Cnaperformancechecklist

FAYETTEVILLE TECHNICAL
COMMUNITY COLLEGE
NURSING ASSISTANT PROGRAM
CURRICULUM
..
PERFORMANCE CHECKLIST
Update Spring 2008

SKILLS PERFORMANCE CHECKLIST
TABLE OF CONTENTS
Procedure Title
Number
0 Beginning and Ending Procedure Actions
1 Documenting on Medical Record
2 Handwashing
3 Putting On and Taking Off Mask and Protective Eyewear
4 Putting On and Taking Off Gown and Gloves .
5 Removing Contaminated Disposable Gloves
6 Disposing of Equipment From Unit with Transmission-Based Precautions
7 Collecting Specimen from Resident Under Transmission-Based Precautions
8 Performing Heimlich maneuver
9 Assisting with Dining/F eeding Resident Who Cannot Feed Self
10 Serving Supplementary Nourishment
11 Providing Fresh Drinking Water
12 Making Closed Bed
13 Opening Closed Bed
14 Making Occupied Bed
15 Assisting with Oral Hygiene (Minimal Assistance From Nurse Aide)
16 Providing Mouth Care (Minimal Assistance From Resident)
17 Providing Mouth Care for Unconscious Resident
18 Cleans Upper and Lower Denture
19 Provides Fingernail Care on One Hand
20 Foot Care
21 Assisting Resident with Shaving
22 Caring for Hair
23 Shampooing Hair in Bed
24 Dressing and Undressing
25 Giving Complete Bed Bath
26 Giving Partial Bath
27 Giving Tub Bath or Shower
28 Giving Perineal Care
29 Giving Back Rub
30 Measuring Oral Temperature (Non-Mercury Glass Thermometer)
31 Measuring Axillary Temperature (Non-Mercury Glass Thermometer)
32 Measuring Rectal Temperature (Non-Mercury Glass Thermometer)
33 Measuring Temperature(Electronic or Tympanic Thermometer)
34 Counting Radial Pulse
35 Measuring Apical Pulse
36 Counting Respirations

37 Measures and Records Blood Pressure (Manual)
38 Measuring Blood Pressure (Electronic-Optional)
39 Measuring Combined Vital Signs
40 Measures and Records Weight and Height of Ambulatory Client
41 Measuring and Recording Fluid Intake and Output
42 Assisting with Use of Bathroom
43 Assisting with Use of Bedside Commode
44 Assisting with Use of Bedpan
45 Assisting With Use of Urinal
46 Providing Catheter Care for Female
47 Emptying Urinary Drainage Bag
48 Collecting Routine Urine Specimen
49 Applying and Caring for Condom Catheters
50 Collecting Stool Specimen
51 Administering Cleansing Enema
52 Applying Warm or Cold Applications
53 Applying Elastic Bandage
54 Assisting with Coughing and Deep Breathing Exercises
55 Applying and Removing Elastic Stockings or Ted Hose
56 Applying Non-sterile Dressing
57 Performing Postmortem Care
58 Assisting to Ambulate Using Cane or Walker
59 Using Mechanical Lift (Hoyer)
60 Performing Range of Motion Exercises
A (PROM) for One Knee and One Ankle
B (PROM) for One Shoulder
61 Assisting to Dangle, Stand, and Walk
62 Transferring From Bed to Chair
63 Transferring From Bed to Wheelchair
64 Transferring From Bed to Stretcher
65 Moving Up in Bed
66 Moving Up in Bed Using Turning Sheet
67 Positioning Resident on Side
68 Applying Restraints
69 Applying Safety Belt Restraints

·-.
N~ _
BEGINNING PROCEDURE ACTIONS
To be done at the beginning of each procedure.
1. Wash hands.
--
___ 2. Assemble equipment.
---:---..:3. Knock and pause at room door before entering.
__ 4. Introduce yourself.
5. Identify the resident.
--
__ 6. Ask visitors to step out and let them know where they may wait and how long
you will be in the room.
__ 7. Provide privacy.
__ 8. Explain what you are about to do, speaking clearly, slowly, and directly,
maintaining face to face contact whenever possible.
__ 9. Raise the bed.
__ 10. Lower the side rail on the side you are working.
__ 11. Position and drape the resident comfortably for the procedure.
__ 12. Set up equipment.
__ 13. Remember to use gloves, masks, gowns, and other PPE when needed.
,14. Remember standard precautions.
--
__ IS. Avoid contact between candidate clothing andsoiled linen/pads throughout
procedure.
ENDING PROCEDURE ACTIONS
To be done at the end of each procedure.
__ 1. Empty, rinse, and wipe equipment and return to proper storage. Dispose of
soiled linen in soiled linencontainer and discard of waste into wastebasket.
__ ,_2.. Remove gloves.
__ 3. Position resident comfortably.
___ 4. Replace the bed covers.
5. Put bed in lowest horizontal position.
---
__ 6. Return side rail to proper position.
__ 7. Leave call bell near resident (also, place the telephone and their water within
reach). ,
,8. Perform a safety check of the area.
--
__ 9. Open privacy curtains.
__ 10. Remove and discard any other PPE appropriately.
11. Care for the used equipment. .
--
12. Wash your hands.--
, 13. Let visitors know they may enter the room.---
14. Report completion of task 'and any observations.
--- 15. Document. '
---
Pass Instructor's Signature ..:-.. Date _

SKILLS PERFORMANCE CHECK LIST
Procedure: 1 Documenting on Medical Record Name _
__ 1. Check for right resident, right record, right room.
__ 2. Date and time each entry.
__ 3. Record care as soon as possible after care is completed.
4. Use correct color of ink.
__ 5. Document according to facility policy and procedures.
__ 6. Record entries in proper time sequence.
__ 7. Print or write legibly.
__ .8. Leave no blank spaces or lines between entries.
.,~
_10. Sign each entry with first initial, last name and title.
_11. Correct errors according to facility policy .
. _._12.Use only abbreviations approved for use by facility.
Pass Instructor's Signature . Date
----~ ----------------~. --------

· :.
SKILL PERFORMANCE CHECK LIST
Procedure: 2 Hand washing Name
------------------
1. Perform beginning procedure actions.
2. Turns on water at sink
3. Wets hands and wrists thoroughly
4. Applies soap to hands
5. Lathers all surfaces of wrists, hands, and fingers producing friction, for at lest 15
(fifteen) seconds
6. Cleans fingernails by rubbing fingertips against palms of the opposite hand
7. "After lathering for at least 15 seconds, rinse all surfaces of wrists, hands, and
fingers keeping hands lower than the elbows and the fingertips down
8. Uses clean, dry paper towel to dry all surfaces of hands, wrists, and fingers
9. Uses clean, dry paper town to turn off faucet then disposes of paper towel into
waste container or uses kneel foot control to turn off faucet.
10. Does not touch inside of sink at any time.
Pass ------
Instructor Signature ~ Date _

· :.
Procedure:3 Putting on and Taking OfT Mask Name _
and Protective Eyewear
__ 1.Perform beginning procedure actions.
__ 2. Pick up mask by upper ties and place mask over nose and mouth.
__ 3. Place upper strings over ears and tie in bow at back of head and tie lower strings
in bow at back of neck.
__ 4. Put protective eyewear over eyes.
__ 5. Replace mask if it becomes moist or contaminated.
__ 6. Wash hands prior to removal of mask.
__ 7. Untie lower strings and then upper strings and remove mask by holding top
strings.
__ 8. Dispose of mask in wastebasket.
_9. Remove protective eyewear and return to proper place according to facility
policy.
_10. Perform ending procedure actions.
Pass.__ .....;Instructor's Signature .....- .Date _

Procedure:4 Putting on and Taking Off Name _
Gown and Gloves
__ I. Perform beginning procedure actions.
__ 2. Slip arms into sleeves of gown ,slipping fingers under inside neckband and grasp
ties in back.
__ 3. Tie in bow or fasten Velcro strip.
__ 4. Grasp edges of gown and pull to back overlapping edges, closing opening so that
uniform is completely covered. .
__ 5. Tie waste strings in bow or fasten Velcro strip.
__ 6. Remove two gloves from clean container.
__ 7. Pull on gloves over hands and wrists, using medical asepsis, Do not allow gloves
to touch contaminated surfaces or objects and replace gloves with obvious holes
or tears.
__ 8. To remove gloves, using dominant hand, remove other glove by grasping it just
below wrist. Pull glove down over non-dominate hand so that it is inside out.
Hold removed glove in gloved hand and with first two fingers of ungloved hand,
reacb inside glove without touching outside of glove and pull glove down (inside
out) over band and remaining glove.
_9. Dispose.of gloves in wastebasket.
.·_10. Untie waist strings and loosen gown.
11. Wash hands.
_12.Untie neck strings and slip fingers of right band inside left cuff without touching
outside of gown. .
_13. Pull gown down over left hand then right hand with gown-covered left hand.
_14. Remove gown by rolling it in ball, contaminated side.inward and dispose of gown
. in appropriate container.
_15. Perform ending procedure acitons.
Pass Instructor's Signature ...;Date _

""
Procedure:5 Removing Contaminated Disposable Gloves Name _
_ I. With dominant hand, remove other glove by grasping itjust below wrist.
__ 2. PuII glove down over non-dominate hand so that it is inside out.
3. Hold removed glove in gloved hand.
-- ,-
__ 4. With first two fingers of ungloved hand, reach inside- glove Without touching
outside of glove, pull glove do~ (inside out) over hand and remaining glove .
.
__ 5. Dispose of soiled gloves into wastebasket.
6. Washes hands.
Pass. Instructor's Signature. .Date _

Procedure:6 Disposing of Equipment from Unit Name _
With Transmission-Based Precautions
_1. Wash hands
__ 2. Put on appropriate personal protective equipment following procedures in Skills
#3 and #4
_" _3. Explains procedure to client, speaking clearly, slowly, and directly, maintaining
face-to- face contact whenever possible.
__ 4. Gather all items to leave room and place in biohazard bags, Use separate bags for
garbage, glass, linens, and equipment to be reprocessed.
__ 5. Seal bags with tape/ties.
__ 6. Remove personal protective equipment in reverse order following procedures in
Skills #5,#6, and #3. "
__ 7. Label biohazard bags properly and take to appropriate area according to facility
policy.
Pass Instructor's Signature -..:... Date _

.. :.
.'.
Procedure:7 Collecting Specimen From Client Name _
Under Transmission-Based Precautions
._: 1.Receive directions from supervisor.
__ 2. Perform beginning procedure actions ..
__ 3. Put on appropriate personal protective equipment following procedures in Skills
#3, #4, and #5.
__ 4. Explains procedure to client, speaking clearly, slowly, and directly, maintaining
face-to-face contact whenever possible.
__ 5. Place specimen container and leak-proof transport bag on clean paper towel on
appropriate surface with container lid oft. Inside of lid should e facing up.
__ 6. Collect specimen following procedures in appropriate skills and place in container
without touching container.
__ 7. Put cover on container and put in leak-proof transport bag.
__ 8. Remove personal protective equipment in reverse order following procedures in
Skills #5,#4, and #3. Perform ending procedure actions.
__ 9. Take specimen to appropriate area.
.r>,
Pass Instructor's Signature -: -'Date _

<z.
~.
Procedure:8 Performing Heimlich Maneuver Name _
Conscious victim:
_1. Ask person who appears to have choked but who is NOT coughing, "are you
choking?"
__ 2. Determine that victim can not expel object on own and state that you will help.
3. Stand behind victim.
__ 4. Wrap arms around victim's waist.
__ 5. Clench fist, keeping thumb straight.
__ 6. Place clenched fist, thumb side in, against abdomen between navel and tip of
sternum.
__ 7. Grasp clinched fist with opposite hand.
__ 8. Push abdomen forcefully with upward thrusts until object is removed, victim
starts to cough, or becomes unconscious.
Chest thrusts (or obese victim:
1. Stand behind victim.
_0 _2. Place arms around victim directly under armpits.
__ 3. Form fist and place thumb side of fist against sternum, level with armpits..
__ 4. Grasp fist in opposite hand and administer thrusts, pulling straight back, until
object is removed, victim starts to cough, or becomes unconscious.
Unconscious victim with obstructed airway:
1. Place victim on back.
__ 2. Activate EMS system.
__ 3. Finger sweep mouth to remove object.
__ 4. Ifunsuccessful, open airway with head-tilt/chin-lift maneuver.
__ 5. Try to ventilate; if still obstructed, reposition head and try to ventilate again.

Procedure:8 Performing Heimlich Maneuver (cont.) Name _
__ 6. If ventilation unsuccessful, give five abdominal thrust:
a. straddle victim's thighs or kneel next to victim
b. place bed of one band on abdomen above navel
c. place other hand in same position over first
d. keep elbows straight and thrust inward and upward five times
. 7. If unsuccessful, finger sweep mouth.
__ 8.Repeat steps 4-7 until effective or EMS arrives.
Pass Instructor's Signature -'Date _

Procedure: 9 Assisting with Dining Name _
(Feeds Client Who Cannot Feed Self)
I. Perform beginning procedure actions.
2. Before feeding, picks up name card and verifies that client has received the tray
prepared for him/her.
3. Before feeding client, ensure client is in an upright sitting position (45-90
degrees).
4. Places tray where it can be easily seen by client.
5. Client's hands are cleaned with hand wipe before beginning feeding.
6. Candidate sits facing client during feeding.
7. Tell client what foods are on tray and asks what client would like to eat first.
8. Using spoon, offers client one bite of each type of food on tray, telling client the
content of each spoonful.
9. Offers beverage at least once during meal
10. Makes sure client's mouth is empty before offering next bite of food or sip of
beverage.
11. At end of meal, client's mouth is wiped and hands are cleaned with hand wipe.
12. Removes food tray and places tray in designated dirty supply area.
13. Signaling device is within client's reach.
14. Washes hands.
Pass ----- Instructor Signature Date _

·..
Procedure:l0 Serving Supplementary Nourishment . Name _
_,_I.
needs.
Receive directions from supervisor regarding individuals with special dietary
__ ,2. Perform beginning procedure actions.
__ 3. Allow each resident to choose from available nourishments.
4. Place nourishment, napkin and utensils within reach.
__ 5. Provide assistance as needed.
6. Remove glasses and dishes after use, Do not touch rim of glass.
__ '7. Repeat steps 4-7 for each client.
__ 8. Return used equipment to kitchen to be washed,
9. Perform ending procedure actions.--
Pass__ .--;Instructor's Signature ,Date _

~.
Procedure:ll Providing Fresh Drinking Water Name _
_ I. Receive directions from supervisor regarding clients with special needs (NPO,
fluid restrictions, no ice) .
.__ 2. Perform beginning procedure actions.
__ 3. Take cart with clean supplies and add ice and water to pitchers (use scoop for ice).
. Do not allow handle of scoop to touch ice.
__ 4. Place fresh drinking water within reach.
__ 5. Offer to fill cup with fresh water.
__ 6. Record on intake/output record if required.
__ 7. Return cart containing any used. supplies to kitchen to be washed.
__ 8. Perform ending procedure actions.
r=-:
Pass__ .....;Instructor'sSignatute -'Date _

..~
SKIlLS PERFORMANCE CHECK LIST
Procedure:12 Making Closed Bed Name
-------------------
.__ 1.Perform beginning procedure actions.
__ 2. Places clean linen on clean surface within candidate's reach (e.g. bedside stand,
over-bed stand, or chair)
__ 3. Provides for client's privacy throughout procedure with curtain or door.
__ 4. Removes soiled linen and places in soiled linen container.
__ 5. Places mattress pad even with top of mattress.
__ 6. Place fitted sheet on top of mattress and tuck under top; side and bottom of
mattress. (If using flat' sheet, place flat sheet on top of mattress pad, hem down,
with bottom edge of sheet even with bottom edge of mattress and centerfold in
.r>; middle of bed tuck in top of sheet over top of mattress and miter comer).
__ 7. Place drawsheet, if used, across bed and tuck in side.
__ 8. Unfold and center; lengthwise, top sheet, wrong side up, hem even with upper
edge of mattress.
__ 9. Unfold and center blanket and/or bedspread lengthwise to center of bed..
_10. Miter top sheet and-spread or blanket together at bottom of bed.
_11. Go to other side of bed and repeat procedure making sure linen is tight and
without wrinkles ..
_12. Insert pillow into clean pillow case and place with open end away from door.
Pass Instructor's Signature Date _

Procedure:13 Opening Closed Bed Name. _
_ 1. Perform beginning procedure actions and raises bed to best level for body
mechanics.
__ 2. Faces head of bed and grasp top sheet, blanket and/or spread and fanfold top
linens to foot of bed.
__ 3. Signaling device is within client's reach.
__ , 4. Leaves bed in low position.
Pass Instructor's Signature. --=- Date .;..

• "r
Procedure: 14 Makes Occupied Bed Name _
2. Places clean linen on clean surface within candidate's reach (e.g. bedside stand,
over-bed stand, or chair)
3. Provides for client's privacy throughout procedure with curtain or door.
4. Lowers head of bed before moving client.
5. Loosens top linen from the end of the bed on working side.
6. Unfolds bath blanket over the top sheet and removes top sheet.
7. Raises side rail, goes to other side, moves client's body toward self, then slowly
rolls client onto side toward raised side rail.
8. Loosens bottom soiled linen on working side and moves bottom soiled linen
toward center of bed.
9. Places and tucks in clean bottom linen or fitted bottom sheet on working side (If
flat sheet is used, tucks in at tip and working side), then raises side rail.
10. Goes to other side of bed, lowers side rails, then assists client to turn onto clean
bottom sheet.
11. Remove soiled bottom linen.
12. Pulls and tucks in clean bottom linen, finishing with bottom sheet free of
wrinkles.
13. Covers client with clean top sheet and removes bath blanket.
14. Changes pillow case.
15. Centers and anchors clean linen over client
16. Avoids contact between candidate's clothing and soiled linen throughout
procedure.
17. Disposes of soiled linen in soiled linen container.
18. Perform ending procedure actions.

Procedure: 15 Assisting with Oral Hygiene Name _
(Minimal assistance from nurse aide)
___ 1. Perform beginning procedure actions.
2. Assist to bathroom and ask to brush teeth.
--
__ .3. Elevate head of bed to sitting position if unable to ambulate to'bathroom.
4. Place towel across chest to protect clothing and linen.
--
__ 5. Pour water over toothbrush and put toothpaste or powder on brush if unable to
do so.
___ 6. Give toothbrush to resident and encourage to brush own teeth. Cleanse
entire mouth including tongue and aU surfaces of teeth, using gentle motions.
__ 7. Put on gloves and brush all surfaces with up and down motion if unable to
brush.
___ 8. Provide cool water in glass to rinse mouth. Use straw, tissues and emesis
basin as needed.
9. Offer diluted mouthwash if desired. Use emesis basin and tissues as
--
needed. Wipe client's mouth and remove towel.
--
Pass, .Instructor's Signature ~ Date _

.:......--......,.
Procedure: 16 Provides Mouth Care Name
-------------------(minimal assistance from resident)
__ 1. Perform beginning procedure actions.
__ 2. Provides for client's privacy throughout procedure with. curtain or door.
__ 3. Before providing mouth care, ensures client is in an upright sitting position.
__ 4. Puts on clean gloves before cleaning client's mouth.
__ 5. Places towel across client's chest before providing mouth care.
6. Moistens toothbrush or toothette.
__ -7. Applies toothpaste to toothbrush or toothette.
8. Cleans entire mouth (including tongue and all surfaces of teeth), using gentle
-- motions. . .
9. Assist client to rinse his or her mouth.
10. Holds emesis basin to client's chin.
_._11. Wipes client's mouth and removes towel.
12. Disposes of soiled linen in soiled linen container.
_13. Maintain clean technique with placement of toothbrush or toothette throughout
the procedure. .
_14. Empties, rinses, and wipes basin, rinses toothbrush (if used), and returns to proper
storage.

Procedure: 17
Providing Mouth Care for
Unconscious Resident
Name
-------
__ .1. Perform beginning procedure actions.
2.
3.
4.
5.
6.
7.
8.
~ bed.
Turn resident to side-lying position, facing you.
Place towel and emesis basin under cheek.
Put on gloves.
Hold mouth open with ton~e blade
Clean entire mouth with swabs: roof, floor, tongue, teeth, cheeks, and lips.
Dry face with towel and apply lubricant to lips.
Position for comfort with call signal in reach, provide for safety and lower
__ 9.. Perform ending procedure actions.

Procedure: 18 Cleans Upper and Lower Denture Name -------
2. Puts on clean gloves before handling dentures
.3. Before handling dentures, protects dentures from possible breakage (e.g. by lining
sinklbasin with a towel/washcloth or by filling it with water).
4. Rinses denture in tepid/moderate temperature running water before brushing them
5. Applies toothpaste or denture cleanser to toothbrush.
6. Brushes dentures on all surfaces.
7. Rinses surface of denture under tepid/moderate temperature running water.
8. Rinses denture cup before placing clean dentures in it.
9. Places denture in denture cup with tepid/moderate temperature water/solution and
places lid on cup.
10. Rinses toothbrush and places in designated toothbrush basin/container.
11. Maintains clean technique with placement of dentures and toothbrush throughout
. procedure.
12. Sink liner is removed and disposed of appropriately and/or sink is drained
13. After rinsing equipment and disposing of sink liner, removes and disposes of
gloves (without contaminating self) into waste container and washes hands.

·'-
'.,
Procedure: 19 Provides Fingernail Care Name _
On One Hand
2. Before immersing fingernails, check water temperature for safety and comfort and
asks client to verify comfort of water.
3. Basin is in a comfortable position for client.
4. Puts on clean gloves before cleaning fmgernails.
5. Fingernails are immersed in basin of water.
6. Cleans under each fingernail with orangewood stick.
7. Wipe orangewood stick on towel after each nail.
8. Dries fingernail area
9. Candidate feels each nail and files as needed.
10. Disposes of orangewood stick and emery board into waste container (for testing
purposes)
11. Empties, rinses, and dries basin
12. After rinsing basin, places basin in designated dirty supply area.
13. Disposed of used linen into soiled linen container.
14. After cleaning nails and equipment, and disposing of used linen, removes and
disposes of gloves (without contaminating self) into waste container and washes
hands.
15. Signaling device is within reach.

.:.
Procedure:20 Foot Care Name
---------------------
__ 2. Provides for client's privacy during procedure with curtain or door.
__ 3. Test water temperature and ensures it is safe and comfortable (105) before
immersing client's foot in water, and adjusts if necessary.
__ 4. Basin placed at a comfortable level for client on protective barrier,
__ 5. Completely submerges and soaks foot in water.
__ 6. Put on clean gloves before washing foot.
__ 7. Washes entire foot, including between the toes, with soapy washcloth.
__ 8. Rinses entire foot, including between toes.
. __ 9. Dries entire foot, including between the toes.
'_10. Applies lotion to top and bottom of foot, removing excess (if any) with a towel.
_11. Supports foot and ankle properly throughout procedure.
_12. Repeat with other foot.
13. Empties, rinses, and wipes basin, and returns to proper storage.-. .
14.Disposes of soiled linen in soiled linen container.
15. Perform ending procedure actions.'
.Pass Instructor's Signature ~ __----- D.ate _

·:~
·Procedure: 21 Assisting With Shaving Name _
I. Perform beginning procedure actions.
2. Elevate the head of bed to semi-Fowlers position.
3. Spread towel under chin.
4. Put on gloves and place dentures in mouth ifwom.
5. Moisten face and apply shaving cream.
6. Hold skin taut and shave in direction that hair grows.
7. Use firm, short strokes and rinse razor frequently.
8. Start under sideburns, in front of ear, and work downward over cheek toward
chin.
9. Shave chin and under nose carefully. Work upward on neck under chin.
10. If skin is nicked, apply pressure with tissue directly over area until bleeding stops.
11. Wash off remaining soap when finished.
12. Apply aftershave lotion or powder if desired.
Electric Razor
1. Carry out steps 1-6 under safety razor.
2. Read instructions that came with electric razor.
3. Follow preference as to dry skin or use of pre-shave lotion.
4. Hold skin taut and shave all areas of face. Some razors require short circular
strokes, while others require short strokes in direction hair grows.
5. Wash and dry face thoroughly when finished.
6. Carry out steps 12-17 under safety razor.
Pass -----
Instructor Signature . Date _

Procedure:22 Caring for Hair Name
------------~---------
2. Assist to chair or elevate head of bed to semi-Fowlers position.
--
3. Place towel around shoulders.----
4. Place towel across pillow if remaining in bed.
--
5. Assist with removal of eyeglasses.
--
__ 6. Put on gloves. (Optional)
7. Part or section hair and comb with one hand· placed between scalp and end of
--
hair.
8. Brush gently from scalp to hair ends.
--
_-:--9. Style hair as requested using preferred supplies and products.
10. Remove towel and place in appropriate container.
--
__ 11. Replace eyeglasses and place signaling device within client's reach.
'Pass Instructor's Signature ....Date _

'.
Procedure:23 Shampooing Hair in Bed Name ..,.-_
__ 1. Receive directions from supervisor regarding clients with special needs.
.__ 3.. Put on gloves. (Optional)
__ 4. Put basin of warm water on towel on chair at bedside. Temperature should be
105 degrees F or less.
5. Provide for resident safety and raise bed to best level for body mechanics and
--
lower head of bed.
__ 6. Place towel across pillow and put trough on pillow. Have resident put head in
trough. Trough should drain into bath basin.
__ 7. Wet hair, using graduate and apply small amount of shampoo. Use dry wash
cloth to protect eyes.
__ 8. Wash hair, using fingertips to massage scalp.
__ 9. Rinse hair thoroughly.
__ 10. Apply conditioner as desired. Clean water may be needed to rinse out
conditioner.
__ 11. Remove trough and raise head of bed. Dry hair thoroughly with towels.
__ 12. Comb or brush hair gently and blow dry with hair dryer if requested. Use
extreme caution with dryer. Use low setting, keep dryer moving, and move hand
between dryer and hair to prevent burns. Ask resident if temperature is comfortable.
__ ' 13. Perform ending procedure actions.
Pass Instructor's Signature -'- Date _

Procedure:24 Dressing and Undressing Name
-------------------
3. Ask client which outfit he/she would like to wear and dresses him/her in outfit of
choice.
__ 4. Removes client's gown without completely exposing client. Removes garments
from the unaffected side first, then remove garments from the affected side.
__ 5. Assists client to put the affectedlweak arm through sleeve of the top before
placing garment on unaffected/strong arm.
__ 6. Put on underwear, slacks, or trousers by sliding garment over feet and pull up legs
as far as possible. Have client raise hips and pull garment to waist. If unable to lift
hips, turn to strong side and pull up garment on weak side. Turn onto weak side
and pull up garment on strong side.
.__ 7. Assist as needed with socks/stockings and shoes.
__ 8. While putting on items, moves client's body gently and naturally, avoiding force
and over-extension of limbs and joints.
__ 9. Finish with client dressed appropriately (e.g., clothing right side out,
zippers/buttons fastened, etc.)..
10.Places soiled linen in soiled linen container
Pass __ -:Instructor's Signature D.ate _

·.'
Procedure:25 Giving Complete Bed Bath Name _
~ 2. Provide privacy and prevent drafts.
3. Offer bedpan or urinal. If used, follow procedures listed in appropriate skill
performance checklist. (Assisting with bedpan or urinal).
4. Provide for resident safety and elevate bed to best level for body mechanics.
Place bed in flat position if tolerated.
__ 5. Put on gloves.
__ 6. Fold blanket and bedspread together and place over back of chair. Provide for
resident safety when leaving bedside.
__ 7. Place bath blanket/equivalent over top sheet, remove top sheet and place in
dirty linen container.
__ 8. Remove clothing and place in dirty linen container.
__ 9. Perform oral hygiene following appropriate correlating skill performance
checklist.
10. Shave male resident following appropriate correlating skill performance
--
checklist.
~_II. Fill basin 2/3 full with water not wanner than 105 degrees F. If using product
that does not need rinsing; add to water as needed.
12. Place wash basin on overbed table.
--
__ 13. Place bath towel across chest and make mitt with washcloth. Use mitt for rest
of procedure.

, ~.
Procedure 25 continued:
14. Observe condition of skin throughout procedure.
15. Wash eyes from nose to outer edge of face with water. Wash rest of face, ears
and neck with soap or water, as resident desires. Pat dry.
16. Pull bath blanket down to waist from under towel.
__ 17. Pick up bottom of towel and wash breasts/chest from under towel, without
exposing resident. Dry. Use care washing and drying under breasts.
__ 18. Turn towel long ways and pull bath blanket down to expose abdomen. Wash
and dry.
__ 19. Bring arm farthest away from you across chest and wash shoulder, axilla, and
arm using strokes toward heart. Support arm by resting on forearm as needed. Rinse
and dry. NOTE: Ifresident large, do not attempt to reach and put undue strain on
back. Provide for resident safety and go to opposite side of bed or get assistance as
needed. This applies to washing legs also.
__ 20. Put basin on bed on your side, place hand in basin and wash hand and
fingernails. Dry.
21. Wash, rinse and dry closest shoulder, axilla, arm and hand in same way.
--
__ .22. Change water in wash basin if soapy or cool.
__ ·.23. Expose leg farthest away and place towel under leg. If possible flex leg,
place foot in basin, soak and wash using strokes toward heart, rinse and dry leg
and foot. Wash and dry between toes.
__ 24. Repeat for other leg and foot without putting strain on back.
25. Provide for resident safety and change water.
--

__ 26. Position on side and place towel on bed under back. Wash, rinse, and dry
back and buttocks.
__ 27. Give back rub following appropriate skill performance checklist.
28. Perform pericare following appropriate skill performance checklist.
--
29. Remove gloves and wash hands.
30. Put on clean gloves.
31. Assist to apply personal care products.
32. Assist to dress.
33. Comb hair.
34. Provide for resident safety and lower bed.
~
35. Assist to chair and change linen.
___ .36. If on bedrest, leave resident in bed to change linen.
37. Follow ending procedure actions.
---
Pass Instructor's Signature D.ate _

Procedure:26 Giving Partial Bath Name _
__ ,2. Provide privacy and prevent drafts.
3. Provide for resident safety and elevate bed to best level for body mechanics.
---'
Place bed in flat position if tolerated.
4. Put on gloves.
--
5. Fold blanket and bedspread together and place over backof chair. Provide for
--
resident safety when leaving bedside. .
6. Place bath blanket/equivalent over top sheet, remove top sheet and gown arid
--
place in dirty linen container.
__ 7. Fill wash basin 2/3 full with water not warmer than 105 degrees F. Ifusing
product that does not need rinsing, add to water as needed.
__ 8. Place wash basin on overbed table.
9. Place bath towel across chest and make mitt with washcloth. Use mitt for rest
--
of procedure.
10. Wash eyes from nose to outer edge of face with water and no soap, using
--
different area of the washcloth for each eye. Wash rest of face, ears, and neck with
.soap or water as resident desires. Pat dry. .
11. Bring arm farthest away from you across chest, placing towel, and wash
--
axilla. Rinse and dry.
12. Put basin on bed on your side, place hand in basin and wash hand and
---
fmgemails. Dry.

__ 13. Wash, rinse and dry closest axilla and hand in sameway,
14. Position on side and place towel oil bed under back. Wash, rinse, and dry
--
back and buttocks.
15. Give back rub.--
__ 16. Perform pericare, cleaning from front to back, place,clean gown on client.
17. Provide for safety, clean washbasin and return to bedside stand.
--
18. Remove gloves and wash hands.
--
19. Assist to apply personal care products.
--
20. Comb hair.
---21. Perform ending procedure actions.--"--

.:.
Procedure:27 Giving Tub Bath or Shower Name
------------------
_I. Perform beginning procedure actions.
__ 2. Wash hands. Gloves optional unless contamination possible.
. 3. Select clothing and personal items needed. Allow resident to select clothing if
able.
4. Provide for client's privacy throughout procedure with curtain or door.-- .
__ 5. Assist to put on robe and slippers and escort to bath/shower room.
6. Fill tub half full of water or turn on shower. Test to ensure water temperature is
-- not more than 105 degrees F for tub or shower and that bottom of tub or floor of
shower not slippery. .
7. Place bath mat or towel in front of tub or shower.
__ 8. Assist to undressand get into tub or shower. Use shower chair as needed.
__ 9. Stay with resident and/or assist with washing as needed.
_._10. Assist out of tub or shower and help dry by patting gently with towel.
11. Have resident stand on bath mat or sit on towel-covered chair as needed.
_12. Assist with deodorant or antiperspirant and personal care products.
_13. Help dress.
14. Return to room.
15. Assist with oral care, Skill #15.
_16. Signaling device within client's reach.
17. Put on gloves, return to bathing area and clean and disinfect tub or shower.- .
18. Place soiled linen in proper container.
Pass Instructor's Signature ....,..... Date _

Procedure:28 Provides Perineal Care (peri-Care) Name _
__ 2. Fill wash basin 2/J full with water not wanner than 105 degrees F. Put at
bedside with other supplies.
3. Provide for resident safety and raise bed to best level for body mechanics.
--
4. Cover resident with bath blanket and fanfold top linen to bottom of bed.
--
5. Remove soiled clothing and incontinent pads if necessary. Change gloves and
--
wash hands as needed, providing for resident safety.
__ 6. Place incontinent pad under resident or put on bedpan.
A. Female Resident
__ 1. Spread labia and wasb front to back witb soap or periwasb-once down
each side and once down center using clean area of wa~hcloth or clean washclotb
for each stroke.
__ 2. Remove pads and replace, if needed, or remove from bedpan and provide for
resident safety. Clean bedpan and replace.
3. Follow steps outlined in part C.
--
B. Male Resident
__ 1. Gently push back foreskin of penis, if resident uncircumcised and wash from
meatus to body.
2. Rinse and return foreskin to natural position.
--

3. Wash scrotum and rinse.
--
__ 4. Pat dry. Provide for resident safety.
5. Follow steps outline in part C.
--
C. Female and Male Resident-as needed when contaminated
1. Wash, rinse and dry upper thighs,
--
2. ASsist to turn to side, away from you.
--
__ 3. Wisti 6iiHock and perianal area, always cleanilig rtoiii front to 6ack. .
Riiise and dry. Reposition resident.
__ 4. Remove incontinent pads and place in waste receptacle. Provide for resident
safety.
5. Perform. ending procedure actions.--'---
Pass Instructor's signature Date_---

Procedure:29 Giving Back Rub Name
--------------------
l.
-- Perform beginning procedure actions.
2. Place lotion in wann water.
3. Provide for client's privacy throughout procedure with curtain or door.
. __ 4. Provide for resident safety and elevate bed to comfortable working level.
5.--
bed.
Cover resident with bath blanket or equivalent and fanfold linen to bottom of
6. Put on gloves (Optional).
__ 7. Position resident in prone or side-lying position so back is toward you,
providing for safety of resident.
8. Position towel on bed next to back.
--
__ 9. Expose, wash, and dry back, if necessary, and examine for pressure areas. Do
not massage reddened areas.
__ 10. Put small amount of lotion in your hands and apply to back.
__ 11. Stoke upward from base of spine to neck, around shoulders and down sides of
back and buttocks forS t05 minutes using circular motions and long, smooth.firm
12. strokes.
__ 13. Straighten and tighten bottom sheet, pull up top linen and remove bath blanket
without exposing resident.
14. Perform ending procedure actions.---,.--
Pass , __ Instructor's Signature Date ...•. _

Procedure:30 Measures and Records Oral Temperature Name _
( Using Non-Mercury Thermometer)
__ 2. Puts on clean gloves before handling oral thermometer ..
. 3. Holds oral thermometer by stem.
4. Before inserting oral thermometer in client's mouth, shakes oral thermometer
down to 96 degrees F or lower:
__ 5. Places a sheath/protective cover on oral thermometer.
__ 6. Insert bulb end of oral thermometer into client's mouth, under tongue and to one
side.
__ 7. Tells client to hold oral thermometer in mouth with lips closed and assists as
necessary.
__ 8. Leaves thermometer in place for 3 minutes (for testing purposes only, may
leave thermometer in place for one minute).
9. Removes sheath/protective cover and disposes ofin wastebasket.
_10. Reads oral thermomete~ before cleaning thermometer.
11.Cleans oral thermometer and returns to container for used thermometers.
_12. Removes gloves and disposes of in wastebasket.
13. Records oral temperature within plus or minus 0.2 degrees of
evaluator's reading.
Pass Instructor's Signature .Date _

Procedure:31 Measures and Records Axillary Temperature Name _
(Using Non-Mercury Thermometer)
_0_1. Perform beginning procedure actions.
2. Provides for client's privacy during procedure with curtain or door.
__ 3. Check thermometer for chips and cracks, shake down to 96 degrees F or below
and place in sheath.
4. Place bulb end of thermometer in center of axilla. Ask resident to hold
thermometer in place by closing arm. Assist in doing so if client unable.
__ 5. Leave thermometer in place for 5-10 minutes.
__ 6. Removes thermometer and removes sheath/protective cover and disposes of in
wastebasket.
__ 7. Reads axillary thermometer before cleaning thermometer.
_0 _8. Cleans axillary thermometer and returns to container for used thermometers.
__ 9. Perfo~ ending procedure actions.
_10. Records axillary temperature with "A" for axillary. Result in within 0.2
degrees of evaluator's reading.
Pass Instructor's Signature , Date _

.';;.
Procedure:32 Measures and Records Rectal Temperature Name _
(Using Non-Mercury Thermometer)
__ 3. Puts on clean gloves before handling rectal thermometer,
__ 4. Checks thermometer for chips and cracks, shake down to 96 degrees F or below
and place in sheath.
__ 5. Lubricates bulb of thermometer and insert one inch into rectum.
__ 6. Holds thermometer in place for 3-5 minutes. Never let go of the thermometer .
....--..... __ 7. Removes thermometer and removes sheath/protective cover and disposes of in
wastebasket.
8. Reads rectai thermometer before cleaning thermometer ..
__ 9. Cleans rectal thermometer and returns to container for used thermometers.
__ 11. Records rectal temperature with "R" for rectal.' Records result within plus
or minus 0.2 degrees of evaluator's reading.

":.
Procedure:33 Measures and Records Temperature Name _
( Using Electronic or Tympanic Thermometer)
__ 3. Puts on clean gloves before handling thermometer.
__ 4. Remove appropriate colored probe from stored position and insert into disposable
probe cover or place cover on tympanic thermometer.
__ 5. Inserts probe cover into mouth, axilla, rectum, or ear, depending on thermometer
being used. Probe should be lubricated for rectal temperature: NOTE:Tympanic
thermometer is only inserted into the ear.
__ 6. Holds probe in place and wait for signal indicating temperature reading is
complete. .
__ 7. Removes probe and eject and discard probe cover. Do not touch cover.
__ 8. Return probe to its stored position or put tympanic thermometer down.
_. _9. Perform ending procedure actions.
_10. Records temperature using "R" ,"A", or "T" as appropriate.
Pass Instructor's Signature --'- D.ate _

·:.
Procedure: 34 Counts and Records Radial Pulse Name _
1.
--
2.--
__ 3.
__ 5.
6.--
__ 7.
Perform beginning procedure actions.
Places fingertips on thumbside of client's wrist to locate pulse.
Counts beats for one full minute.
4. Signaling device is within client's reach.
Washes hands.
Records pulse rate within plus or minus 4 beats of evaluator's reading.
Perform ending procedure actions.

.~.
."
."
Procedure:35 Measuring Apical Pulse Name
------------~---------
2. Clean earpieces on stethoscope with antiseptic swabs. Put earpieces in ears.
---Warm diaphragm of stethoscope by holding in palm of hand for several seconds.
3. Uncover left side of chest or place stethoscope underclothing. Avoid
--
overexposure.
4. Locate apex of heart by placing bell of stethoscope under left breast, just
--below and to inside of left nipple. Listen for heart sounds.
__ 5. Count heart beats for one full minute. Note anything abnormal in sounds, rate
andrhytlun. -
6. Cover resident and make comfortable.
--
7. Clean earpieces of stethoscope with antiseptic swabs. "
--
8.· Perform ending procedure actions.
--
__ 9. Record apical pulse.
Pass Instructor-s Signature- ------..:.....------------.Date------

Procedure: 36 Counts and Records Respirations Name _
__ .2. Counts respirations for one full minute.
__ 3. Signaling device is within client's reach.
_4. Washes hands.
__ 5. Records respiration rate within plus or minus 4 beats of evaluator's reading.
Pass .Instructor's Signature Date _

Procedure: 37 Measures and Records Name
------------------
Blood Pressure
2. Before using stethoscope, wipes bell/diaphragm and earpieces of stethoscope with
alcohol.
3. Client's arm is positioned with palm up and upper arm is exposed.
4. Feels for brachial artery on inner aspect of arm, at bend of elbow.
5. Places blood pressure cuff snugly on client's upper ann, with sensor/arrow over
brachial artery site.
6. Earpieces of stethoscope are in ears and bell/diaphragm is over brachial artery
site.
7. Candidate does one of the following
a. Inflates cuff between 160mm Hg to 180mm Hg. (If beat heard
immediately upon cuff deflation, completely deflate cuff.) Re-inflate cuff
to more than 200mm Hg
Or
b. Inflates cuff 30mm Hg beyond where radial or brachial pulse was last
heard or felt.
8. Deflates cuff slowly and notes the first sound (systolic reading), and last sound
(diastolic reading). (If rounding needed, measurements are rounded UP to the
nearest 2mm of mercury)
9. Removes cuff.
10. Signaling device is within reach.
11. Washes hands.
12. After obtaining reading using BP cuff and stethoscope, records both systolic
and diastolic pressures each within plus or minus 8 mm of evaluator's
reading.
Pass --------
Instructor Signature Date _

~:.
Procedure:38 Measures Blood Pressure (Electronically) Name _
(Optional)
. __ 3. Bare and extend arm and rest level with heart, palm upward on bed or table.
.__ 4. Locate brachial artery.
__ 5.·Wrap cuff snugly around upper arm, one inch above elbow with arrow on cuff
over brachial artery.
6. Follow manufacturer's directions for cuff inflation/deflation and reading of
-- results. .
__ 7. Remove cuff and replace.
__ 8. Perform ending procedure actions. .
9. Record both systolic and diastolic pressures.- .
Pass Instructor's Signature .....;Date _

' ..
Procedure:39 Measuring Combined Vital Signs Name_· ..•..
_,_1. Explains procedure to client, speaking clearly, slowly, and directly, maintaining
face-to- face contact whenever possible.
__ .2. Provide for client's privacy throughout procedure with curtain or door ..
J. Washes hands and put on gloves ..
__ 4. Position client in sitting or lying position, providing for comfort and safety.
__ 5. Follow steps 3-15 from 29 or
.Follow steps 4-12 from 32
6. Follow steps 2-6 from 33 and 2-6 from 35
__ 7. Follow steps 2-12 from 36 or
Follow steps 1-11 from 37
Pass Instructorts Signature. __.Date _

Procedure: 40 Measures and Records Weight and Name _
Height of Ambulatory Client
2. Client has shoes on before walking to scale.
3. Sets scale to zero before obtaining client's weight.
4. While client steps onto scale, candidate stands next to scale and assist client, if
needed, onto center of scale.
5. Records weight based on indicator on scale. Weight is within plus or minus 2
Ibs. of evaluators reading. (If weight recorded in kg weight is within plus or
minus 0.9 kg of evaluators reading)
6. While client steps off scale, candidate stands next to scale and assists client, if
needed, off scale before recording weight.
Measuring Height
7. Raise the height bar.
8. Lower height bar until it rests on head.
9. Record number of inches indicated.
10. Assist client to step down from scale.
11. Returns weight to extreme left on scale.
12. Perform ending procedures.

Procedure:41 Measuring and Recording Intake and Output Name _
1.Record intake on bedside intake/output record. Intake includes: amount, of fluid
resident takes with meals, amount of water and fluids taken between meals.
(Other fluids such as N's and tube feedings are recorded by the administering
nurse).
_' _2. Use listing of standard facility amounts for measuring.
__ 3. Record fluids in milliliters(ml).
__ 4. Puts on clean gloves before handling bedpan.
__ 5. Pours the contents of the bedpan into measuring container without spilling or
splashing any of the urine. '
__ 6. Measures the amount of urine at eye level.
__ 7. After measuring urine, empties contents of measuring container into toilet.
without splashing.
_,_8. Rinses measuring' container and pours rinse water into toilet.
__ 9. Rinses bedpan and pours rinse water into toilet.
_10. Returns bedpan and measuring container to proper storage.
_,_11. Removes and disposes of ~loves into wastebasket.
-12. Washes hands before recording output.
_13. Records contents of output container within plus or minus 25ml of
evaluator's reading.

Procedure:42 Assisting with use of Bathroom Name _
___ 2.
Help to put on robe and footwear if not already dressed.
__ 3. Assist to stand and ambulate to bathroom.
__ 4. Adjust clothing so able to sit comfortably on toilet.
__ 5. Place toilet tissue and call signal within reach and ask to signal when finished.
6.-- If resident can be safely left alone, leave room or wait outside.bathroom door;
. '.
ifunable to be left safely alone, remain with resident,
__ 7. Watch for call signal and respond promptly.
~_8. If left room, wash hands, put on gloves and assist resident to clean genital area
if necessary.
__ 9. Remove.gloves and wash hands.
__ 10. Ask if voided or defecated without difficulty and approximate amounts.
Pass._-'--- __ Instructors Signature ; Date _

....
•.....
,.Procedure:43 Assisting with use of Bedside Commode 'Name _
__ I. Perform beginning procedure actions.
__ ,2. Place commode next to bed. Open cover and adjust container under toilet seat
as necessary.
3. Assist resident to sit on side of bed, put on footwear and transfer to bedside'
--'
commode.
__ 4. Place tissue and call signal Withinreach and ask to signal when finished.
__ 5. Leave room if resident can be safely left alone or stay asnecessary.
__ 6. Watch for call signal and respond promptly.
__ 7.' If returning to room, wash hands, put on gloves and assist to clean genital
area, as needed.
__ 8. Remove gloves and wash hands.
__ 9. Assist with hand washing if resident cleaned genital area.
__ 10. Return to bed and make comfortable with call signal in reach.
__ 11. Close cover on commode as soon as possible.
13. Remove container from commode, cover, and take to bathroom.
--
__ 14. Observe appearance of feces or urine and measure output if on Intake and
Output.
__ 15. Empty container into toilet and flush.

Procedure: 44 Assist with Use of Bedpan Name _
2. Privacy is provided with a curtain, screen, or door.
3. Before placing bedpan, lowers head of bed
4. Puts on clean gloves before handling bedpan
5. Places bedpan correctly under client's buttocks.
6. Removes and disposes of gloves (without contaminating self) into waste container
and washes hands.
7. After positioning client on bedpan and removing gloves, raises head of bed.
8. Toilet tissue is within reach
.- ·9. Hand wipe is within reach and client is instructed to clean hands with hand wipe
when finished.
10. Signaling device within reach and client is asked to signal when finished.
11. Puts on clean gloves before removing bedpan.
12. Head of bed is flat before bedpan is removed.
13. Avoids overexposure of client.
14. Empties and rinses bedpan and pours rinse into toilet.
15. After rinsing bedpan, places bedpan in designated dirty supply area,
16. After placing bedpan in designated dirty supply area, removes and disposes of
gloves (without contaminating self) into waste container and washes hands.
17. Signaling device is within reach and bed is in low position.
Pass ----- Instructor Signature _ Date -----

Procedure:45 Assisting with use of Urinal Name ~----
__ .2. Offer urinal or place between legs, positioned downward to prevent spills,
with penis inside opening. Use incontinent pad as needed. Cover with top linen.
3. Place toilet tissue and call signal within reach.
--
4. Ask to signal when finished.
--
__ 5. If caII?ot be safely left alone, wait in room on other side of curtain.
6. If leaving room, remove gloves and wash hands.. Watch for call signal and
--
respond promptly. Wash hands and put on gloves upon return.
__ 7. Bring warm water (105 degrees F) and supplies for pericare to bedside if
necessary.
8. Remove urinal. cover, and take to bathroom.
--
9. Observe amount and appearance of urine. Measure output if ordered.--
10. Empty urine into toilet and flush.--
II. Clean urinal and return to bedside stand.--
__ 12. Assist with perineal care or perform perineal care using appropriate
correlating skill performance checklist.
__ 13. Return equipment to bedside stand and discard wash cloth and towel.
"14. Remove gloves and wash hands.
--
15. Assist resident to wash hands.--
"Pass Instructor's Signature Date _

Procedure: 46 Provides Catheter Care Name
------------------for Female
3. Before washing checks water temperature for safety and comfort and asks client
to verify comfort of water.
4. Puts on clean gloves before washing.
5. Places linen protector under perineal area before washing.
6. Exposes areas surrounding catheter while avoiding overexposure of client.
7. Applies soap to wet washcloth
8. While holding catheter near meatus without tugging, cleans at least four
inches of catheter nearest meatus, moving only one direction (i.e., away from
meatus) using a clean area of the cloth for each stroke.
9. While holding catheter near meatus without tugging, rinses at least four
inches of catheter nearest meatus, moving only one direction, away from
meatus, using a clean area of the cloth for each stroke.
10. While holding catheter near meatus without tugging, dries four inches of catheter
moving away from meatus.
11. Empties, rinses, and dries basin.
12. After rinsing basin, places basin in designated dirty supply area.
13. Disposes of used linen into soiled linen container and disposes oflinen protector
appropriately.
Pass ------ Instructor Signature _ Date _

Procedure:47 Emptying Urinary Drainage Bag Name
------------------
2. Put paper towel on floor and place graduate on towel under drain.
3. Remove drain from holder, open clamp and allow urine to run into graduate.
4. Prevent contamination of drain opening and splashing of urine ...
5. Clean top of drain with antiseptic as directed.
6. Close clamp and replace drain in holder.
7. Measure urine, empty into toilet and flush.
8. Clean graduate and store in appropriate area
__ 10. Record output on Intake & Output record:
~
Pass I.nstructor's Signature -'Date _

SKILLS PERFORMANCE CIiECK LIST
Procedure:48 Collecting Routine Urine Specimen Name
------------------
1. Receive directions from supervisor.
--
3. Fill out label, put on specimen container and put container in bathroom with
--lid offInside of lid should be facing up. Use paper towel for clean surface as needed.
4. Perform pericare or instruct resident to perform ifperineal area dirty.
--
Otherwise, pericare not needed.
5. Instruct not to put toilet tissue into bedpan/toilet hat or urinal.
--
6.. Take covered bedpan or urinal to bathroom or use urine in toilet hat.
--
7. Pour urine into clean graduate and measure if resident on intake and output.
--
__ 8. Fill specimen container about ~ full of urine. Do not touch inside of container
or inside surface of lid. Avoid touching outside of container with contaminated
gloves. If gloves contaminated, change gloves.
9. Discard excess urine and flush toilet.
--
11. Transport specimen to proper location.
--
.Pass Instructor's Signature D.ate _

Procedure:49 Applying and Caring for Condom Catheters Name _
2. Put on gloves and place incontinence pads under resident.
--
3. Secure drainage bag to bed frame.
--
__ 4. Remove old condom catheter by rolling sheath off penis and discard.
5. Provide perineal care using Skill #27.
--
__ 6. Apply skin barrier to shaft of penis if directed by supervisor.
7. Hold penis firmly and roll on condom, leaving one inch space between penis
--
and end of condom.
__ 8.· Connect condom catheter to drainage bag and attach drainage bag to bed
frame.
-----------------.-~

Procedure:50 CollectingStoolSpecimen 'Name _
__ 1. Receive directions from supervisor.
2. Perform beginning procedure actions.---
__ 3. Fill out label, put on specimen container and put container in bathroom with
lid off. Inside of lid should be facing up. Use paper towel for clean surface as needed.
4. Instruct not to put toilet tissue or urinate into bedpan/toilet hat.
__ 5. While wearing gloves, take covered bedpan/commode to bathroom with
sample.
__ 6. Use tongue blade to put approximately two tablespoons of stool into specimen
container, discard excess stool and flush toilet. Discard tongue blade.,
__ 7. Remove gloves, dispose of in wastebasket and wash hands.
__ 8. Put lid on specimen container and place container in leak-proof transport bag.
9. Assist resident to wash hands.
__ 1O.Perform ending procedure actions.
__ 11. Transport specimen to proper location.
,~
Pass Instructors Signature -:- -'Date _

Procedure:51 Administering Cleansing Enema Name
-----------------
--
_---.:2. Perform beginning procedure actions
__ .3. Close clamp on tubing and fill enema container with correct amount of water
no warmer than 105 degrees. Open clamp, expel air in tubing by filling with
solution and close clamp.
__ 4. Put lubricant on paper towel and lubricate 6 inches of tubing..Take to bedside.
. .
5. Provide for resident safety and raise bed to best level for body mechanics.
--
__ 6. Cover resident with bath blanket or equivalent and fanfold top linen to bottom
of bed.
__ 7. Lower underwear as needed to expose anus.
__ 8. Place incontinence pads under buttocks and bedpan within reach.
__ 9. Position resident on left side with knees flexed (left Sims). Provide for
resident safety if unable to turn alone.
__ 10. Ask to take deep breath and gently insert lubricated tube into rectum 6 inches.
Stop if pain or resistance.
__ 11. Hold enema container approximately 12 inches above anus or at height which
allows solution to flow in very slowly and open clamp. Ask to take slow, deep
breaths and to report any cramping, nausea, sweating or feeling of faintness.
_____ 12. Encourage to take all of solution ordered, but clamp tube immediately if any
symptoms listed in Step11, other than feeling of fullness or urge to defecate, occurs.
13. Put on call signal for help if nausea, sweating and feeling of faintness
--occurs.
__ 14. Slowly and gently remove tube from rectum and wrap in paper towel.

Procedure:51 Administering Cleansing Enema (cont.) Name _
_ 15.Assist resident onto bedpan or into bathroom, helping to put on robe and slippers.
Remove gloves, dispose in wastebasket and wash hands as needed.
_16. Place toilet tissue and call light within reach if on bedpan. Provide for resident
safety.
17. If in bathroom, ask not to flush toilet when finished.
_18. Stay in room if cannot safely be left alone. Dispose of enema bag in appropriate
waste container.
_19. Put on gloves and assist to clean genital area, if indicated. Remove gloves and
wash hands.
_201. If resident is on bedpan, put on gloves, assist to clean genital area, remove
bedpan, cover, provide for resident safety, take bedpan to bathroom and clean.
Remove gloves and wash hands.
_21. Note amount, color, odor and consistency of stool and how enema was tolerated.
22. Assist to wash as needed.
__ 23. Put on-g~oves,remove incontinence pads, and put in wastebasket.
-_24. Perform endin~ procedure actions.

Procedure: 52 Applying Warm or Name -.-:.. _
Cold Application
Warm Application
3. Prepare warm application following manufacturer's directions. Temperatures for
warm sitz bath, soaks/compresses are never more than 105°F. Heating devices
will have set temperature. Follow manufacture's directions.
4. Assist to comfortable position with call signal in reach.
5. Place body part into warm water, put on compress or apply heating device as
directed. Use towels and incontinence pads as needed to keep linen dry or to
place under basin.
6. Cover compress with plastic wrap in towel. Heating device may be added as
directed .:
7. Check resident every five minutes for redness. Instruct to report complaints of
pain or discomfort.
8. Maintain temperature of application for amount of time ordered.
9. Remove body part from warm water, compress, or heating device. Pat skin dry.
10. Perform ending procedures.
Cold Applications
11. Follow steps 1-4.
12. Place ice bags and cold packs in appropriate cover after removing excess air or
following manufacturer's instructions.
13. Place body part into cold water or apply cold application with caps or lids facing
away from resident. Protect linens with incontinence pads.
14. Check skin every 10 minutes for blisters, pale, gray or white areas. Instruct to
report complaints of pain or discomfort. Provide warmth with bath blanket for
sitz bath.
15. Maintain application for amount of time ordered.
16. Remove body part from cold water or remove application. Pat skin dry.
Pass -----

Procedure:53 Applying Elastic Bandages Name _
__ .2. Expose part to be bandaged, malcingsure it is clean and dry.
__ .3. Hold bandage so that roll is up and loose end is on bottom.
__ 4. Make two circular turns around extremity, and proceed with overlapping
spiral turns in upward direction. Overlap about 2/3 of previous turn.
. 5. Apply bandage smoothly with firm, even pressure.
__ 6. Pin, tape, or clip end of bandage to hold in place, malcing sure pin or clip is
not under body part.
__ 7. Check extremity for Signature and symptoms of cyanosis. Instruct to report
complaints of pain, numbness, or tingling. Remove bandage if symptoms present and
report immediately.

Procedure:54 Assisting with Coughing and Name ~_
Deep breathing Exercises
2. Assist to semi-Fowler's if possible.
--
__ 3. Instruct to take deep breath and hold for 3 t05 seconds.
__ 4. Exhale slowly through pursed lips.
__ 5. Repeat this step four more times.
__ 6. Instruct to hold pillow or blanket over incision, if present, and coughvery
deeply. USETIDS STEP ONLY IF CONGESTION PRESENT.
__ 7. Repeat deep breathing and coughing at least twice
__ 8. Repeat as many times as ordered.
__ 9.. Perform ending procedure actions.

Procedure: 55 Applying and Removing Name _
Elastic Stockings/Ted Hose
For infection control purposes this skill is to be performed on a mannequin
2. Provides for client's privacy during procedure with curtain or door
3. Client is supine position (lying down in bed) while stocking is applied
4. Turns stocking inside-out
5. Places foot of stocking over toes, foot, and heel
6. Pulls top of stocking over foot, heel, and leg
7. Moves foot and leg gently and naturally, avoiding force and over-extension of
limb and joints
8. Finishes procedure with no twists or wrinkles and heel of stocking, if present,
is over heel and opening in toe area (if present) is either over or under toe
area.
9. Signaling device is within reach and bed is in low position
10. Washes hands
Removing Elastic Stocking
11. To remove, roll stocking from top down to ankle, ease over heel and pull over
foot
12. Perform ending procedures
Pass ----- Instructor Signature -'-- Date _

Procedure:56 Applying Nonsterile Dressing Name, _
___ 1=0 Receive directions from supervisor.
_~2. Perform beginning procedure actions.
3. Select correct size and type of dressing. Dressing should extend
--
approximately one inch beyond wound edge or cover area of skin to be protected.
__ 4. Open package without touching dressing.
6. Remove old dressing, if present, and discard in biohazard bag. Observe
--condition of wound or skin.
7. Remove gloves, dispose in wastebasket and wash hands.--
__ 8. Put on clean gloves.
__ 9. Pick up comer of new dressing and place untouched side of dressing directly
. on area to be dressed.
__ 10. Secure dressing with tape or bandage wrap as needed.
Pass, Instructors Signature Date _

,Procedure:57 Performing Postmortem Care Name, _
__ l.Wash hands and puton gloves..
__ 2. Identify body.
__ 3. Provide for client's privacy throughout procedure with curtain or door.
, __ 4. Raise bed to best level for body mechanics.
__ 5. Place body in supine position with incontinence pads under buttocks.
__ 6. Close eyes and replace dentures.
__ 7. Close mouth. Use rolled towel to support chin if needed.
__ '8. Remove drainage bottles, bags and containers. Receive directions regarding
removal of tubes. '
__ 9. Remove jewelry, eyeglasses, and hearing aids following facility policy.
_10. Bathe soiled areas of body as needed and brush or comb hair.
_11. Change dressings as needed.
_'12. Apply clean gown and cover body with sheet and prepare for viewing.
_13. Lower bed and remove used supplies andequipment.
_14. Straighten room, close curtains and turn offbright lights, leaving soft lighting.
_15. Provide privacy for family to view body. Give possessions to family, as directed;
_16. Identify body according to facility policy OR put ID tag on toe or ankle and place
, body in shroud or cover with sheet and secure (ties, tape or pins) as directed or as
, per facility policy. Attach second tag to shroud or sheet accordingly.
_17. Remove gloves, .dispose in wastebasket and wash hands.
'Pass Instructor's Signature, Date _

Procedure:58 Assisting to Ambulate Using
Cane or Walker
Name
--------~--------
__ 2. Check cane or walker for safety.
3. Help put on footwear.,.--
4. Assist to sitting position with feet resting on floor.
--
5. Secure gait belt snug enough to provide support and loose enough to provide :
--
comfort.
6. Place walker or cane within reach.
--
7. Assist to stand.
--
8. Have resident use cane or walker to maintain balance.
--
__ 9. Walk mostly beside but slightly to rear of the resident while grasping gait belt
to provide support.
__ 10. Ambulate as ordered, observing for correct use of cane or walker.
. 11. Observe for discomfort or weakness.
--
__ 12. Return to room and provide for comfort with call signal in reach.
13.· Perform ending procedure actions.-......,.-
Pass ~Instructor's Signature --..;. Date _

Procedure:59 Using Mechanical Lift (Hoyer) Name _
__ 1. Assembleequipment andrequesthelp from co-workers:
2. Performbeginning procedureactions.
--
3. Place footwear on feet.
--
4. Positionchair and bed appropriatelyfor transfer. Lock wheels on bed and
--wheelchair.
_~5. Followmanufacturer's directionsfor transferringresident.
__ 6. Performending procedure actions.
_~7. Reverseprocess to returnto bed.
. Pass Instructor's Signature . Date
----- -----~-------~------~-

"."
Procedure:60 Performing Range of Motion (ROM) Name _
1. Perform beginning procedure actions. -
2. Cover with bath blanket or equivalent and fanfold top linens to bottom of bed.
3. Place in supine position.
4. Perform exercises on one side of the body and repeat exercises on
opposite side of the body. Repeat each movement gently, slowly, and smoothly
three times unless otherwise directed. Always support joint being exercised and
never go beyond point of pain, discontinuing-exercise if pain occurs.
5. Exercise neck: Head flexion, extension, and hyperextension. Head right and
--
left rotation. Head right and left lateral flexion.
__ 6. Exercise shoulder: Shoulder flexion, extension, and hyperextension.
Shoulder abduction and adduction. Shoulder internal and external rotation.
Shoulder horizontal abduction and adduction.
7. Exercise elbow, forearm and wrist: Elbow flexion and extension. Forearm
---
pronation and supination. Wrist flexion, extension, and hyperextension. Wristulnar
and radial deviation.
_~8. Exercise hand and each fmger: Finger flexion and extension. Finger
abduction and adduction. Finger/Thumb opposition.
9. Exercise hip and knee: Hip flexion and extension. Hip abduction and
--
adduction. Hip internal and external rotation. Knee flexion and extension.

__ 10. Exercise ankle, foot and toes: Ankle dorsal flexion and plantar flexion.
Foot eversion and inversion. Toe abduction and adduction. Toe flexion and
extension.
__ 11. Repeat exercise on opposite side of body after providing for resident safety.
12. Lower bed.
--
__ 13~ Replace top linens.
__ 14. Return bath blanket or equivalent to appropriate place.
__ ,15. Perform ending procedure actions.
Pass.; Instructors Signature Date _

Procedure: 60a Performs Passive Range of Motion Name
------------------
(PROM) for One Knee and One Ankle
3. Instructs client to inform nurse aide ifpain is experienced during exercise.
4. Supports leg at knee and ankle while performing rand of motion for knee.
5. Bends the knee and then returns leg to client's normal potions
(extensionlflexion)(A T LEAST 3 TIMES unless pain is verbalized)
6. Supports foot and ankle close to the bed while performing range of motion for
ankle.
7. Pushes/pulls foot toward head (dorsiflexion), and pushes/pulls foot down, toes
point down (plantar flexion) (AT LEAST 3 TIMES unless pain is verbalized)
8. While supporting the limb, moves joints gently, slowly, and smoothly
through the range of motion, discontinuing exercise if client verbalizes pain.
10. Washes hands.
Pass ------- Instructor Signature Date _

Procedure: 60b Performs Passive Range of Motion Name _
(PROM) for One Shoulder
3. Instructs client to inform nurse aide if pain is experienced during exercise.
4. Supports client's upper and lower ann while performing range of motion for
shoulder.
·5. Raises client's arm from side position upward toward head to ear level and returns
ann to side of body. (extensioniflexion)(AT LEAST 3 TIMES unless pain is
verbalized)
6. Moves client's straightened ann away from the side of body to shoulder level and
returns to side of body. (abductioniadduction)(AT LEAST 3 TIMES unless pain is
verbalized)
7. While supporting the limb, moves joints gently, slowly, and smoothly
through the range of motion, discontinuing exercise if client verbalizes pain.
9. Washes hands.
-----~--- --

.~.
Procedure: 61 Assists to Ambulate Using Transfer Belt Name _
2. Before assisting to stand, client is wearing shoes
.3. Before assisting to stand, bed is at a safe level
4. Before assisting to stand, checks andllocks bed wheels
5. Before assisting to stand, client is assisted in sitting position with feet flat on the
floor
6. Before assisting to stand, applies transfer belt securely over clothing/gown
7. Before assisting to stand, provides instructions to enable clientto assists in
standing including prearranged signal to alert client to begin standing
8. Stands facing client positioning self to ensure safety of candidate and client
during transfer. Counts to three (or says other prearranged signal) to alert client
to begin standing
9. On signal, gradually assists client to stand by grasping transfer belt on both sides
with an upward grasp (candidate's hands are in upward position), and maintaining
stability of client's legs
10. Walks slightly behind and to one side of client for a distance often (10) feet,
while holding onto the belt
11. After ambulation, assists client to bed and removes transfer belt
12. Signaling device is within reach and bed is in low position
13. Washes hands

Procedure:62 Transferring From Bed to Chair Name. _
2. Place chair beside bed on strong side.
--
__ .3. Lock wheels on bed and place in lowest position.
4. Elevate head of bed.
5. Fanfold top linens to bottom of bed.
--
6. Assistto put on nonskidfootwear,
--
__ 7. Help to move to side of bed.
__ 8. Assist to sitting position with feet flat on floor and allow to dangle for
several minutes, providing instructions for resident to assist with transfer.
__ 9. Assist to stand: Place your hands under the resident's arms with hands around
shoulder blades or use gait belt. Block feet with your feet and brace your knees
against knees of resident to prevent slipping. Use good body mechanics to assist to
standing position on count of three.
__ 10. Assist to turn slowlyuntil back faces chair with back of resident's legs
against chair.
_. _._11.. Lower slowly to sitting position with hips touching back of chair and
remove transfer (gait) belt.
Pass Instructor's Signature. .Date _

·-",
..
"
Procedure: 63 Transfers from Bed to Wheelchair Name
-------------------Using Transfer Belt
2. Provides for client's privacy throughout procedure with curtain or door.
3. Position wheelchair close to bed.
4. Before transferring client, folds up footrests.
5. Before transferring client, places bed at a safe and appropriate level for the client.
6. Before transferring client, locks wheels on wheelchair.
7. Before transferring client, checks and/or locks bed wheels.
8. Before transferring client, supports client's back and hips and assists client to a
sitting position with feet flat on the floor.
9. Before transferring client, puts non-skid footwear on client and securely fastens.
10. Stand in front of client, positioning self to ensure safety of candidate and client
during transfer (e.g., knees bent, feet apart, backs straight), places belt around
client's waste, and grasps belt.
11. Provides instructions to enable client to assist in transfer.
12. Braces client's lower extremities to prevent slipping.
13. Counts to three (or says other prearranged signal) to alert client to begin transfer.
14. On signal, gradually assist client to stand.
15. Assists client to pivot to front of wheelchair with back of client's legs against
wheelchair.
16. Lowers client into wheelchair.
17. Positions client with hips touching back of wheelchair and removes transfer belt.
18. Positions client's feet on footrests.
Pass ------- Instructor Signature ~ Date _

Procedure: 64 Transferring from
Bed to Stretcher
Nmne ~ _
1. Obtain instructions from supervisor and secure assistance from coworker.
3. Bring stretcher into room and place beside resident's bed.
4. After assuring resident's safety, raise bed to same height as the stretcher and
lower side rail that is on the side nearest the stretcher. Position resident close to
the side nearest the stretcher.
5. Fanfold top linens to the foot of the bed being careful not to expose the resident
more than necessary.
6. Assure that the stretcher is against the resident's bed and that the wheels are
locked on the stretcher and the bed.
7.. Stand on side of stretcher to reach across and grab the resident's turn (draw)
sheet.
8. If the resident can assist: Have the resident to scoot their hips toward the
stretcher while you and the other nurse aide pull the turn (draw)sheet toward you ..
If the resident cannot assist: Use the turn (Draw) sheet to gently position them
onto the stretcher. It may also be helpful to have a third person on the opposite
side to the bed to assist with the transfer.
9. Be sure to maintain good body mechanics for yourself and the resident.
10. Once the resident is on the stretcher, position him or her into a properly aligned
position.
11. Secure the stretcher straps on the resident and raise the side rails.
Pass -------

·..'
Procedure:65 Moving Up in Bed Name ~ _
1. Request help from co-workers as needed.
3. With co-worker at one side of bed. provide for resident safety and then raise
bed to best level for body mechanics. Check that wheels are locked.
4. Lower bed to flat position and place pillow against headboard.
__ 5. Person on either side of bed places one arm under shoulder and one arm under
thigh.
__ 6. Ask to help. if able. by flexing both knees, placing feet on bed and grasping
headboard with hands.
__ 7. Explain that on count of "3". resident should pull up with hands and push
r=>. agairist bed with feet, as you and co-worker move resident up. This may take more
than one attempt.
__ 8. Place ·pillow under head.

, "
Procedure:66 Moving Up in Bed Using Turn Sheet Name, _
.,.-_1. Request help from co-workers.
_--:2. Perform beginning procedure actions.
3. With co-worker at one side of bed, provide for resident safety and then raise
--
bed to best level for body mechanics. Check that wheels are locked.
__ 4. Lower bed to flat position and place pillow against headboard.
__ 5. Position turning sheet under resident, if not already in place.
__ 6. Roll turning sheet up close to resident and grasps sheet fmnly at shoulder and
buttocks. -
__ 7. Move up on count of"3". Buttocks must clear mattress to avoid shearing.
__ 8. Place pillow under bead,
__ 9. Perform ending procedure actions,
Pass,__ -.:Instructor's Signature D-ate_---,- _

...
Procedure:67 Position Resident on Side Name. _
2. Provide for resident safety and then raise bed to best level for body
--
mechanics.
3. Lower bed to flat position. Lock bed wheels.
__ 4. Stand on opposite side of bed to which you will turn resident, raise siderails
. on side to which resident's body.will be turned.
5. Move the resident to the side of the bed nearest you.
__ 6. Cross resident's arms over chest.
__ 7. Cross leg nearest you over the opposite leg and provide for resident safety.
8. Go to opposite side of bed.
--
__ 9. Roll gently toward you.
__ 10. Position in good bodily alignment.
__ 11. Place pillow under head and shoulder. Adjust shoulder so resident is not
lying on arm.
12. Position other pillows as needed for support with call signal in reach.
--
__ 13. Provide for resident safety and lower bed; replace linens on resident.
--
Pass Instructor's Signature .....•.. Date _

",
SKIiLS PERFORMANCE CHECK LIST
Procedure:68 Applying Restraints Name _
--
--
3. Position in good bodily alignment.
--
4. Apply restraint according to manufacturer's instructions. Hands must be
--clean, dry and padded when applying mitt restraints. Vest restraints are worn over
clothing and must not restrict breathing.
__ 5. Ties ends to bed frame or wheelchair using slipknot.
__ 6. Check pulse, color and temperature of any restrained extremity and
breathing of resident in vest restraint every 15 minutes.
--
-,

·.
Procedure:69 Applying Safety Belt Restraint Name,....:-: _
--
2. Perform beginning procedure actions. '
--
3. Assist to sitting position.
--
4. Place belt over top of clothing in front, passing ties across back.
--
5. Check restraint to be sure there are no wrinkles and that restraint does not
---restrict breathing.
6. Put ties through belt slots.
--
7. Assist to lie down if in bed.
--
8. Position in good body alignment (in bed or chair).
--
__ 9. Tie straps to bed frame or wheelchair using slipknot for easy release.
--

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