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Form Test
GI/Endoscopy RN
Name
*
Full Name
Date
MM slash DD slash YYYY
Self-Assessment Rating Scale:
No Experience
Theory or observation only during the past 12 months
Limited Experience
Performed less than 12 times within the past 12 months and may need a review
Experienced
Performed at least once per month within the past 12 months and may need minimal assistance
Highly Skilled
Performed on at least a weekly basis over the past 12 months; proficient
Cardiovascular
No Experience
Limited Experience
Experienced
Highly Skilled
Assessment - Ausculation (rate,rhythm)
Assessment - Blood Pressure/Non-Invasive
Assessment - Heart Sounds/Murmurs
Assessment - Perfusion
Assessment - Pulses/Circulation
Interpret - Arterial Blood Glasses
Monitoring - EKG Interpretation
Perform - Cardiac Resucitation
Perform - Emergency Defibrillation
Perform - Setup andRun 12-Lead EKG
Pulmonary
No Experience
Limited Experience
Experienced
Highly Skilled
Airway Management - Endotracheal/Suctioning
Airway Management - Nasal/Suctioning
Airway Management - Oropharyngeal/Suctioning
Airway Management - Tracheostomy/Suctioning
Assessment - Breath Sounds
Assessment - Rate and Work of Breathing
Assessment - Respiratory Complications
Assist with Bronchoscopy
Assist with Emergency Tracheostomy
Assist with Setup/Insertion of Chest Tube
Care of Child - Foreign Body Aspiration
Care of Child - Respiratory Failure
Care of Child - Status Asthmaticus
Care of Intubated Patient
Care of Patient - Aspiration
Care of Patient - Bronchoscopy
Care of Patient - Laryngospasm
Care of Patient - Pulmonary Embolism
Care of Patient - Status Asmaticus
Chest Tube - Use of Pleurevac or Thoraclex
Chest Tube - Use of Water Seal Drainage System
Establishing an Airway
Management - Endotracheal/Suctioning - Open ET Catheter
Oxygen Therapy and Medication Delivery via Bag and Mask
Oxygen Therapy and Medication Delivery via Face Mask
Oxygen Therapy and Medication Delivery via Nasal Canula
Oxygen Therapy and Medication Delivery via Oral Airway
Oxygen Therapy and Medication Delivery via Tent
Oxygen Therapy and Medication Delivery via T-Piece
Oxygen Therapy and Medication Delivery via Trach Collar
Oxygen Therapy and Medication Delivery via Transtracheal Cannulation
Perform - Obtain Sputum Specimen
Pulse Oximetry
Teach and Understand Incentive Spirometry
Ventilate with Ambu-Bag
Gastrointestinal
No Experience
Limited Experience
Experienced
Highly Skilled
Assessment - Abdominal/Bowel Sounds
Care of Patient - Colostomy
Care of Patient - Ileostomy
Interpret - Blood Chemistry
Perform - Administer Tube Feeding
Perform - Placement of NG Tube
Perform - Test for Occult Blood
Pain Management
No Experience
Limited Experience
Experienced
Highly Skilled
Assessment - Pain Level/Tolerance
Assist with Delivery of Anesthesia - Coaching Patient
Assist with Delivery of Anesthesia - Documentation of Anesthesia
Assist with Delivery of Anesthesia - Intravascular Injection
Assist with Delivery of Anesthesia - Positioning Patient
Care of Child - IV Conscious Sedation
Care of Patient - IV Conscious Sedation
Medications - Conscious Sedation Reversal
Endoscopic
No Experience
Limited Experience
Experienced
Highly Skilled
Bronchoscopy
Colonoscopy
Esophagoscopy
Gastroscopy
Sigmoidoscopy
Phlebotomy/IV Therapy
No Experience
Limited Experience
Experienced
Highly Skilled
Assessment - Site and Patency
Equipment - IV Pump
Perform - Draw Venous Blood
Perform - Rate Calculation
Perform - Start IV (Butterfly)
Perform - Start IV (Heparin Lock)
TJC/OSHA
No Experience
Limited Expeirence
Experienced
Highly Skilled
Handwashing
Isolation Techniques
Understand TJC National Patient Safety Goals
Understand TJC Prohibited Abbreviations
Universal Precautions
Use of Restraints
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