVER 50 LBS - ASSISTANCE NEEDED

GRASPING USING BOTH HANDS

(F)

RENDERING PT. CARE AND PROCEDURES FOR PT. CARE

PUSHING/PULLING

(F)

WHEEL CHAIRS, CARTS

FINE MANIPULATING USING BOTH

HANDS

(F)

DRESS PATIENTS, WRITE NOTATIONS, OPEN PACKETS, DOCUMENTATION

MOVE AROUND MACHINES

(O)

MACHINES IN PATIENTS ROOMS

MANIPULATING FEET USING BOTH

FEET

(O)

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 DUTIES

CAN DISTINGUISH SMELLS

FOUL ODORS ARE OFTEN SYMPTOMATIC OF

THE DISEASE PROCESS OR INFECTION

CAN HEAR

NORMAL TONES SOFT TONES

PATIENTS CALLS AND CALL BELLS MUST BE

ANSWERED HEARD FROM CLOSE AND FAR DISTANCES

CAN DISTINGUISH TEMPERATURES BY TOUCH OR PROXIMITY

BATH WATER FOR PATIENTS, TEMPERATURE OF

EQUIPEMENT AND PATIENTS.

EYESIGHT: NORMAL OR CORRECTED

AND ABLE TO DO CLOSE EYE WORK

OBSERVE PATIENTS, GIVE PATIENTS CARE

THERMOMETERS, CHARTS, ETC.

MENTAL REQUIREMENTS

REQUIREMENT

COMMENTS/RELATED JOB DUTIES

READ, WRITE AND SPEAK

NECESSARY – TO COMMUNICATE WITH PTs.,

COMPREHEND NURSING SUPPLIES, CHARTS,

DIET CARDS, ETC.

MEMORY AND RECALL

NECESSARY

POSITIVE ATTITUDE TOWARD THE ILL, ELDERLY, HANDICAPPED

NECESSARY

IS COHERENT

NECESSARY

CAN CONTROL EMOTIONS, CAN

HANDLE STRESS

NECESSARY RELATES TO BOTH PHYSICAL AND MENTAL REQUIREMENTS, NOT GETTING ANGRY, etc.

TASKS

ASSISTING PATIENTS WITH BATHING, ENSURING THAT WATER IS APPROPRIATE TEMPERATURE

ASSISTING PATIENTS TO AND FROM BATHROOM

RECORDING INTAKE AND OUTPUT INFORMATION

CHECKING VITALS AND WEIGHTS

ANSWERING PATIENT’S CALL LIGHTS AND REQUESTS

REPORTING OBSERVATIONS OF THE PATIENT TO NURSING SUPERVISOR

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.


CNA SKILLS CHECKLIST

It is mandatory that you read and fill out this form. The checklist is used to assess you experience and skills. Please provide and accurate self-assessment of your skill using the following guidleines.
0=No Expeience
1=Limited Experience
2=Experiened
3=Highly Experiened

Documentation:

Clincal Note:

Personal Care:

Total Bed Bath: Tub Bath:

Shower: Sponge Bath:

Sitz Bath: Hair Care:

Nail and Foot Care: Skin Care:

Perineal Care: Oral Care:

Denture Care: Shave Patient

Asst. W/ Dressing: Other:

General Nursing:

Admit & Orient Patient: Dischage Patient:
Vital Sign Monitoring: Pulse Ox:
Urine Dipstick: Blood Glucose Monitoring:
Wound Care: Dressing Changes:
Pre-Op Care: Post-Anesthesia Care:
Restraints-Apply/Monitor: Isolation Techniques:
Advance Directives: Postmortem Care:

Cardiac:

Use of Cardiac Monitors: Telemetry:

Perform 12-leed EKG: Assist w/ Code

Acute MI: Congestive Heart Failure:

Pre/Post Cardiac Cath: Pre/Post Cardiac Sugery:

Aneursym: Perm Pacemaker:

Temp Pacemaker:

Orthopedic:

Crutch Walking: Cast Care:

Traction: Amputation:

Skeletal Traction: Arthoscopy:

Total Hip Replacement: Total Knee Replacement:

Activity:

Postitioning: Transferring:

Walker: Passive Range of Motion:

Active Range of Motion: Walking W/ Assistance:

Walking with Supervision: Hoyer Lift

Assist W/ Exercise Program:

Vascular:

Apply Noninvasive BP Monitor: Monitor Noninvasive BP Monitor:

Peripheral Pulses: Discontinue Peripheral IV:

Intake and Output: Ultrasound Doppler

Respiratory:

Open/Monitor Airway: Asst. W/ Intubation

Asst. W/ Extubation 02 Saturation Spot Checks

02 Saturation Monitors: Incentive Spoirometry:

Nasal Cannula: Face Masks:

Asthma/COPD: Pre/Post Thoracic Sugery:

Tracheostomy: Chest Tubes:

Neurology:

Neurological Eval: Glascow Coma Scale

Assist W/ Lumbar Puncture: Seizure Precautions:

Open/Close Head Surgery: CVA:

Spinal Cord Injury Craniotomy:

Drug Overdose:

Gastrointestinal:

Asst. W/ Nutritional Eval: Asst. W/ Feeding:

Gastrostomy Tube Monitor/Feed: Ostomy Care

GI Bleed: Abdominal Wound:

Drains:

Genitourinary:

Straight/Foley Cath Female: Straight/Foley Cath Male:

Obtain/Instruct Clean Catch Urine Shunts/Fistuals:

Renal Failture: Nephrectomy:

Renal Transplant: Mastectomy:

Hysterectomy: Prostate Surgery:

Other:

Diabetes: AIDS

Multiple Traumas: Burns:

Oncology: Bone Marrow Transplant:

Liver Transplant:

Age:

Newborn: Toddler (1-3):

Preschooler (3-5): School Age (5-12):

Adolecents (12-18): Young Adult (18-39):

Middle Adult (39-64): Older Adult (64+)



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