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Respiratory Therapy

Experience
A No Practice
B Less than one year
C One - Two years
D Two Plus Years experience

First Name       Last Name

Treatments / Procedures
Assessment
Breath sounds
Peak flow rate
Pulmonary function testing
Rate and work of breathing
Transcutaneous monitoring
Treatment / Procedures
Interpretation of lab results
Arterial blood gases
Basic EKG
Blood chemistry
Chest X-ray
Treatment / Procedures
Equipment and procedures
Airway management devices / suctioning Check intracuff pressure
  Endotracheal tube / suctioning
  Nasal airway / suctioning
  Oral airway placement
  Oropharyngeal / suctioning
  Sputum specimen collection
  Tracheostomy / suctioning
Analyze oxygen
Arterial line insertion
Care of patient with a chest tube Assessment of function / proper operation
  Placement assistance
Chest physiotherapy
Drawing arterial blood gases Arterial line
  Brachial artery
  Femoral artery
  Radial artery / Alien tests
Extubate
Extubation assistance
Hemodynamic monitoring
Incentive spirometry
Infection control practices
Intube
Intubation assistance
Medication delivery systems Aerosol heated / cool
  Aerosol set up-mask
  Aerosol set up-trach
  IPPB
  Medihaler
  Metered dose inhalers
O2 Bag and mask
  ET tube
  External CPAP
  Face masks
  Nasal cannula
  Nebulizer Cold
  Hand held
  Heated
  Ultrasonic
  O2
  T-Piece
  Trach collar
Thoracentesis assistance
Ventilator set up and care Assist / control
  CPAP
  Flow-by
  High frequency jet ventilator
  High frequency oscillator
  IMV
  Inverse ratio ventilator
  Pressure support
  Pressure vents
  SIMV
  Trouble shooting high pressure alarms
  Trouble shooting low pressure alarms
  Volume vents
  Weaning
Care of patients with:
Acute / chronic bronchitis
ARDS ( adult respiratory distress syndrome)
Aspiration
Asthma
Bronchoscopy
Cardiac surgery
CHF
COPD
Cystic fibrosis
Epiglottitis
Fresh tracheostomy
Gullian Barre
Hemopneumothorax
Laryngospasm
Myasthenia
Pneumonia
Pulmonary edema
Pulmonary embolism
Smoke inhalation
Status asthmatic us
Tension pneumothorax
Thoracotomy
Tracheo-esophageal fistula
Tubercilosis
Medications
Administration of:
Aerobid, Vanceril
Aminophylline (Theophylline)
Azmacort
Bicarbonate
Combivent
Decardron
Flonase
Flovent
Inhaled steroids
Ipratropium bromide (Atrovent)
Isoetharine (Bronkosol)
Isoproterenol (Isuprel)
Metaproterenol (Alupent)
Mucomyst
Nasalcort
Racemic epinephrine
Salbutamol (Albuterol, Proventil, Ventolin)
Terbutaline sulfate (Bricanyl)
Medications
Familiar with effects of:
Anectine
Atropine
Corticosteriods
Digitalis
Digoxin
Dopamine
Duramorph
Heli/ox theraoy
Ketamine
Lidocaine
Morphine Sulfate
Care of patients with:
Nipride
Nitric oxide therapy
Pavulon
Pentamidine isethionate
Propofol
Theo-dur
Valium
Versed
Phlebotomy
Equipment and procedures
Drawing blood from central line
Drawing blood from peripheral line
Drawing venous blood
Phlebotomy
Equipment and procedures
Assist in high risk delivery
Capillary blood gases
ECMO
O2
Umbilical blood gases
Phlebotomy
Care of the infant or child with:
Bronchopulmonary dysplasia (BPD)
Croup
Epiglottitis
Meconium aspiration
Near drowning
Persistent pulmonary hypertension (PPHN)
Pulmonary interstital emphysema (PIE)
Respiratory distress syndrome (RDS)
Respiratory syncytial virus
Transient tachypnea of the newborn

Age Specific Practice Criteria
Please check the boxes below for each age group for which you have                                                              expertise in providing age-appropriate nursing care

A. Newborn / Neonate (birth - 30 days) 
B. Infant (30 days - 1 year)
C. Toddler 1 - 3 years)
D. Preschooler (3 - 5 years)
E. School age children (5 - 12 years)
F. Adolescents (12-18 years)
G. Young adults (18 - 39 years)
H. Middle adults (39 - 64 years)
I. Older adults (64+ years)

Experience with age groups A B C D E F G H I
Able to adapt care to incorporate normal growth and development
Able to adapt method and terminology of patient instructions to their age, comprehension and
Can ensure a safe environment reflecting specific needs of various age groups

Experience with following ventilators

Series Name Series Number
Bear
Bird
BP
Hamilton Amadeus, Voelar
MA
Newport
Sechrist
Servo
Drager infant
Emerson
Engstrom
Puritan Bennett 7200
Others, list
 

My Experience is primarily in:

 

General adult inpatient Year(s)
Home care Year(s)
Intensive care unit Year(s)
Long term care Year(s)
Neonatal ICU Year(s)
Pediatrics Year(s)
Pulmonary rehab Year(s)
Sleep lab Year(s)
Sub acute Year(s)
 

Certification:

 

BCLS Exp Date:
PALS Exp Date:
EKG technician Date:
EEG technician Date:
ACLS Exp Date:
NRP Exp Date:
RRT Date:
CRTT Date:
Arterial blood gas technician Exp Date:
Other type: Exp Date:
Computerized charting system Type:

 

The information I have provided is true and accurate to the best of my knowledge. I give authorization to Sierra Staffing, Inc. to release this information to facilities in consideration of my employment at said facility.