PERIOPERATIVE SKILLS CHECKLIST___________________

This Skills Checklist is for use by nurses with more than one
NAME:       year experience in their discipline and specialty. Please be
ID #:       accurate with your assessment.
DATE:       SCRUB CIRCULATE
DESCRIPTION 1 2 3 4 1 2 3 4
DIRECTIONS: Please indicate your EAR NOSE & THROAT
level of experience by placing a check 1. Adenoidectomy
(√) in the box. Experience level: 2. Caldwell-LUC
1 NO EXPERIENCE 3. Cleft lip/palate repair
4. Closed reduction nasal fracture
5. Ethmoidectomy
MINIMAL EXPERIENCE-requires
2 6. Excision of salivary gland tumor
supervision/assistance
7. Fenestration Procedure
8. Frontal flap sinus procedure
MODERATELY EXPERIENCED- 9. Glossectomy
3 requires initial review, then performs 10. Laryngectomy
independently 11. Mandibulectomy
12. Mastoidectomy
13. Maxillary advancement w/hipgraft
4 VERY EXPERIENCED- proficient
14. Maxillectomy
15. Myringoplasty
16. Myringotomy/w/PE tube insertion
17. Nasal polypectomy
18. Open reduction facial fracture
19. Open reduction nasal fracture
20. Parotidectomy
21. Pharyngeal Flap Procedure
22. Radical Neck Dissection
23. Ranulectomy
24. Rhinoplasty/septoplasty
25. Selective osteotomy of maxilla/mandible
26. Sinus endoscopy
27. Sinusotomy
28. Stapedectomy
29. Submucous Resection
30. Tonsillectomy
31. Tracheostomy
32. Tympanoplasty
ENDOSCOPIC PROCEDURES
1. Bronchoscopy
2. Colonoscopy
3. Culdoscopy
4. Cystoscopy
5. Esophagoscopy
6. Gastroscopy

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 PERIOPERATIVE SKILLS CHECKLIST___________________
NAME:       SCRUB CIRCULATE
ID#:       DESCRIPTION 1 2 3 4 1 2 3 4
DATE:       ENDOSCOPIC PROCEDURES (cont.)
7. Laryngoscopy
8. Laparoscopic procedures
a.Appendectomy
b.Cholecystectomy/cholangiogram
c.Colon resection
d.Diagnostic
e.Hernia repair
f.Nissan fundoplication
g.Salpingo-oophorectomy
h.Tubal ligation
i.Vaginal hysterectomy
9. Laryngoscopy & microlaryngoscopy
10. Mediastinoscopy
11. Pelviscopy
12. Sigmoidoscopy
13. Thoracoscopy
GENERAL SURGERY
1. Abdominal perineal resection
2. Adrenalectomy
3. Anal fissurectomy
4. Appendectomy
5. Breast biopsy
6. Cholecystectomy (open)
7. Colectomy
8. Colon/Bowel Resection
9. Colostomy/ileostomy
10. Esophogeal resection
11. Exploratory laparotomy
12. Gastrectomy
13. Gastroplasty
14. Hemicolectomy
15. Hemorrhoidectomy
16. Hepatic Resection
17. Herniorrhaphy – femoral
18. Herniorrhaphy – inguinal
19. Herniorrhaphy – umbilical
20. Herniorrhaphyhiatal, transabdominal/
transthoracic
21. Hickman/Groshong/Portacath insertion
22. Hydrocelectomy
23. Imperforate anus reconstruction
24. Laparotomy

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 PERIOPERATIVE SKILLS CHECKLIST___________________
NAME:       SCRUB CIRCULATE
ID#:       DESCRIPTION 1 2 3 4 1 2 3 4
DATE:       GENERAL SURGERY (cont.)
25. Lumbar sympathectomy
26. Mastectomy, radical
27. Omphalocele repair
28. Pancreatectomy/pancreatogram
29. Pilonidal cystectomy
30. Portal caval shunt
31. Pyloric stenosis
32. Saphenous vein ligation and stripping
33. Sentinel node biopsy
34. Splenectomy
35. Tenchknoff duct cyst excision
36. Thyroglossal duct cyst excision
37. Thyroidectomy
38. Tracheostomy
39. Vagotomy
GYNECOLOGY
1. Cesarean Section
2. Colposcopy
3. Colpotomy
4. Dilation & curettage (D & C)
5. Hysterectomy, abdominal
6. Hysterectomy, vaginal
7. Marshall - Marchetti
8. Marsupialization, Bartholin cyst
9. Ovarian cystectomy
10. Radium insertion
11. Sacral spinus fixation
12. Salpingoplasty
13. Shirodkar procedure
14. Suction curettage
15. Termination of pregnancy
16. Tubal ligation
17. Vaginal reconstruction
18. Vaginectomy/vulvectomy
IV THERAPY
1. Start peripheral IV – angio cath
IV THERAPY – ASSIST WITH
1. Insertion of A-lines
2. Insertion of CVP - jugular
3. Insertion of CVP - sublavian
4. Insertion of Swan-Ganz
5. Drawing blood from central line

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 PERIOPERATIVE SKILLS CHECKLIST___________________
NAME:       SCRUB CIRCULATE
ID#:       DESCRIPTION 1 2 3 4 1 2 3 4
DATE:       IV THERAPY – ASSIST WITH (cont.)
6. Drawing venous blood
ADMINISTRATION OF BLOOD & PRODUCTS
1. Packed red blood cells
2. Plasma/Albumin
3. Whole blood
NEUROLOGY
1. A-V malformation
2. Anterior cervical fusion
3. Anterior laparoscopic spine procedures
4. Anterior lumbar interbody fusion (ALIF)
5. Burr holes for subdural hematoma
6. Carotid ligation
7. Cervical sympathectomy
8. Craniectomy for decompression fracture
9. Cranioplasty/Craniotomy
a. Clipping of Aneurysm
b. Tumor excision
c. Using stealth equipment (stealth craniotomy)
10. Discectomy
11. Hypophysectomy
12. Insertion nerve stimulators/medication pumps
13. Laminectomy
14. Myelomeningocele repair
15. Pedicle screw insertion
16. Posterior lumbar interbody fusion (PLIF)
17. Shunt procedure/VP, VA/LP
18. Spine Fusion – List systems you have used
a.
b.
19. Ulnar Nerve Transfer
20. Ventriculography procedure/ventriculoscopy
21. Ventriculostomy
OPTHALMOLOGY
1. Canthotomy
2. Cataract extraction with IOL
3. Corneal transplant
4. Correction of ectropian/entropian
5. Dacryocystectomy
6. Dacryocystorhinostomy
7. Excision of chalazion
8. Eye enucleation
9. Eye transplant

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 PERIOPERATIVE SKILLS CHECKLIST___________________
NAME:       SCRUB CIRCULATE
ID#:       DESCRIPTION 1 2 3 4 1 2 3 4
DATE:       OPTHALMOLOGY (cont.)
10. Iridectomy
11. Lacrimal duct probing
12. Lid and muscle procedures
13. Orbital Implant
14. Phaco emulsification
15. Ptergium Repair
16. Recession Resection
17. Repair orbital blowout fracture
18. Scleral Buckle
19. Vitrectomy
ORAL
1. Closed reduction facial fractures/wiring
2. Excision odontoma
3. Extraction of deciduous teeth
4. Extraction of impacted molars
5. Fractured jaws, mandibular and zagomatic
6. Ginivectomy
7. LeFort osteotomies
8. Maxillary procedure with graft
9. Pediatric dentistry
10. Sagittal osteotomy
11. Temporomandibular joint (TMJ) with
arthroplasty
12. TMJ exploration
ORTHOPEDICS
1. Acetabular/pelvic ORIF
2. Achilles tendon repair
3. Amputation – leg, arm
4. Anterior cruciate ligament repair
5. Application of external fixators
a. Extremities
b. Pelvis
6. Application of halo traction
7. Arthroscopy
a. Ankle
b. Elbow
c. Knee
d. Shoulder
8. Arthrotomy
9. Bipolar/unipolar hips
10. Bunionectomy
11. Calcanel reconstruction

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 PERIOPERATIVE SKILLS CHECKLIST___________________
NAME:       SCRUB CIRCULATE
ID#:       DESCRIPTION 1 2 3 4 1 2 3 4
DATE:       ORTHOPEDICS (cont.)
12. Capsulorrhaphy
13. Carpal tunnel release
14. Closed reduction fracture
15. Hand surgery with implants
16. Harrington rod instrumentation and/or Dwyer
procedure
17. Heel Cord Lengthening
18. Hip compression nails & lag screws
a. Jewett
b. Kuntscher rod
c. Lottes
d. Rush
e. Schneider
f. Zimmer
g. Others - list
19. Iliac crest bone graft
20. Insertion Austin Moor hip prosthesis
21. Intramedullary rods
a. Extraction
b. Femoral
c. Humeral
d. Insertion
e. Supracondylar
f. Tibial
22. Laminectomy
23. Olecranon bursa, excision of
24. ORIF, internal fixation with compression set
25. Patellectomy
26. PuttiPlatt/Bankart procedure/rotator cuff
repair
27. Reduction with compression sets
28. Reimplanation of digits
29. Repair hammer toes
30. Sacro-iliac (SI) joint screws
31. Sharrard procedure
32. Spica cast, application
33. Spinal fusion
34. Tendon transplants (hand and foot)
35. Total joint replacements/revisions
a. Hip
b. Knee
c. Shoulder

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 PERIOPERATIVE SKILLS CHECKLIST___________________
NAME:       SCRUB CIRCULATE
ID#:       DESCRIPTION 1 2 3 4 1 2 3 4
DATE:       PLASTICS
1. Abdominal lipectomy
2. Abdominoplasy
3. Blepharoplasty
4. Cleft lip repair
5. Dermabrasion
6. Face lift
7. Mentoplasty
8. Otoplasty
9. Pedicle grafts
10. Rhytidectomy
11. Scar revisions
12. Split thickness skin grafting
13. Tissue expanders
14. Mammoplasty
a. Augmentation
b. Reduction
c. Tramflaps with reconstructive mammoplasty
THORACIC AND OPEN HEART
1. CABG
2. Cardiac valve replacement
3. Cervical rib excision
4. Chamberlain procedure
5. Closed thoracotomy
6. Correction pectus excavatum
7. Esophagectomy
8. Heller procedure
9. Mitral commissurotomy
10. Mitral or aortic valve replacement
11. IABP insertion
12. Pacemaker implantation – endocardial
13. Pacemaker implantation – myocardial
14. Pacemaker – temporary
15. Patent ductus arteriosus repair
16. Pericardiectomy
17. Pericardial window
18. Portacaval shunt
19. Resection coarctation aorta
20. Septal defect repairs
21. Tetrology of fallot
22. Thoracoplasty
23. Tracheal resection
24. Transthoracic diaphragmatic heniorrhaphy

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 PERIOPERATIVE SKILLS CHECKLIST___________________
NAME:       SCRUB CIRCULATE
ID#:       DESCRIPTION 1 2 3 4 1 2 3 4
DATE:       TRANSPLANT
1. Bone
2. Bone marrow
3. Corneal transplant
4. Harvesting
5. Heart
6. Kidney
7. Liver
8. Lung
9. Multi-organ
10. Pancreas
11. Skin
TRAUMA
1. Burns
2. Motor vehicle accidents (multiple injuries)
3. Traumatic amputations
4. Gunshot/stab wounds
a. Abdomen
b. Chest
c. Head
UROLOGY
1. Adult circumcision
2. Cystectomy
3. Cystoscopy/ureteroscopy
4. Hypospadias repair
5. Ileal loop
6. Implants – penial and testicular
7. Lithotripsy
8. Nephrectomy
9. Nephrolithotomy
10. Orchiopexy
11. Prostatectomy - perineal
12. Prostatectomy – supra-pubic
13. Phleoplasty
14. Radical node dissection
15. Scott incontinence device
16. TURP
17. Ureterolithotomy
18. Vasectomy
19. Vasovasostomy
20. Waterhouse procedure
VASCULAR
1. A-V access graft

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 PERIOPERATIVE SKILLS CHECKLIST___________________
NAME:       SCRUB CIRCULATE
ID#:       DESCRIPTION 1 2 3 4 1 2 3 4
DATE:       VASCULAR (cont.)
2. Aortic aneurysm with graft replacement
3. Endarterectomy/carotid – femoral
4. Fem-pop bypass
5. Peripheral vascular bypass procedures
6. Resection carotid aneurysm with graft
7. Thrombectomy/embolectomy
8. Vena cava filter/umbrella
9. Vena cava ligation
EQUIPMENT
1. Argon beam coagulator
2. Bair hugger
3. Blood/fluid warmer
4. Camera/video systems
a. Camera controller
b. Light source
c. Printers
d. VCRs
5. Cardiac monitor and pacemaker
6. Cell saver
7. Cidex soak
8. Cry-opthalmic unit
9. Defibrillator/pacer
10. Dermatome
a. Brown
b. Padgett
c. Zimmer
d. Disposable grounding pads
11. Drills
a. 3-M maxi driver
b. Codman craniotome
c. Hall air-driver
d. Hall dental
e. Hall neurotome
f. Midas Rex/Anspach
g. Minidriver
h. Stryker drills – large battery
i. Stryker drills – small battery
j. Surgairtome
k. Synthes A-O drill
12. Electrosurgical unit
13. Emerson thoracic pump

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 PERIOPERATIVE SKILLS CHECKLIST___________________

NAME:       SCRUB CIRCULATE

ID#:       DESCRIPTION 1 2 3 4 1 2 3 4
DATE:       EQUIPMENT (cont.)
14. ETO sterilizer
15. Eye magnet
16. Fracture tables
a. Chick/Marquet tables
b. Jackson table
c. Rush/Skytron tables
17. Fiber optic luminator
18. Flash autoclave
19. Hypo/hyperthermia units
20. Intestinal stapling devices
a. EEA
b. GIA
c. LDS
d. TA
21. Kreiselman resuscitor
22. Laser
a. CO2
b. Eye magnet
c. Yag
d. Other
23. Mesh graft
24. Microscopes Nerve stimulator
25. Nitrous oxide bank
26. Ohio suction units
27. Orthopedic arm board with drain
28. Pleurevac disp. chest drainage
29. Pneumatic tourniquet
30. Sterad machine
31. Steri-vac aeratopm cabinet
32. Steris unit
33. Tele thermometer
34. Ultrasonic cleaner
35. Vac-pac positioner
36. Vacuum curettage
37. Washer sterilizer
MISCELLANEOUS
1. Assist with intubation
2. Conscious sedation administration
3. Conscious sedation monitoring
4. Management of malignant hypertensive crisis

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 PERIOPERATIVE SKILLS CHECKLIST___________________

Name:      

4. Able to provide a safe environment according to the

DESCRIPTION 1 2 3 4 specific needs of various age groups.
COMPUTERIZED CHARTING A B C D E F G H I
1. Cerner
2. Eclipsys
3. Epic MY EXPERIENCE IS PRIMARILY IN:
4. McKesson NEUROLOGY       years
5. Meditech PULMONARY       years
6. Other: SURGICAL       years
MEDICAL       years
Please check the boxes below for each age group for CARDIAC CARE       years
which you have expertise in providing age-appropriate TELEMETRY       years
nursing care.
I HAVE CURRENT CERTIFICATIONS FOR:
A. Newborn/Neonatal (birth – 30 days) TYPE EXPIRATION DATE (MM/DD/YY)
B. Infant (30 days – 1 year) ARRHYTHMIA      
C. Toddler (1 – 3 years) CRITICAL CARE      
D. Preschool (3 – 5 years) ACLS      
E. School Age Children (5 – 12 years) BLS      
F. Adolescent (12 – 18 years) TNCC      
G. Young Adults (18 – 39 years) NRP      
H. Middle Adults (40 – 64 years) PALS      
I. Older Adults (64 + years) NALS      
Other            
EXPERIENCE WITH AGE GROUPS: Other            
1. Able to assess age appropriate behavior, motor skills Other            
and physiological norms. Other            
A B C D E F G H I
The information I have provided in this knowledge and
skills checklist it true and accurate to the best of my
2. Able to adapt care according to normal growth and knowledge.
development.            
A B C D E F G H I Signature (Written/Electronic) Date
ID #:      

3. Able to communicate and instruct patient according to This skills checklist has been reviewed and approved by
their age, maturity and comprehension ability. Nicole Bloxham, RN.
A B C D E F G H I            
Signature (Written/Electronic) Date
ID #:      

Please return to: Northwest Nurse Staffing Company, PA

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 PERIOPERATIVE SKILLS CHECKLIST___________________
ATTN: Records Dept.
Fax: (866) 352-4338

Email: records@nns-ic.com

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