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Interventional Radiology RN
Interventional Radiology RN
Name
First
Last
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
General
No Experience
Limited Experience
Experienced
Highly Skilled
Admit patient to pre-procedure holding
Complete assessments, obtain family history & risk factors
Start Peripheral IV
Complete pre-procedure checklist
Transport pre-procedure patient to the Lab
Transport post-procedure patient to in-hospital units
Procedures
No Experience
Limited Experience
Experienced
Highly Skilled
Cerebral Angiogram – Prepare
Cerebral Angiogram – Assist
Lower Extremity Angiogram – Prepare
Lower Extremity Angiogram – Assist
Upper Extremity Angiogram – Prepare
Upper Extremity Angiogram – Assist
Ultrasound Guided Biopsy – Prepare
Ultrasound Guided Biopsy – Assist
CT Scan Guided Biopsy – Prepare
CT Scan Guided Biopsy – Assist
Liver Biopsy and Embolization – Prepare
Liver Biopsy and Embolization – Assist
Prepare and Assist with Line Placement – Broviac
Prepare and Assist with Line Placement – Groshong
Prepare and Assist with Line Placement – Hickman
Prepare and Assist with Line Placement – PICC
Prepare and Assist with Line Placement – PortaCath
Uterine Fibroid Embolization – Prepare
Uterine Fibroid Embolization – Assist
Temporary Hemodialysis Shunt Placement – Prepare
Temporary Hemodialysis Shunt Placement – Assist
Permanent Hemodialysis Shunt Placement – Prepare
Permanent Hemodialysis Shunt Placement – Assist
AV Fistula/Shunt Declotting – Prepare
AV Fistula/Shunt Declotting – Assist
Vertebroplasty – Prepare
Vertebroplasty – Assist
Lumbar Puncture – Prepare
Lumbar Puncture – Assist
Myelogram – Prepare
Myelogram – Assist
Provide care for the post-procedure patient
Other Procedures (please list and indicate level of experience):
Cardiovascular
No Experience
Limited Experience
Experienced
Highly Skilled
Assess heart sounds and peripheral pulses
Interpret arrhythmias
Perform CPR
Perform defibrillation
Participate as a team member in resuscitation
Pulmonary
No Experience
Limited Experience
Experienced
Highly Skilled
Assess lung sounds
Set up oxygen devices
Obtain pulse oximetry reading
Interpret ABG
Use Ambu bag
Assist with intubation
Assist with chest tube insertion
Provide care for the patient with mechanical ventilation
Neurological
No Experience
Limited Experience
Experienced
Highly Skilled
Identify sudden change in level of consciousness
Assess sensory, motor, speech
Assess reflexes (Babinski, gag)
Medications
No Experience
Limited Experience
Experienced
Highly Skilled
Titrate vasoactive drugs
Calculate mcg/min and mcg/kg/min
Use IV infusion pump to calculate drug doses
Administer IV dopamine
Administer IV nitroglycerine
Administer IV dobutamine (Dobutrex)
Administer IV lidocaine
Administer IV diltiazem (Cardizem)
Administer IV epinephrine
Administer IV atropine
Administer IV heparin
Administer IV benzodiazepines (Valium, Versed, Ativan)
Administer IV propofol (Diprivan)
Administer IV neuromuscular blocking agents (Pavulon, Norcuron)
Administer IV narcotics (morphine, fentanyl)
Pain/Wound Management
No Experience
Limited Experience
Experienced
Highly Skilled
Assess pain level/tolerance
Care of patient with anesthesia/analgesia
Care of patient with IV conscious sedation
Care of patient with narcotic analgesia
Care of patient with patient controlled analgesia (PCA pump)
Assess surgical wound status with/without drain(s)
Care of patient with sterile dressing changes
Care of patient with FemoStop device
Assessment of VasoSeal, AngioSeal, PerClose success
Age-Specific Practice Criteria
Pediatric (1-18 years)
Adolescents (12 - 18 years)
Adult (19 - 65 years)
Older adults (Older than 65 years)
From the choices above, please check the box corresponding to each age group for which you have expertise in providing age-appropriate nursing care.
Experience with Age Groups
No Experience
Limited Experience
Experienced
Highly Skilled
Calculate body weight to verify correct dosing of medication
Assess immunization status for pediatric, and adolescent
Set age-appropriate short-term and long-term goals in care planning
Provide age-appropriate education, considering possible vision and hearing impairment for Older than 65 years.
Certification : ACLS
Please add the completion date (mo/day/year)
Certification: BCLS
Please add the completion date (mo/day/year)
Other Certifications: (specify)
Please specify other certifications and add completion date (mo/day/year)
Signature
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