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MEDICAL SURGICAL CHECKLIST
Your first name:

Your last name:

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Attach your critical care checklist:
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1=Done Frequently; well skilled          2=Occasionally done; moderately skilled
3=Rarely done; skill limited    4=Observed only; never done

Administration/Mixing of IV meds meds via IV push

Administration of continuous fluids
Blood/blood product administration/precautions
Autotransfusion
Calculation of rates :Mcg/min, Mcg/kg/min, Mg/min

Hang IV Piggyback

Heparin Lock
Hyperalimentation
Peripheral/Central Line
Knowledge of solution

Insertion of Central line

Use of Broviac/Hickman/Groshong Catheters

Blood/blood product administration/precautions
Lab Assessment
Implanted venous access ports

Dressing changes

Insertion of peripheral line:
Dressing change
d/c line
Universal precautions

Isolation procedures

Airborne isolations
Contact Isolation/Universal Precautions
SPECIMEN COLLECTION
Arterial line blood draw

Blood culture

Capillary blood draw
Central line blood draw
PICC line blood draw
Sputum

Stool

Urine Culture
Urinalysis
Venipuncture
Wound Culture
MEDICATIONS  
Activase
Amiodarone
Atropine
Bretylium

Bumex

Bicarbonate
Cardizem
Dextrose
Digoxin

Dilantin

Dobutamine
Dopamine
Epinephrine
Esmolol

Heparin

Inderal
Inocor
Insulin
Isuprel

KCl

Levophed
Lidocaine
Mannitol
Magnesium Sulfate

Morphine

Neosynephrine
Nipride
Nitroglycerine
Phenobarbital

Pavulon

Prednisone
Pitressin
Procainamide
Streptokinase

Tpa

Verapamil
Vasopressin
CARDIOVASCULAR:  
Assess heart sounds
Obtain 12 lead EKG
Normal Anatomy of the Heart
Left Side
Right Side
Normal Physiology of CV system
Post Angiogram care
Resuscitation
Team Member
Perform defibrillation
Perform/set up emergent cardioversion
Prepare and administer meds
Set up and interpret 12 lead EKG
Proper lead placement
Use of Doppler
CARE OF PATIENTS WITH:  
Acute Aneurysm
Acute MI
Angina
CHF

Airway maintenance

Deep vein thrombosis
Pulmonary edema
Shock: Cardiogenic
Shock: Hypovolemic
Shock: Septic
PULMONARY:  
Care of patients with:
Acute respiratory distress
AIDS
Asthma
COPD
Hemothorax
Pneumonia
Pneumothorax
Pulmonary embolism
TB
Transplant/Pulmonary
ARDS
Interpretation of labs
Ambu bag techniques
Administer oxygen
Use of apnea monitor
Assess lung sounds
Incentive spirometer
Nebulizer
Normal physiology of pulmonary vascular system
Obtain arterial blood gas Result interpretation
Pavulonized patient
Pulse oximetry
Suctioning: Oral, NT, ETT Use of emergency equipment
NEUROLOGICAL SYSTEM  
Assessing sensory-motor function extremities
Assist with lumbar puncture

Cervical traction

Cervical traction

Cranial nerve assessment

Crutchfield tongs
Halo traction
LOC assessment
Monitoring of ICP

Appropriate interventions for changes in Pressure

Pre/post neuro surgical care
Seizure precautions
Use of Glascow coma scale
Visual acuity measurement
Stryker Frame
CARE OF PATIENTS WITH  
Aphasia
Closed head injury
Craniotomy
VP shunt
Neuro Shunt
CVA
Multiple Sclerosis
Multiple trauma patient
Overdose patient
Seizure disorder
Spinal cord injury
GI/GU/ENDO  
Administer med via NG/gastrostomy tube
AV shunt/fistula care
Catheter insertion  
Female
Male
Care of burn patients
Dialysis
Hemo
Peritoneal
CAVHD

Insulin preparation and administration blood glucose monitoring

Equipment used
Jejunostomy care
NG tube insertion/lavage
Normal physiology of renal and GI system
Ostomy/stoma care
Peritoneal lavage
Poison control

Wound care irrigations

CARE OF PATIENTS WITH  
Acute cholecystitis
Acute renal failure
Bowel obstruction
Diabetes

GI bleed

Hyper/hypoglycemia
Multiple abdominal wounds
Paralytic ileus
Nephrectomy
Pancreatitis
Transplant/Kidney
T.U.R.P.
Whipple procedure
ORTHO  
Total joint replacement
Arthroscopic surgery
Bucks extension
K-wires/Steinman pins
Removal of hardware
Spika Cast/body cast
Cast removal
Amputation
Skeletal traction
Ortho trauma
Laminectomy
PSYCH  
Adolescent patients
Isolation
Rapid tranquilization
Eating disorders
Procedure for patient signing AMA
Disaster protocols
Assist with peritoneal lavage
MISC. TRAYS/INSTRUMENTS, CHECK YES IF YOU EVER HAD EXPERIENCE WITH:  
Cut down tray
Pelvic tray
Procto tray
CVP tray
Culdocentesis tray
Thoracentesis tray

Employment Application consent form

I authorize the investigation of my background including all information contained in this application and information provided in the interview.  I understand that misrepresentation or omission of information in connection with my application and interview will be sufficient cause, in and of itself, for rejection or dismissal whenever discovered.  I understand and agree that any offer of employment is contingent upon satisfactory completion of MSG pre-employment investigation which includes but is not limited to health assessment, criminal history check, educational and work verification, reference checks, consumer report and any investigation required by local, state, or federal laws.  I understand that if I am hired by MSG, my employment will be for an indefinite period of time and will be “at will” which means that either MSG or I may terminate the employment relationship at anytime and for any reason or no reason.

I further understand that, if hired, my at-will employment status my only be changed in written contract signed by the management of
MSG,  and that no representative of MSG has the authority to make oral promise to me concerning my employment.  Finally, I also understand that MSG may adopt, from time to time, policies or handbooks dealing with benefits and other terms or conditions of employment.  These policies or handbooks do not constitute a contract of employment between MSG and me. MSG reserves the right to change or discontinue these policies and/or handbooks at any time with or without notice to me.

MSG strives to provide a safe, healthy and productive work environment and supports a smoke free, alcohol-free work environment.

By signing your name below, means your signing the employement application consent form.

   Signature:





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