Peri-Operative Checklist


Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Total Stars:

Obtained Stars:

Ranking: 0%

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

  IV Therapy         Rating Stars (Click) 1 2 3 4
  Start peripheral IV - angio cath  
  IV Therapy - Assist with:         Rating Stars (Click) 1 2 3 4
  Insertion of A-lines  
  Insertion of CVP - jugular  
  Insertion of CVP - sublavian  
  Insertion of Swan-Ganz  
  Drawing blood from central line  
  Drawing venous blood  
  Administration of blood and products         Rating Stars (Click) 1 2 3 4
  Packed red blood cells  
  Plasma/Albumin  
  Whole blood  
  General Surgery         Rating Stars (Click) 1 2 3 4
  Abdominal perineal resection  
  Adrenalectomy  
  Anal fissurectomy  
  Appendectomy  
  Bowel resection  
  Breast biopsy  
  Cholecystectomy (open)  
  Colectomy  
  Colostomy/ileostomy  
  Esophogeal resection  
  Exploratory laparotomy  
  Gastrectomy  
  Gastroplasty  
  Hemorrhoidectomy  
  Hemicolectomy  
  Hepatic resection  
  Herniorrhaphy - femora  
  Herniorrhaphy - inguina  
  Herniorrhaphy - umbilical  
  Herniorrhaphyhiatal transabdominal/transthoracic  
  Hiatal hernia repair  
  Hepatic resection  
  Insertion - Hickman  
  Insertion - Groshong  
  Insertion - Portacath  
  Hydroceletomy  
  Imperforate anus reconstruction  
  Lumbar sympathectomy  
  Omphalocele repair  
  Pancreatectomy / pancreatogram  
  Pilonidal cystectomy  
  Portal caval shunt  
  Pyloric stenosis  
  Radical mastectomy  
  Saphenous vein ligation and stripping  
  Sentinel node biopsy  
  Splenectomy  
  Tenchknoff duct cyst excision  
  Thyroglossal duct cyst excision  
  Thryoidectomy  
  Vagotomy  
  Thoracic and Open Heart         Rating Stars (Click) 1 2 3 4
  Cervical rib excision  
  Chamberlain procedure  
  Closed thoracotomy  
  Correction pectus excavatum  
  Esophagectomy  
  Heller procedure  
  Mitral commissurotomy  
  Mitral or aortic valve replacement  
  IAPB insertion  
  CABG  
  Cardiac valve replacement  
  Patent ductus arteriosus repair  
  Septal defect repairs  
  Pacemaker implanation - endocardial  
  Pacemaker implanation - myocardia  
  Pacemaker - temporary  
  Pericardiectomy  
  Pericardial window  
  Resection coarctation aorta  
  Portocaval shunt  
  Tetrology of fallot  
  Thoracoplasty  
  Tracheal resection  
  Transthoracic diaphragmatic heniorrhaphy  
  Vascular         Rating Stars (Click) 1 2 3 4
  A-V access graft  
  Aortic aneurysm with graft replacement  
  Endarterectomy/carotid - femoral  
  Fem-pop bypass  
  Peripheral vascular bypass procedures  
  Resection carotid aneurysm with graft  
  Thrombectomy/embolectomy  
  Vena cava filter/umbrella  
  Vena cava ligation  
  Neurology         Rating Stars (Click) 1 2 3 4
  A-V malformation  
  Anterior cervical fusion  
  Anterior laparoscopic spine procedures  
  Anterior lumbar interbody fusion (ALIF)  
  Burr holes for subdural hematoma  
  Carotid ligation  
  Cervical sympathectomy  
  Craniectomy for decompression fracture  
  Discetomy  
  Hypophysectomy  
  Insertion nerve stimulators  
  Insertion medication pumps  
  Laminectomy  
  Myelomeningocele repair  
  Pedicle screw insertion  
  Posterior lumbar interbody fusion (PLIF)  
  Shunt procedure/VP  
  VA/LP  
  Spine fusion  
  Ulnar nerve transfer  
  Ventriculography / ventriculoscopy  
  Ventriculostomy  
  Neurology - Cranioplasty/craniotomy         Rating Stars (Click) 1 2 3 4
  Clipping of aneurysm  
  Tumor excision  
  Stealth crainiotomy  
  Urology         Rating Stars (Click) 1 2 3 4
  Adult circumcision  
  Cystectomy  
  Cystoscopy/ureteroscopy  
  Hypospadias repair  
  Ileal loop  
  Implants - penile and testicular  
  Lithotripsy  
  Nephrectomy  
  Nephrolithotomy  
  Orchiopexy  
  Prostatectomy - perineal  
  Prostatectomy - supra-pubic  
  Pyleoplasty  
  Radical node dissection  
  Scott incontinence device  
  TURP  
  Ureterolithotomy  
  Vasectomy  
  Vasovasostomy  
  Waterhouse procedure  
  Gynecology         Rating Stars (Click) 1 2 3 4
  Cesarean section  
  Colpotomy  
  Dilation and curettage (DandC)  
  Hysterectomy - abdominal  
  Hysterectomy - vaginal  
  Marshall - Marchetti  
  Marsupialization-Bartholin cyst  
  Ovarian cystectomy  
  Radium insertion  
  Salpingo-oophorectomy  
  Sacral spinus fixation  
  Shirodkar procedure  
  Suction curettage  
  Termination of pregnancy  
  Tubal ligation  
  Vaginal recontruction  
  Vaginectomy/vulvectomy  
  Orthopedics         Rating Stars (Click) 1 2 3 4
  Acetabular/pelvic ORIF  
  Achilles tendon repair  
  Amputation- leg  
  arm  
  Anterior cruciate ligament repair  
  Application of external fixators - extremeties  
  Application of external fixators - pelvis  
  Application of halo traction  
  Arthrotomy  
  Bipolar/unipolar hips  
  Bunionectomy  
  Calcanel reconstruction  
  Capsulorrhaphy  
  Carpal tunnel release  
  Closed reduction fracture  
  Hand surgery with implants  
  Harrington rod instrumentation and / or Dwyer procedure  
  Heel cord lengthening  
  Laminectomy  
  Olecranon bursa-excision of  
  ORIF  
  internal fixation with compression set  
  Patellectomy  
  PuttiPlatt/Bankart procedure/rotator cuff repair  
  Reduction with compression sets  
  Reimplanation of digits  
  Repair hammer toes  
  Sacro-iliac (SI) joint screws  
  Sharrard procedure  
  Spica cast-application  
  Spinal fusion  
  Tendon transplants (hand and foot)  
  Orthopedics - Arthroscopy         Rating Stars (Click) 1 2 3 4
  Ankle  
  Elbow  
  Knee  
  Shoulder  
  Orthopedics - Hip compression nails and lag screws         Rating Stars (Click) 1 2 3 4
  Jewett  
  Kuntscher rod  
  Lottes  
  Rush  
  Schneider  
  Zimmer  
  Iliac crest bone graft  
  Insertion Austin Moore hip prosthesis  
  Orthopedics - Intramedullary rods         Rating Stars (Click) 1 2 3 4
  Extraction  
  Femoral  
  Humeral  
  Insertion  
  Supracondylar  
  Tibal  
  Orthopedics - Total joint replacements/revisions         Rating Stars (Click) 1 2 3 4
  Hip  
  Knee  
  Shoulder  
  Plastics         Rating Stars (Click) 1 2 3 4
  Abdominal lipectomy  
  Abdominalplasty  
  Blepharoplasty  
  Cleft lip repair  
  Dermabrasion  
  Face lift  
  Mentoplasty  
  Otoplasty  
  Pedicle grafts  
  Rhytidectomy  
  Scar revisions  
  Split thickness skin grafting  
  Tissue expanders  
  Plastics - Mammoplasty         Rating Stars (Click) 1 2 3 4
  Augmentation  
  Reduction  
  Tramflaps with reconstructive mammoplasty  
  Ear, Nose and Throat         Rating Stars (Click) 1 2 3 4
  Adenoidectomy  
  Caldwell - Luc  
  Cleft lip/palate repair  
  Closed reduction nasal fx  
  Ethmoidectomy  
  Excision of salivary gland tumor  
  Fenestration procedure  
  Frontal flap sinus procedure  
  Glossectomy  
  Laryngectomy  
  Mandibulectomy  
  Mastoidectomy  
  Maxillary advancement with graft  
  Maxillectomy  
  Myringoplasty  
  Myringotomy with PE tube insertion  
  Nasal polypectomy  
  Open reducation facial fx  
  Open reducation nasal fx  
  Parotidectomy  
  Pharyngeal flap procedure  
  Radical neck dissection  
  Ranulectomy  
  Rhinoplasty/septoplasty  
  Selective osteotomy of maxilla/mandible  
  Sinus endoscopy  
  Sinusotomy  
  Stapedectomy  
  Submucous resection  
  Tonsillectomy  
  Tracheostomy  
  Tympanoplasty  
  Oral         Rating Stars (Click) 1 2 3 4
  Closed reducation facial fractures/wiring  
  Excision odontoma  
  Excision of deciduous teeth  
  Extraction of impacted molars  
  Fractured jaws  
  mandibular and zagomatic  
  Ginivectomy  
  LeFort osteotomies  
  Maxillary procedure with graft  
  Pediatric dentistry  
  Sagittal osteotomy  
  Temporomandibular (TMJ) with arthroplasty  
  TMJ exploration  
  Ophthalmology         Rating Stars (Click) 1 2 3 4
  Cataract extraction with IOL  
  Corneal transplant  
  Dacryocystectomy  
  Eye enucleation  
  Exicison of chalazion  
  Canthotomy  
  Correction of ectropian/entropian  
  Enucleation  
  Eye transplant  
  Iridectomy  
  Lacrimal duct probing  
  Lid and muscle procedures  
  Orbital implant  
  Phaco emulsification  
  Ptergium repair  
  Recession resection  
  Refractive keratoplasty  
  Repair orbital blowout fracture  
  Repair of retinal detachment  
  Scleral buckle  
  Vitrectomy  
  Endoscopic Procedures         Rating Stars (Click) 1 2 3 4
  Bronchoscopy  
  Colonscopy  
  Culdoscopy  
  Esophagoscopy  
  Gastroscopy  
  Hysteroscopy  
  Laparoscopic procedures         Rating Stars (Click) 1 2 3 4
  Appendectomy  
  Cholecystectomy / cholangiogram  
  Colon resection  
  Diagnostic  
  Hernia repair  
  Nissen fundoplication  
  Salpingo-oophorectomy  
  Tubal ligation  
  Vaginal hysterectomy  
  Larynoscpy and microlaryngoscopy  
  Mediastinoscopy  
  Pelviscopy  
  Sigmoidoscopy  
  Thoracoscopy  
  Transplant         Rating Stars (Click) 1 2 3 4
  Bone  
  Bone marrow  
  Corneal transplant  
  Harvesting  
  Heart  
  Kidney  
  Liver  
  Lung  
  Multi-organ  
  Pancreas  
  Skin  
  Trauma         Rating Stars (Click) 1 2 3 4
  Burns  
  Motor vehile accidents (multiple injuries)  
  Traumatic amputations  
  Trauma - Gunshot/stab wounds         Rating Stars (Click) 1 2 3 4
  Abdomen  
  Chest  
  Head  
  Equipment         Rating Stars (Click) 1 2 3 4
  Argon beam coagulator  
  Bair hugger  
  Blood/fluid warmer  
  Cardiac monitor and pacemaker  
  Cell saver  
  Cidex soak  
  Cry-opthalmic unit  
  Defibrillator/pacer  
  Electrosurgical unit  
  Emerson thoracic pump  
  ETO sterilizer  
  Eye magnet  
  Fiber optic luminator  
  Flash autoclave  
  Hypo/hyperthemia units  
  Kreiselman resuscitor  
  Mesh graft  
  MicroscopesNerve stimulatorNitrous oxide bank  
  Nitrous oxide bank  
  Ohio suction units  
  Orthopedic arm board with drain  
  Pleurevac disp. chest drainage  
  Pneumatic tourniquet  
  Sterad machine  
  Steri-vac aeratopm cabinet  
  Steris unit  
  Tele therometer  
  Ultrasonic cleaner  
  Vac-pac positioner  
  Vacuum curettage  
  Washer sanitizer  
  Washer sterilizer  
  Equipment - Fracture tables         Rating Stars (Click) 1 2 3 4
  Chick/Marquet tables  
  Jackson table  
  Rush/Skytron tables  
  Equipment - Intestinal stapling devices         Rating Stars (Click) 1 2 3 4
  EEA  
  GIA  
  LDS  
  TA  
  Equipment - Laser         Rating Stars (Click) 1 2 3 4
  CO2  
  Eye magnet  
  Yag  
  Other  
  Camera/video systems         Rating Stars (Click) 1 2 3 4
  zCamera controller  
  Light source  
  Printers  
  VCRs  
  Dermatome         Rating Stars (Click) 1 2 3 4
  Brown  
  Padgett  
  Zimmer  
  Disposable grounding pads  
  Drills         Rating Stars (Click) 1 2 3 4
  3-M maxi driver  
  Codman craniotome  
  Hall air-driver  
  Hall dental  
  Hall neurotome  
  Midax Rex/Anspach  
  Minidriver  
  Stryker drills - large battery  
  Stryker drills - small battery  
  Surgairtome  
  Synthes A-O drill  
  Electrosurgical unit  
  Miscellaneous         Rating Stars (Click) 1 2 3 4
  Assist with intubation  
  Conscious sediation administration  
  Conscious sediation monitoring  
  Management of malignant hypertensive crisis  
  Able to assure a safe environment for the specific needs of various age groups         Rating Stars (Click) 1 2 3 4
  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+)  
  Able to communicate and/or instruct patients according to their age, maturity, comprehension         Rating Stars (Click) 1 2 3 4
  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+)  
  Evaluate age-appropriate behavior, motor skills and physiological norms         Rating Stars (Click) 1 2 3 4
  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+)